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Group art activities and arts therapies for people using substances: A rapid review of the literature

Honorary Associate Professor, Institute of Mental Health, University of Nottingham

Theo Stickley initially trained as a nurse, his MA is in Counselling Studies and his PhD focused on participatory arts and mental health. He worked as a mental health rehabilitation nurse and as a counsellor and has over in the last twenty years concentrated on developing and researching arts and mental health practice; authoring over 100 articles and edited five books.

PhD student, Social Sciences, University of Nottingham

Collette Adams gained her BSc in psychology and her MSc in psychological research methods from Bangor University. She went on to train as a nurse by acquiring a Master of Nursing Science from the University of Nottingham, where she is now studying for a PhD. Collette also worked at Broadmoor Secure Hospital for six years as a staff nurse clinical team leader.

Background: Literature on the arts and their role in enabling recovery in individuals with mental health issues is fairly extensively researched and the valuable effectiveness documented. However, the influence of group arts activities and arts therapies and their role in enabling recovery of individuals who use substances is not widely researched, especially not outside of the arts therapies literature.

Objectives: This study reviews the academic literature relating to group arts activities and arts therapies and their role in enabling recovery of people who use substances.

Method: A rapid review methodology was used for the literature search using the PRISMA framework.

Findings: The discussion evaluates the evidence to support the use of group arts activities and arts therapies in the recovery of individuals who use substances. The majority of relevant literature relates to evaluation of arts therapies interventions. The effects of the use of music are most frequently reported within the relevant literature.

Conclusion: The article concludes that group arts activities and arts therapies have health and well-being benefits for individuals who use substances. The current evidence would benefit from further research in this area using larger sample sizes, with quantitative measures used, in addition to the qualitative methodology that has been used to date. Furthermore, follow-up studies are needed to assess whether the benefits are maintained.

Keywords: addiction, arts, activities, art therapies, groups, substance use, misuse

Introduction

The aim of this rapid review is to analyse the literature relating to participatory arts and cultural activities and the role of these in enabling recovery of people who use substances. In the course of this research, it quickly became apparent that the published evidence was minimal and mainly related to the arts therapies. The study was initiated to help inform the development of an ERASMUS (EU programme) funded Life-Long Learning programme called Art & Social Change (the research was not funded by ERASMUS). The study focuses on group arts and cultural activities amongst people in recovery from substance use and addictions, but with a specific interest in how arts activities may help people participating in groups, whether provided as art therapy or as arts-based activity. No limit was placed on the nature of these activities. For pragmatic reasons, a rapid review methodology was employed (Khangura, Konnyu, Cushman, Grimshaw & Moher, 2019) using a systematic approach.

It is acknowledged that there exists a difference between the arts therapies and arts-based activities implemented to promote health and healing. Usually, the latter are delivered by artists, not therapists. Historically, these two areas of practice have been positioned against one another, but in recent years there has been a focus on what the practices share; namely, using arts interventions to promote health, recovery and wellbeing. However, this article is not concerned with the different approaches, but does consider the literature where both group arts activities and arts therapies are used as part of recovering from substance misuse. Before we present the method and findings of this review, we offer a brief theoretical background to the study in order to provide an adequate context for the understanding of the findings and conclusion.

Background

Literature on the arts and their role in enabling recovery in individuals with mental health issues is widely researched and the valuable impact documented. However, the influence of group arts activities and their role in enabling the recovery of individuals who use substances is not widely researched, especially outside of the arts therapies field of practice. In a review of the literature more than 30 years ago, Moore (1983) recognised the benefits of art therapy for people using substances in allowing individuals to explore imagery, in order to symbolically represent their feelings and experiences as a means of gaining their own insight, as well as reducing distorted thinking by sharing ideas with the wider group. Other researchers have highlighted how the arts may help to promote emotional expression and exploration of these emotions in a safe and contained environment (Holt & Kaiser, 2009), as well as fostering spirituality, which can aid recovery by giving individuals a different identity and meaning to their lives (Feen-Calligan, 2007), which may also be achieved by engagement in the art alone (Johnson, 1990).

Horay (2006) identifies how art therapies for people who misuse substances largely fit into two theories: the 12-step model as proposed by Alcoholics Anonymous (Bill, 1939), and the stages of change model (Prochaska & DiClemente, 1982) which, in practice, utilises motivational interviewing techniques (DiClemente & Velasquez, 2002; Miller & Rollnick, 2002). Horay (2006) found that American studies on art therapy used to aid the recovery process in individuals who misuse substances predominately sat in line with the 12-step treatment model, whereas British literature on the same topic often fit more in line with the stages of change model. Thus, in order to aid understanding into how group arts activities can enable recovery amongst people that use substances, we briefly outline the key components of each model.

Prochaska and DiClemente (1982) suggest that for lasting change to be effective in any individual, they may go through five stages, which include pre-contemplation, contemplation, preparation, action and maintenance. Literature that likens art therapy to the stages of change model (SOC) suggests that during the pre-contemplation stage, little happens other than a collection of consequences and experiences of using substances. In the contemplation stage, the individual becomes aware of the consequences of their drug use and is considering change. During this stage, the arts may be used as a tool to raise awareness of the consequences of drug use, but also to bring the individual’s ambivalence about drug use to their consciousness and enable them to weigh up the pros and cons (Horay, 2006). The preparation stage involves supporting the individual to come up with a plan of change built upon their strengths while becoming aware of their weaknesses (Horay, 2006). The action stage puts the plan into action and the maintenance stage is about maintaining sobriety and engaging in arts activities that can play a role in reintegrating participants into the community. This may assist both in keeping their stories of being a wounded healer alive (Johnson, 1990) and also by providing an alternative ‘high’. Additionally, this may give the individual the means to explore an alternative identity that is not associated with drug use (Humphreys, 2000; Johnson, 1990; Zontou, 2012; Zontou, 2013).

Contrasting with this, the 12-step approach is a more confrontational method, closely associated with religious practice. The first step involves individuals’ acknowledgment of being powerless and of their drug use as unmanageable (Alcoholics Anonymous Publishing, 2003). This is somewhat similar to the SOC contemplation stage as it implies recognising that there is a problem. Steps two and three are about the individual connecting with a higher power, which involves recognising their true sense of self – that is, their strengths and weaknesses – which can be likened to the pre-contemplation stage of the SOC model wherein individuals also explore their strengths and weaknesses in preparation for change. Steps four to ten involve confronting the substance use and its impact on the individual’s own life and other people within their lives (Johnson, 1990). There is a religious element to these steps involving connecting with God, which is why some clinicians suggest that this model is not effective with individuals who consider themselves to be atheist (Spring, Smith & DaSilva, 2017). Step eleven connects to further developing their spirituality, and step twelve is about becoming healers for others, which draws similarities to the maintenance stage of the SOC model.

In an opinion paper by Johnson (1990), he highlights the benefits of group arts activities and their value in aiding people in recovery from substance misuse by providing an outlet to share the gift of the arts activity and as a way of conveying their insight and support to other individuals with similar issues as ‘wounded healers’. Research exploring group music therapy as a creative process in addition to a group addiction treatment programme for outpatients found that it aided not only the gelling of the group, but also communication and self-expression, which helps to promote the effectiveness of group work. Additionally, the researchers found that this helped participants gain an awareness of the denial stage of change, which is a key cornerstone of any addiction work (Treder-Wolff, 1990). A literature review from the 1980s (Moore, 1983), examined 20 studies of art therapy with people who abuse substances published between 1953 and 1982 and found that art productions provided a channel for the release of emotions as self-expression for the participants as well as allowing shared experiences.

Research by Cox and Price (1990) examines the use of ‘incident drawings’ in group sessions with adolescent substance abusers. Incident drawing is a specific technique where the participants are asked to draw specific trauma-causing events that have resulted from using substances. They observed that incident drawings provide a means for participants to link their inner experiences with an outer visualisation, providing an outlet for their emotions and a bridge for thoughts, feelings and emotions that had been supressed through substance misuse. This allows individuals to reawaken emotions and sensations that have been suppressed by drug use. As well as opening up dialogue with the therapists in a safe space, it allows the individuals to share what they are willing to share at their own pace.

Milliken (1990) suggests that substance users often have distorted sensations and an intolerance to coping with sensations, as these have been supressed by the substances for so long, so without the use of substances they may find these overwhelming. Dance and movement therapy allows participants to identify and name simple sensations, and research from case studies and observational work highlights that it helps the individuals re-establish links between physical sensations and their internal worlds, with the aim of reconnecting the two using verbal language (Milliken, 1990). In a study highlighting anecdotal evidence where dance therapy was used alongside a 28-day substance misuse programme for inpatients, Fisher (1990) suggests that the dance therapy helped participants to take the first steps in recognising that their drug use was out of control and that they were powerless, in line with the 12-step model for addiction recovery. Additional findings come from a study investigating the use of dance therapy with four alcohol-dependant women where the women’s articulation of the body concept rating scale were measured by a standardised test examining the individuals perception of shape, size of body parts, as well as identity and sex differentiation and level of detailing: The study found that three out of four individuals improved on these scores after 4 to 6 weeks of dance therapy, which was also found to be statistically significant using paired t-tests (Reiland, 1990). The study suggest that dance therapy can improve women’s articulation of the body concept rating scale as it aids their articulation, allowing the participants to relink words with sensations and experiences. Building on this brief overview of the background, the aim of the review is to analyse how engagement with group arts activities and arts therapies enable the recovery of people that use substances.

Method

A pragmatic approach to the literature search was adopted for two reasons; firstly, the study was implemented within a short time-scale to help inform the development of a programme of work, and secondly, it quickly became evident that there were few peer-reviewed research articles on the role of group arts and cultural activities in enabling recovery amongst people who use substances; of those studies published, the majority were on arts therapies. Thus, peer-reviewed literature in English for the period 2000 to May 2018 became the focus, and a rapid review approach was used (Khangura et al., 2012). Although, rapid reviews are not as comprehensive as systematic reviews, they do allow an analytic synthesis of the chosen topic so that valid conclusions can be identified (Lal & Aadair, 2014). The PRISMA framework (Preferred Reporting Items for Systematic Reviews and Meta-analysis) (Moher, Liberati, Tetzlaff & Altmann, 2009) was used to guide the searching and identification of articles for the review and to ensure that the methods used and the reporting was clear and understandable. This also provided the framework for a methodical approach to the study.

The keywords we used were as follows: addiction(s); arts; art therapy/ies; drugs; alcohol; substance misuse or use or abuse or dependency; recovery; mental health; cultural activities; participatory group arts or music or dance or theatre/drama or writing. These were applied to databases, including ASSIA, CINAHL, Embase, Google Scholar, Medline, OVID, PsycINFO, Web of Knowledge and Web of Science. Leading researchers in the field of arts and recovery of people who use substances were also contacted to request additional relevant research papers.

Strict inclusion criteria were not applied due to the lack of literature on the subject; all articles that were considered to make a contribution to the topic were included; both art therapies and arts-based activities and those employing a rigorous research design and those using observation and anecdotal methods. Articles on art therapy/ies were initially screened and included if the intervention involved group work rather than work with individuals. Regarding the population, the literature search included articles involving populations that use substances at all ages and at any stage of the recovery journey, including those still actively using substances. Articles included in this study are listed in Table 1.

Table 1. Included studies.

Citation of included studyStudy DesignData collection methodArt form
Albornoz (2011)QuantitativeQuestionnaires: Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression Music therapy
Baker et al. (2007)Qualitative questionnaire Self-report questionnaire CBT with Music therapy
Biley, F. (2006)Literature reviewLiterature reviewVarious
Cevasco et al. (2005)QuantitativeAnalysis of variance (ANOVA) questionnaire Music therapy
Dickson, C. (2007)QualitativeAnecdotal evidence from patientsArt therapy
Dingle et al. (2008)QuantitativeSurvey questionnaire Music therapy
Feen-Calligan, H. (2007)QualitativeThe art therapist’s observationsArts therapy
Hanes, M. (2007)Qualitative: case studyAnecdotal evidence from two case studiesSelf portrait
Hohman et al. (2017)Systematic reviewSystematic reviewMusic therapy and music interventions
Holt, E., & Kaiser, D. (2009)QualitativeObservationArt therapy
Hong, R., Guo, S., Huang, C., & Yin, C. (2017)Mixed methodsQuestionnaires and interviewsArt therapy
Humphreys, K. (2000)QualitativeSecondary, narrative data analysisCommunity and personal narrative
Jaaniste, J. (2008)Qualitative and service evaluationSubstance Abuse Treatment ScaleDramatherapy
Kirane (2008)DescriptiveObservations of practiceDance therapy
Klingemann, J. & Klingemann, H. (2016)QualitativeAnalysis of drawingsFree drawing
Megranahan, K., & Lynskey, M. (2018)Systematic reviewSecondary analysis of dataMusic therapy
Newman, T. (2017)Qualitative: case studyObservation and Anecdotal evidenceDrama therapy
Reynolds, J. (2017)QualitativeAnecdotal evidenceTheatre
Roy, A., & Manley, J. (2017)QualitativeAnecdotal evidenceDance and movement workshops
Silverman, M. (2011)Randomised Control Trial (RCT)Analysis of data from psychometric toolsMusic therapy/song writing
Silverman, M. (2012)RCTThematic analysis of lyricsA single song writing session
Silverman, M. (2015)RCTAnalysis of standardised tools to assess triggers and coping skillsEducational music therapy
Silverman, M. (2016a)RCTBrief Substance Craving Scale self-reporting toolLyric analysis/song
Silverman, M. (2016b)RCTAnalysis of standardised tools to assess working alliance and trustEducational and recreational music
Skeffington, P., & Browne, M (2014)Qualitative: case studyObservation from a single case studyArt therapy
Spring, L., Smith, M., & DaSilva, M. (2017)Qualitative: case studyPeer group discussionsFine art/ visual Thinking
Zontou, Z. (2012)QualitativeAnecdotal evidenceApplied theatre
Zontou, Z. (2013)QualitativeAnecdotal evidenceApplied theatre

Findings

Key details of the articles included in the rapid literature review are summarised to assist in understanding what comprises the evidence base. From the initial search of 151 articles, forty-three articles were identified as having the potential subjects covered to be included in the literature review; however, 10 articles were removed as they were outside of the 18-year time frame, and 11 further articles were removed as they did not fit the inclusion criteria – for example, book reviews and e-debates. The remaining literature included in the study was largely from the USA, followed closely by the UK, with some studies in other countries including Australia, Taiwan, Poland, Switzerland, Greece and Canada. In total, 28 articles were selected for this review.

Discussion

From reviewing the literature it would appear that participation in group arts has positive outcomes on the recovery pathways of people who misuse substances. There is convergent support from both qualitative (Biley, 2006; Dickson, 2007; Feen-Calligan, 2007; Hanes, 2007; Holt & Kaiser, 2009; Hong, Guo, Huang & Yin, 2017; Humphreys, 2000; Jaaniste, 2008; Klingemann & Klingemann, 2016; Newman, 2017; Reynolds, 2017; Roy and Manley, 2017; Skeffington & Browne, 2014; Spring, Smith & DaSilva, 2017; Zontou, 2012, 2013) and quantitative studies (Hong, Guo, Huang & Yin, 2017; Megranahan & Lynskey, 2018; Silverman, 2011; 2012; 2015; 2016ab). However, research into this area is still emerging and there is substantial room for further research involving larger sample sizes. The quantitative research often suggests positive outcomes; however, these are often not statistically significant (Silverman, 2011; 2016b). This may prove more fruitful with larger sample sizes; however, Roy and Manley (2017) suggest that group arts have benefits to the clients that are not measurable or quantifiable, and which are best explored though the rich depths of qualitative research. The remainder of the discussion is organised into different arts activities and approaches reported in the literature.

Guided gallery visits

This is an area of study that by and large has not been explored using populations that misuse substances. The literature review revealed only one study using guided-art gallery visits, in Canada. Spring, Smith and DaSilva (2017) reflect on their experiences of offering ‘Art tours’ for women with mental illness and comorbid substance misuse over the past seven years. They highlight the importance of care in the community rather than in clinical environments as this promotes social inclusion, assisting them in practising their skills in everyday environments. Additionally, individuals may be reluctant to talk openly in clinical environments for fear of what the therapist documents and of being analysed. They suggest that growth and change is stimulated by exploring what is going on in pictures and what makes us think that. The sessions are facilitated by a guide and include peer group discussions with the aim of empowering individuals to use art as a tool for interpreting the world around them and improve communication skills.

Dance and movement

A study on dance and movement by Roy and Manley (2017), who carried out two group sessions of dance and movement with people in recovery from substance misuse in the UK, used a visualisation and association method to allow participants to emotionally express their experiences of recovery, rather than verbalising the experience. Looking at their anecdotal evidence, they found that these sessions aided the building of therapeutic relationships, companionship and bonding, rather than other quantifiable targets and goals that previous addiction research has attempted to measure (Roy & Manley, 2017). The research mentions the 12-step model; however, it highlights that life is more impulsive and is a journey, unlike the defined phases of the twelve steps. In this way, the approach may fit more in line with the SOC model. Set in the USA, Kirane (2018) identifies the role of dance and movement in inpatient psychiatric units in response to what they refer to as ‘our nation’s opioid epidemic’ (p.12). Kirane (2018) illustrates how dance and movement may enhance engagement with treatment regimes and promote discussion about addictive behaviours, and may also ‘contribute to the healing of the nation’s opioid crisis’ (p.16).

Applied theatre / Drama therapy

In a qualitative study using drama therapy with five people at various stages of recovery from drug and alcohol addiction in Australia, Jaaniste (2008) studied patients’ opinions of their experience both before and after engagement in 11 sessions of group drama therapy. They found that after their 11th session, participants had achieved over 50% of their expectations; however, standardised measures for abstinence found little variance pre- and post-test, and also the use of statistical tests would have been heavily disadvantaged by the small sample size and the fact that they were at different stages of recovery. As much of the literature discussed suggests different arts may be more appropriate for different stages of change. Zontou (2012; 2013) suggests that drama can be useful in helping ‘recoverists’ to keep their stories alive, thus assisting them to maintain sobriety; participation in arts groups on the other hand, may be more helpful in raising awareness in people in the ambivalent or denial stages of change by supporting participants to increase their awareness and motivation of the need for change (Holt & Kaiser, 2009).

Reynolds (2017) examined anecdotal evidence from the experience of using theatre to aid the recovery process with people who use substances in the UK. He suggests that theatre can assist those who are beyond the denial stage of change to reclaim their identity so that they can shed the stigma and role of a substance user (Reynolds, 2017). Newman (2017) reports upon a case study of two individuals who accessed drama therapy after active addiction. The study points out that the additional support offered by drama therapy and the safe space it provides assists addicts in re-creating their identities (Newman, 2017).

In a UK study exploring anecdotal evidence of using applied theatre as part of a wider treatment programme for adults with addiction, Zontou (2012) suggests that it provides an ‘escape’ from their current communities of exclusion, allowing them breathing space so that they can gain motivation towards social reintegration. In a later study by the same author about ‘recoverists’ who had been clean from drug consumption for a minimum of 10 months, Zontou explored anecdotal evidence from engagement with applied theatre and found that it helps maintain sobriety by keeping their stories alive. Additionally, it helps to challenge the social stereotypes and misconceptions of addiction in audiences (Zontou, 2013). In much the same way, Alcoholics Anonymous’s ‘The Big Book’ and their community groups claim to keep past stories and experiences alive. This also enables a sense of shared experiences and hope for newcomers to the group (Humphreys, 2000).

Music and music therapy

The literature on the therapeutic use of music and substance misuse in this review found five American quantitative studies (Megranahan & Lynskey, 2018; Silverman, 2011; 2012; 2015; 2016ab). However, four of these studies are all from the same researcher and the additional study (Megranahan & Lynskey, 2018) is a systematic review involving the five studies. Although not all of the studies make overt reference to the underpinning models used, some of Silverman’s papers liken music therapy to the SOC model. The key findings show that there were no significant differences between the music and verbal therapy groups outcomes; however, the music therapy group had slightly higher scores for change and slightly lower scores for depression (Silverman, 2011). The music therapy group had higher perceptions of helpfulness, enjoyment and comfort in comparison to the control group; however, only the significant differences of increased enjoyment in the music therapy group were maintained at one month follow-up post-treatment (Silverman, 2011). A limitation of the study is that it only measured variables post-test, which gives no indication of whether the variables were affected by the intervention.

In another study (Silverman, 2015), groups were exposed to either educational music therapy, education without music or recreational music therapy and researchers measured their knowledge of triggers and coping, motivation and treatment eagerness, both pre- and post-intervention. The study showed no significant differences between the groups, but found that all groups had significant increases of motivation and treatment eagerness after the interventions. Additionally, the educational music therapy group showed significant greater motivation in comparison to the other two conditions (Silverman, 2015). In a study investigating group song writing and its effects on motivation and readiness for treatment in patients in a detoxification unit, Silverman (2012) found that the participants in the song-writing group showed significantly higher means for motivation and readiness than those on the waiting list control group. However, this could be because of an inflation of the intervention effects by reason of comparison with a waiting-list group (Cunningham, Kypri & McCambridge, 2013). Hence, further research comparing song writing to other interventions would be helpful in ascertaining the benefits to participants’ motivation and readiness for treatment.

Silverman (2016a) reports the effects of music therapy on the experience of cravings, finding that music therapy was able to distract from cravings. However, this study again has the limitation of using the tool only post-test, so it is difficult to ascertain whether there was any impact on the measures after participation; additionally, a waiting-list control group was used. Silverman (2016b) studied the effects of music therapy on trust and alliance with patients in a detoxification unit. However, no statistical differences were found. This may mean that there is little difference in how music is used in adjunct to the substance misuse treatment programme; however, further research using the standardised tests both pre- and post-test would help to clarify this. Silverman (2016a) further studied the impact of a single group session of lyricists’ analysis on withdrawal and cravings of individuals in an inpatient treatment unit for detoxification, and found that music therapy acted as a distraction from withdrawal and cravings. Megranahan and Lynskey’s (2018) systematic review clearly reflects the previous findings, showing a strong positive effect for the role of music therapy in enhancing contemplation, treatment readiness, motivation, as well as highlighting its role in reducing cravings (Megranahan & Lynskey, 2018). In a randomised study by Albornoz (2011), the effect of group improvisational music therapy on depression in adolescents and adults with substance abuse was investigated. Of twenty-four Spanish-speaking patients receiving treatment for substance abuse, an experimental group received 12 group improvisation sessions over a three-month period. Results showed that both groups were equally matched on all pre-test measures. The intervention group, however, was significantly less depressed after treatment than the control group and the author asserts that improvisational music therapy had a clinically significant effect. In a systematic review of music therapy for patients with substance use disorders, Hohmann et al. (2017) state, however, that there is no consensus regarding the effects of music therapy and music-based interventions for this client group.

Groups using a cognitive behavioural approach

In the wider mental health literature, there is evidence of the effectiveness of group approaches for Cognitive Behavioural Therapy (CBT) and there are examples of this approach being combined with arts activities specifically for people using substances. For example, Dingle, Gleadhill and Baker (2008) describe a seven-week trial of music therapy as a group cognitive behaviour therapy with the aim of increasing patient engagement in a private hospital open group programme. Twenty-four surveys were analysed, showing that music therapy was able to engage patients regardless of their age group or substance (alcohol only vs. other drugs) and the study asserts that “Music therapy is a promising approach to improving engagement in substance abuse treatment groups” (p.190). Baker et al. (2007) make similar claims in their paper based upon the same study.

Group art therapy

All included groups art therapy studies used qualitative outcome measures, with one study also investigating quantitative outcome measures. All the studies gave participants a means by which to share and explore their experiences (Biley, 2006; Dickson, 2007; Feen-Calligan, 2007; Hanes, 2007; Holt & Kaiser, 2009; Skeffington & Browne, 2014; Hong, Guo, Huang & Yin, 2017). Some studies highlight how the role of group art therapy can help individuals become aware of their addictions (Feen-Calligan, 2007; Hanes, 2007) as well as recognising ambivalence, which is necessary in order to fully assess the pros and cons of drug use prior to effecting any changes (Holt & Kaiser, 2009; Hong, Guo, Huang & Yin, 2017). Other studies explored challenging social stigma, which can be a barrier to change (Biley, 2006), since ‘problems with living’ require solutions in the community (Spring, Smith & DaSilva, 2017). It was found that group art therapy also provided a distraction from substance misuse and helped individuals to concentrate better (Hong, Guo, Huang & Yin, 2017). One study highlighted how group art therapy safely contained an individual’s emotions, allowing exploration; this was particularly notable since the individual had a history of traumatic experiences, and talking therapies failed (Skeffington & Browne, 2014). The final study highlighted the benefits of using art as an assessment tool where individuals are on their recovery pathway, supporting the therapist in which strategies to apply in order to get the greatest impact on their willingness to work towards lasting change (Klingemann & Klingemann, 2016).

Models underpinning participatory arts groups

Looking at the models underpinning the studies covered in this review, unlike Horay’s (2006) previous research, it would appear that the affiliation to either model is no longer determined by country. Four studies conducted in the USA were associated with the stages of change model (Silverman, 2011; 2012; 2016a; Holt & Kaiser, 2009), although three of these studies were from the same author (Silverman, 2011; 2012; 2016a). Four studies suggest their approaches fit more closely with the 12-step model of addiction recovery (Dickson, 2007; Feen-Calligan, 2007; Humphreys, 2000; Newman, 2017); one of these studies was carried out in the UK (Newman, 2017) with three in the USA (Dickson, 2007; Feen-Calligan, 2007; Humphreys, 2000). Although the 12-step model is thought to be more confrontational and entwined with religion, there is some overlap between the 12-step model and the SOC model; for example, both of the initial stages involve overcoming denial, and exploring the individual’s strengths and weaknesses in preparation for change, and the final steps may involve roles as the expert-patient or ‘wounded healer’, which play a role in the maintenance of abstinence. Interpreting the models may more loosely assist their effectiveness across the wider population of substance users. In addition, looking for common themes in both models have help to identify the active ingredients of long-lasting change.

Conclusion

The rapid review of the literature on using group arts activities and arts therapies suggests that the creation of something, being part of a group, and the building up of a trusting therapeutic relationship is more important than the specific art. An important aspect appears to be the opportunity for discussion about what has been produced and using this as a platform to re-awaken feelings and sensations that have been suppressed over the years by substances. The literature shows that this is particularly useful in assessing where an individual is in their stage of change – for example, pre-contemplation, contemplation, etc. Engaging the individual in discussions regarding the artwork opens up an opportunity to discuss ambivalence towards change and allows the individual to engage in honest reflections on their behaviours. This opportunity may be inaccessible through talking therapies, especially in complex cases where the substance misuse began in adolescence when personal identities have not been fully formed. This may also be the case when an individual’s difficulties are further complicated by past trauma, or in participants who are unwilling to acknowledge that their behaviour is harmful to them and others, or for those who are particularly skilled in avoidance and distraction techniques. The group art activities and arts therapies offer a different route to accessing supressed feelings in a way that is less threatening than using talking therapies. Using the arts allows the facilitator and participants to access their feelings and stories for processing, by the creation, production or co-production of something, and people can disclose at their own pace. Furthermore, participants may have a sense of control, and they can be supported by the facilitator and the wider group to find the words to their story.

In this study, we have not attempted to compare the effectiveness of the various arts approaches. However, an important aspect that has been highlighted throughout this literature review suggests a paradigm shift in treatment approaches being that ‘recovery happens only in community’ (Shay, 2014, p. 288). This is also recognised more widely in the treatment of mental health issues and includes the importance of addressing stigma and social exclusion, as well as finding creative ways to reintegrate people back into the community. Findings from the current literature, shows that there is room for further research in this area, particularly from longitudinal research with larger sample sizes as well as a continuance of in-depth qualitative studies. An increase in narrative methods may help in-depth understanding of individuals’ personal processes of recovery and how arts and cultural activities may help in the future.

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