Betts D J 2012 Positive Art Therapy Assessment Looking Towards

Introduction

Formal elements of art products such as line, color and shape are frequently used in art therapy observation in youth as well every bit developed mental health care. The fine art therapists' underlying assumption seems to be that formal elements reflect clients' mental health problems (e.g., Cohen et al., 1986; Gantt and Tabone, 1998; Hacking, 1999; Conrad et al., 2011; Schoch et al., 2017). Observing formal elements could thus be used by fine art therapists to formulate their perspective on clients' functioning, strengths and challenges and support their contribution to the descriptive diagnosis. This could help the art therapist to decide whether fine art therapy and which fine art interventions may be benign. This interest in the use of formal elements is reflected in a large number of studies (eastward.g., Elbing and Hacking, 2001; Stuhler-Bauer and Elbing, 2003; Betts, 2005, 2006; Mattson, 2009; Kim et al., 2012; Eytan and Elkis-Abuhoff, 2013; Thyme et al., 2013). These studies, however, demonstrate a broad range of opinions apropos which formal elements are relevant and how they are described and interpreted in fine art therapy ascertainment and assessment. Also, prior studies used a different number of formal elements. In the diagnostic drawing series (DDS) (Cohen et al., 1986; Cohen, 1986/1994, unpublished) twenty-two formal elements are included. In the formal fine art therapy scale (FEATS) (Gantt and Tabone, 1998) xiv formal elements are incorporated, in the descriptive assessment of psychiatric fine art (DAPA) (Hacking, 1999) 5 categories, and in the Nürtinger Rating Scale (NRS) (Elbing and Hacking, 2001; Stuhler-Bauer and Elbing, 2003) four categories of twenty-iv formal elements. Even if similarities in these formal elements can exist recognized, the way they are described differs largely. For case, regarding line some emphasize the quality of the line (Gantt and Tabone, 1998), whereas others emphasize the presence of line versus the absence of line (Cohen et al., 1986). Regarding colour, the intensity of color is included in the DAPA (Hacking, 1999), whereas others include the mixture of color (Cohen et al., 1986). Additionally, diversity can exist recognized in the methods used to find and assess the formal elements. In some studies, open observation of formal elements is used to inquire into an in-depth agreement of the individual customer (Stuhler-Bauer and Elbing, 2003; Thyme et al., 2013; Pénzes et al., 2015, McNiff in Gilroy et al., 2012). In other studies, specific assessment methods are used such as the DDS, in which an art therapist assesses three drawings that are made with colored pastels according to 3 different tasks, or the FEATS, in which a drawing made with markers is assessed.

The same kind of variety is seen in the way formal elements are interpreted. In previous studies, formal elements are related to distinctive psychological features. In near studies, formal elements are related to disorders of the Diagnostic and Statistic Manual of Mental Disorders (DSM) or the International statistical classification of diseases and related health problems (ICD) (Cohen et al., 1986; Gantt and Tabone, 1998; Hacking, 1999; Kim et al., 2014). Whereas in more recent studies formal elements are related to clients' strengths (Hinz, 2009, 2015; Pénzes et al., 2014, 2015) in line with perspectives on positive mental health (Huber et al., 2016) and recovery (Anthony, 1993). These perspectives have found their way into fine art therapy observation and cess (Betts in Gilroy et al., 2012; Wilkinson and Chilton, 2013).

Thus, until now, literature has been far from consequent in presenting tools or suggestions directed toward the clinical use of formal elements in art therapy observation and assessment. Despite this ambiguous evidence, formal elements are very oft used in clinical practise. Art therapists employ existing fine art therapy assessment instruments in their own way, oftentimes developing their own assessment methods with their own favorite formal elements (Claessens et al., 2016). It is, however, unclear which formal elements art therapists find relevant in their clinical practise, how they observe and translate them, and how art therapists chronicle formal elements to mental wellness. In this study, we will systematically investigate these aspects by interviewing fine art therapists with many years of feel in clinical practice. If indeed art therapists in clinical practice use formal elements in a consequent mode, the outcomes of the present report may contribute to the 'body of knowledge' regarding if and how formal elements can exist used in art therapy observation and cess to estimate clients' mental health, and direct further treatment.

Materials and Methods

In this report, we used Constructivist Grounded Theory (Charmaz, 2014). This qualitative arroyo inductively generates theory grounded in empirical information. Data was gathered through interviews with eight very experienced art therapists and analyzed by initial, focused and theoretical coding principles of qualitative analysis (Charmaz, 2014). Run into Figure 1.

Effigy one. The research procedure.

Participants

In total eight art therapists were purposely selected from the existing professional network of a research centre of arts therapies in the Netherlands¹. Participating art therapists were women with fifteen- >25 years experience with different populations and settings in adult mental health care. Based on the principle of theoretical sampling (Corbin and Strauss, 2008; Charmaz, 2014) they had unlike nationalities (Dutch, United states of america, and United Kingdom), diverse training backgrounds and fine art therapy perspectives. This diverseness provided a disquisitional exploration and variation of the concepts investigated in this report. All art therapists gave written informed consent in accordance with the Declaration of Helsinki.

Data Collection

Fine art Products

The participating fine art therapists were asked to find six fine art products of five clients with various mental health issues (see Table 4). Two art products (3 and 6) were fabricated by one customer. The fine art products were randomly selected from a larger sample of 138 products made by 48 clients of 11 art therapists. All clients gave written informed consent in accordance with the Declaration of Helsinki. All three paintings were made with acrylic paint on paper (size: 50 × 40 cm.) over a period of 3 weeks. For the showtime and 2d painting, the clients received standardized instructions to paint a landscape; for the third painting clients were asked to create a painting without education. For all paintings, clients received the same paint, colour palette, brushes and pencils. The sampled clients had but started treatment in art therapy in a range of mental health settings. In this stage of treatment it is common in kingdom of the netherlands that the head of handling (usually a psychologist or psychiatrist) formulates a preliminary DSM-diagnosis that might change during the class of assessment. Fine art therapists practise not formulate a DSM-diagnosis. In a later phase they codify an art therapy diagnosis and contribute to a general descriptive diagnosis.

Interviews

The art therapists were interviewed using "intensive interviews" (Charmaz, 2014). The aim of these interviews was to explore in detail which formal elements the art therapists observed and how they described mental health. In particular how exactly they related formal elements to what aspects of mental health. The first half-dozen interviews took place in the piece of work setting of the art therapist. Interview vii and 8 were conducted on Skype. All interviews were videotaped. During the alive interviews the art products were spread out randomly. During the Skype interviews the art products were discussed in numerical order. The interviews were conducted with an interview guide based on the research questions of this written report. First, every art therapist was asked to wait at the art products separately, depict the formal elements and depict the first impression she gained well-nigh the client. 2d, more general questions were asked about how she would ascertain the concept of mental health. Finally, every art therapist was asked how she would relate the formal elements of the art production to diverse aspects of mental health.

This guide was used equally a flexible structure to ensure detailed exploration of the art therapists' view on formal elements of the art product, mental health and the interrelatedness of formal elements and mental wellness. Open and investigative questions (Charmaz, 2014) were asked to pinpoint these relationships in order to gain an agreement of the diagnostic value of formal elements of art products in art therapy observation; which formal elements exactly are important and how are they related to exactly which aspects of clients' mental health?

Information Assay

Initial Coding

After total transcription of the interviews, text fragments were organized according to the topics of the interview guide. These topics, (1) formal elements, (ii) mental wellness and (three) relationship between formal elements and mental health, were used as 'sensitizing concepts' (Charmaz, 2014). First, incident-past-incident coding took place; within each interview, each art product separately was analyzed. This assay resulted in a ready of codes.

Focused Coding

In the next stage these initial codes were further categorized by comparative analysis (come across dotted line in Figure 1); input of all therapists and over all art products were compared and preliminary categories emerged. Codes almost which nigh therapists agreed or that had similarities were amassed into theoretical codes regarding the formal elements, mental health and their interrelatedness. Based on the initial codes, these categories were described. Inside the coding rocess, it became clear that some of these categories, such equally several formal elements, were mentioned by nearly all therapists about every fine art product; these became principal theoretical categories. Some other categories were mentioned less often; these became sub theoretical categories. In this stage, a first perspective emerged on how the formal elements of the art product were related to mental health.

Theoretical Coding

Theoretical coding conceptualized the interrelatedness between the categories. Comparative analysis over the eight interviews supported synthesizing and organizing the links between the theoretical categories. Inside this process some of the main theoretical categories were merged into cadre concepts. For case, the main and secondary formal elements (see Effigy ii) became primary categories under the core concept "structure." Of others, it became clear that they were related -but separated- main theoretical categories, such as flexibility and creativity under the core concept of "adaptability." This led to a theoretical framework, conceptualizing the relatedness between sub- and main categories and cadre concepts. All were divers in detail.

FIGURE 2. Combinations of formal elements determining the corporeality of structure.

Quality

The whole process of analysis was peer debriefed to ensure that the codes, categories and concepts fit the data. The results of analysis were member checked with all art therapists on two occasions; (1) after initial coding; no additions or changes were made and (2) after focused coding; the art therapists gave some refinements and elaborations that were incorporated into the analysis.

Results

Formal Elements

Initial coding showed that art therapists used a diverseness of words (codes) related to the formal elements of the art products. Focused coding clustered these codes into 7 categories (run into Tabular array one). The formal elements "move," "dynamic," "profile," and "repetition" were mentioned most frequently. "Mixture of colour," "color saturation" and "figuration" were only mentioned by the art therapists when the element was dominantly present or absent within the art production.

TABLE 1. Clarification and illustration of formal elements.

Structure and Variation

The fine art therapists stated that formal elements might enhance or weaken each other and that the combination determined the "structure" of the fine art product (meet Table 1). Structure varied between very high and very low structured.

Therapist 6: "I look for presence or absence of formal elements; which ones dominate? And how are they connected; the interplay determines the character of the art production."

Therapist 5: "The structure of the art production consists of the interconnectedness of several formal elements and is indicative for how stuck a person is, how much space there is for change and that influences treatment."

Focused and theoretical coding of all art products showed that highly structured art products consisted of the presence of "contour" and "repetition" (shown as "+" in Figure two) in combination with the absenteeism of "movement" and "dynamic" (shown as "-" in Figure 2). Absence of "mixture of color" and presence of "color saturation" enhanced the amount of structure. "Figuration" contributed sometimes to a highly structured product (e.chiliad., art product 3), at other times not (due east.g., art product 1).

Low structured art products consisted of the presence of "movement" and "dynamic" in combination with the absence of "contour" and "repetition." Low structure was further weakened past the presence of "mixture of color" and absenteeism of "figuration." "Color saturation" contributed sometimes to a low structured fine art production (east.chiliad., art product five), at other times not (east.g., art production 1 or ii).

The presence or absence of "movement," "dynamic," "contour" and "repetition" adamant the structure of the art product. These formal elements were mentioned most frequently. "Mixture of color," "figuration" and "color saturation" reinforced or weakened this construction. To indicate the conciseness of "move," "dynamic," "contour" and "repetition" in comparison with the other formal elements, the stardom between "primary" and "secondary" formal elements was introduced (see Figure 2).

How formal elements are combined and how strongly they are present appeared to determine the amount of structure fine art therapists perceived in the art product. The more ascendant a formal element was present or absent, the more than clear the structure of the art product was loftier or low.

The art therapists were in understanding about clearly structured art products. The dominant present or absent formal elements were consistently mentioned kickoff. The art therapists were less consistent near fine art products that were less clearly structured. It seemed as if the art therapists hesitated and needed more than fourth dimension describing the formal elements. This was for example the instance with art production half dozen (see Table 4) that showed high structure but was far less structured than art product 1:

Therapist 2: "Somehow the others [fine art products] are more than articulate to me, here nothing jumps out. Information technology is all the same, but the color is a fleck different, and nothing is placed in the foreground. Those flowers experience a bit foreign. It is non connected somehow."

Therapist v: "Information technology has something threatening, almost every bit if it comes rolling toward me. It is a mountain, but it rolls in my direction. Probably accidentally painted in this manner…sort of. I don't know…there are actually only 4 shapes with a cloud and some dots. Kind of duality, contradiction within the art product."

Also, clear high or low structured fine art products demonstrated less variation. Variation emerged every bit a core concept past clustering categories related to the diverseness within the art product (see Table one). Variation existed when a range of formal elements was present or when there was variety inside i or more than formal elements (e.g., diversity in movement past the presence of short and long, bended and straight lines). All therapists mentioned the amount of variation in each art product explicitly.

Therapist 8: Near art product 1: "There is footling variation; no mixing of colors, non playing with them, out of the bottle and more over he keeps them very separate. Lines are repetitive, no fluidity, absolutely boxed-off, rigid distinctions, no overlapping, juncture position of colors."

Mental Health

Anyone who expects that art therapists in these interviews used diagnostic terms such as depression and anxiety disorder in society to draw mental health volition be disappointed. Art therapists were exceptionally reserved in using these terms and did not explicitly relate art products to psychopathology. Yet, art therapists did consider the art product as an important basis for clients' mental state and consequently the possibilities and focus for treatment. Clients' possibilities were mentioned more explicitly than their mental problems.

Clients' Mental Land: Balance

The art products provided cues to the art therapists about the clients' inner world. They seemed to use an implicit conceptual model most the customer'southward rest. To describe this, they used a diversity of terms. Most of them were related to "feeling" or "idea" (see Tabular array 2).

Table 2. Categories of balance.

With regard to feeling, all therapists mentioned emotion regulation and nearly all therapists focused on the customer's potential to regulate emotions. Fine art therapists extracted cues nigh feelings and emotions from the art products. Sometimes they referred to positive emotions (happy, lively), more often to negative emotions (anger, sadness, fright). It was as if they scanned the art production for cues with regard to the content of the emotion likewise equally the intensity of expression. Art therapists differentiated between clients who tended to limited impulsively, i.due east., physical acted on feeling, and clients that tended to express emotional, i.e., allowing and experiencing feeling.

Therapists 5: "Well, hither [art product 4] information technology is nearly expressing feeling by using variation in colour and motility and it seems to be most a memory or a story, whereas here [art product 5] it seems to be just about expressing emotions in an impulsive, more physical manner."

Adjacent, fine art therapists used words that could be related to thought. This category included thoughts, cognitions and cognitive processes such every bit planning, organizing, analyzing and structuring. Art therapists did not refer to the content of the cognitions but generally to a continuum of cognitive control (run into Tabular array two).

Balance existed when allowing, experiencing and expressing emotions and cerebral control were in proportion to each other. Withal, many clients showed themselves to exist out of balance, either because of the high levels of emotion or considering of the loftier levels of cognitive control.

Adaptability: Toward More than Rest

Observation of a client's tendency toward either "thought" or "feeling" enabled the fine art therapists to proceeds a perspective on clients' actual residual. The art therapists stressed the importance to search for cues to judge the client'south potential ability to achieve balance. This was related to clients' "adjustability." Adaptability was clustered into four categories; "self-management," "flexibility," "openness," and "creativity" (see Tabular array 3).

Table 3. Categories of adaptability.

The combination of self-direction, flexibility, openness and creativity adamant clients' adaptability. Art therapists were less positive about the adaptability of clients who were observed equally struggling with being flexible, open, self-managed and artistic (see Table iv).

Tabular array 4. Fine art therapists' observation of the art products and mental health.

Therapist 7: "Persons that are willing in an unfamiliar situation, to put themself out, willing to acquire and make mistakes and learn course their mistakes shows me something about their prognosis in therapy. Being able to face up this job and accommodate, that tells me something virtually their ability to larn and accommodate in real life and that is a good prognosis."

Fine art therapists in this study agreed that gaining a perspective on the customer'south balance and the presence of adjustability gave direction to the formulation of handling goals (run into Table 4).

Therapist 2: "When someone over overregulates his emotions, tries to control them, treatment so is often focused on losing a flake of that control, beingness able to play, move and act and permit to feel. When someone under regulates his emotions, treatment is often focused on creating structure and calming downwardly."

Formal Elements and Mental Health

Through theoretical coding, relationships between formal elements and mental health were conceptualized in which the core concepts were related; structure was related to clients' remainder and variation was related to adaptability (come across Figure iii).

FIGURE iii. Formal elements in art therapy observation.

Structure and Balance

Based on the observed master and secondary formal elements, the extent to which they were present/absent-minded and in which combination, art therapists ascertained the structure of the art product on a continuum from high to low. The construction was related to clients' balance; based on i fine art product, art therapists were able to estimate the client's balance. Art therapists preferred to discover at least three art products to notice if each art products had similar amounts of structure over fourth dimension. If the structure of the art products did not modify over time, their initial estimation of clients' balance was confirmed. The art therapists assumed that art products with articulate high or low structure indicated that the client was more than out of residual. 3 full general patterns could be recognized; (1) highly structured art products were related to much "idea" and less "feeling", (two) low structured art products were related to more "feeling" and less "thought" and (iii) art products that alternated between high and low structure were related to much "thought" and much "feeling".

Variation and Adaptability

Art therapists observed the amount of variation of the art production, which they related to "adaptability". Variation was associated with experimentation, exploration, playfulness, taking risks, and discovery (see Table 1). These aspects were related to openness, self-management, flexibility and creativity; the categories of adaptability. Generally, more variation was related to more adaptability until a "turning point". This means that art therapists causeless an "optimum" amount of variation; absent-minded or limited variation too as over- presence of variation was related to express adjustability. Art therapists stressed their preference to observe at least iii art products to observe variation within art products over time. Art therapists assumed that art products with express or no variation over fourth dimension indicated less adaptability. Variation over several art products indicated openness, willingness to larn and adapt. If variation was present over different art products fine art therapists were more optimistic about clients' prognosis, as they associated adaptability with potential to alter in therapy.

Balance, Adjustability and Further Treatment

The aim of treatment was to restore or develop balance between "thought" and "feeling" and to raise adaptability. The art therapists in this study formulated the focus of treatment mainly on the estimated balance and potential adaptability. The focus of treatment directed the selection for fine art interventions. In general, the art therapists estimated that clients with a lot of cognitive command (i.due east., thought) might do good from more "affective" interventions, whereas clients with difficulties regulating their emotions might benefit from more "cognitive" interventions. Art therapists stressed the importance of the observation of clients' private position on the continuum of balance to choose the art interventions specific to the client'due south needs.

Art therapists establish clients' balance and adaptability indicative for handling elapsing and prognosis. They were more optimistic about the handling duration and prognosis of clients who were more than balanced and adaptive. Fine art therapists were alarm to clients lack of residuum and adjustability. They emphasized the importance of clients' capacity to bargain with alter; they stated that a clear lack of balance and adaptability might have a role in survival and daily functioning. Therefore, treatment might take longer and prognosis, i.due east., the expected amount of change, might be more limited.

Word

Based on art products made with acrylic paint and the instruction to either paint a landscape or create a painting without pedagogy, all the art therapists in this study focus on four primary (motility, dynamic, contour, and repetition) and iii secondary (mixture of color, figuration and color saturation) formal elements in art therapy ascertainment. This implies that the fine art therapists in this written report agree largely on the relevance of formal elements besides as their hierarchy. These seven formal elements bear witness some resemblance to formal elements incorporated in existing studies on formal elements in fine art therapy east.g., "mixture of color" is too incorporated in the DDS, "color saturation" resembles "color intensity" of the DAPA, and "figuration" tin can exist related to "color fit" of the FEATS. Some existing studies point out that individual elements mean naught unless considered every bit a cluster (Gantt, 2001) or use a "profile" related to specific disorders, such equally in the DDS. The findings of this report add to these studies by conceptualizing specific combinations of formal elements that construct the "structure" of the art product.

The art therapists in this written report use the formal elements to estimate how clients make their art product. This is in line with existing studies in which information technology is theorized that formal elements reveal how the customer makes the art product. Information technology is this relation between formal elements and the making process that could explicate why they provide data about clinically significant emotional and behavioral concerns of clients (Hinz, 2009; Conrad et al., 2011). In previous studies this was specified past the concept of material interaction (Pénzes et al., 2014, 2015).

With regard to the art therapists' perspective on mental wellness, results of this study evidence that art therapists practice estimate potential psychopathology. They rarely use symptoms or specific diagnoses used in DSM or ICD. Instead, they use concepts as balance and adaptability (i.e., cocky-management, openness, flexibility, and creativity). Emphasis on adaptability, i.e., resources and strengths, is in line with the perspective of positive wellness (Huber et al., 2016) in which health is defined every bit "the ability to adapt and self manage physical, emotional and social challenges in life." This perspective shows resemblance to the "recovery arroyo"(Anthony, 1993), which focuses on fulfilling, meaningful life beyond the limitations of illness or symptomatology and emphasizes the empowerment of clients' and their potential for alter and growth.

The fine art therapists' perspective on mental health certainly influences the way the formal elements are interpreted. Not relating the formal elements to symptoms and/or disorders, transcends whatsoever nomenclature and is in line with other perspectives on mental health such every bit those of Siegel (Siegel, 2010, 2012, 2017) and Cozolino (2017) who likewise stress the importance of integrating "thought" and "feeling" to achieve, restore or maintain mental wellness and well-operation.

If the art therapists notice clients existence out of balance - which is more than or less e'er the instance in wellness care situations- they actively start searching for the elements of variation. Variation is associated with making choices, play, experimentation and exploration of the fine art materials. This relates to what in the literature is referred to as 'material interaction' (Pénzes et al., 2014, 2015). Material interaction refers to the clients' dialog with art materials' properties. Variation is subsequently related to self-management, openness, flexibility and creativity, i.e., adaptability. Hinz (2009); Lusebrink (2010), and Bucciarelli (2011) also pointed out inventiveness might exist a sign of mental health, which emerged….however, they did not explore this further.

Residue and adaptability are conceptualized as ii separate concepts; out of rest indicates the severity of the bug, whilst adaptability indicates present or potential resources which allow alter in therapy. One might say that existence out of residuum refers to "mental-illness" and variation to "positive mental-health." However, the therapists in this study oft mention them together and point out that these concepts are closely interrelated, i.e., the severity of the problem and the potential resources of the customer are seen equally two sides of the same coin. This raises the question whether and to what degree balance and adaptability are independent, singled-out, concepts. Literature on this affair is divided. Some studies question the distinction between mental illness and mental health (adaptation) (Lukat et al., 2016; Van Erp Taalman Kip and Hutschemaekers, 2018). The vii formal elements that emerged in this study might enable art therapists to gain perspective on the strengths and resources as challenges of clients. The findings add together to studies that chronicle formal elements either to specific disorders or clients' strengths and recourses in fine art therapy observation and assessment. The use of formal elements in art therapy observation provides a broader perspective on the client as a person.

Critical Reflection and Implications for Practise and Future Research

This study conceptualizes three patterns of balance in combination with the variation in the art product. These patterns provide perspective on clients' strengths, resources and challenges. It may be of interest in future research to investigate if and how the formal elements may differentiate in the way they are present betwixt clients with various mental health bug." Due to the express number of art products included in this study, future research might include more art products to investigate if the same patterns emerge or if these patterns tin can be differentiated, specified or added.

Additionally, information technology may be useful to incorporate more than 1 art product of each client in future research to investigate if that leads to a more than precise and differentiated observation of variation and adaptability. Even though all therapists largely agreed on clients' variation and adaptability, they preferred more than i art product to guess the variation.

Art therapists of three nationalities participated in this study. They cannot represent current international perspectives on art therapy cess (Gilroy et al., 2012). However, they agreed on the formal elements and concepts of mental health. Findings of this report could be a valuable starting point to replicate the report in a broader international telescopic. Future research may address the potential of these concepts in contributing to the international current literature.

Existing studies on formal elements testify that the formal elements observed are likely to change in response to the given job and the art media used. One could question if other formal elements would have emerged in this report when fine art products were fabricated with a different task and art media. For case, the formal element "filled infinite" might have emerged when art products would take been fabricated on larger paper size, with smaller brushes and/or allowing more time.

Even so, the properties of acrylic paint, allow the observation of those formal elements which enable the art therapists to observe the structure and variation of the fine art product. The ability to discover the structure and variation related to the level of balance and adaptability may support fine art therapists to codify treatment goals to suit the private needs and potential and to choose those art interventions that raise or develop the client's balance and adaptability. Previous studies point out the therapeutic potential of diverse art material properties to accomplish a more "affective" or "cognitive" experience to enhance "thought" or "feeling" (Hinz, 2009; Hyland Moon, 2010; Snir and Regev, 2013; Pénzes et al., 2014). The therapeutic value of experiential interventions is pointed out in many recent studies (e.k., Cozolino, 2017; Porges and Flores, 2017). Hereafter research may address the use of art interventions to generate different melancholia or cognitive experiences.

Conclusion

Formal elements are frequently used in clinical do. In this study, we addressed two questions, namely which formal elements art therapists observe, and how they interpret them in terms of mental health. Findings add to the electric current torso of cognition. They evidence that the combination of seven formal elements construct the structure and variation of the art product and are indicative of clients' level of residual and adaptability. Fine art therapists in this study gain insight into clients' mental health through these concepts. This insight supports the art therapists in formulating treatment goals that suit the individual needs and potential and to choose those art interventions that improve the client's balance and adaptability.

Ethics Statement

With regard to ethics approval, this study was conducted in 2016 and an ethics approval was not required as per our Institution's guidelines and national regulations (Dutch "Law of medical research involving Human Subjects" ["Wet Medisch-wetenschappelijk Onderzoek (WMO)]."

The participants of this study consisted of art therapists, which were interviewed with regard to their professional method of observation of art products, their perspective on mental wellness and how they used the formal elements of the art production to gain insight in mental health. Prior to the interviews these art therapists were provided with written information with regard to the research aims and process. The interviews had elapsing of 1–1.5 h, in which the fine art therapists were interviewed on a familiar and professional topic. This research procedure was non considered equally a risk of bringing the art therapist any possible harm. Written informed consent was obtained from all therapists in accordance with the Proclamation of Helsinki.

With regard to the inclusion of the clients' art products, written informed consent was obtained from all clients in accord with the Declaration of Helsinki. Making art products with specific instructions as used in this study is common in clinical practice of art therapy and therefore considered as non harmful for clients.

Author Contributions

IP adult the enquiry design, conducted the inquiry, and start authored this commodity. SvH, DD, and GH supervised the evolution of the research design and enquiry procedure, and co-authored this article.

Conflict of Interest Statement

The authors declare that the enquiry was conducted in the absence of whatsoever commercial or financial relationships that could be construed every bit a potential conflict of interest.

Acknowledgments

The authors would like to acknowledge all involved therapists and clients and Dieuwertje Abeling-Boselie for peer-debriefing. This report is a part of a Ph.D. research project at KenVaK and the Radboud Academy.

Footnotes

1. ^ http://world wide web.kenvak.nl/en/

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Source: https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01611/full

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