Art Therapy for Schizophrenia: The Evidence and Realistic Expectations

What can art therapy for schizophrenia offer, and what can't it? Read about the limits of research, how it can accompany treatment and the family's role.

A mother whose son was diagnosed with schizophrenia a few years ago comes across a video online titled "healing through painting". A flicker of hope stirs in her: her son loved drawing as a child, so perhaps this would do him good. But she also has questions: can this replace his medication? Is it suitable for everyone? Does it really work? Art therapy for schizophrenia is a topic families often wonder about, but it is also one around which exaggerated and unrealistic information circulates. In this article we look at what creative work can offer people diagnosed with schizophrenia, what research can and cannot tell us today, and information that will help families build realistic expectations.

A Brief Framework for Schizophrenia and Its Treatment

Schizophrenia is a serious but treatable mental illness that affects the way a person thinks, perceives, experiences emotions and behaves. Alongside symptoms such as hearing voices or seeing things that are not really there, firm beliefs that others do not share, and disorganised thinking and speech, there may also be symptoms such as lack of motivation, emotional flatness and withdrawal from social life.

The foundation of schizophrenia treatment is assessment by a psychiatrist and regular medical treatment. This is accompanied by psychosocial support such as psychoeducation, family support, psychotherapy, social skills work and vocational rehabilitation. The first thing to know, therefore, is this: art, music or drama-based work does not replace treatment in schizophrenia; but for some people, it can be a supportive part of this whole.

If you are wondering how the roles of a psychiatrist and a psychologist differ, take a look at our article on the difference between a psychologist and a psychiatrist.

Creative work does not make schizophrenia go away; but it can help a person living in the illness's shadow remember that they have a voice of their own.

What Can Art Therapy for Schizophrenia Offer?

The general logic of art-based work is that feelings and experiences can be expressed through image, colour and materials before words. We have explained the basic principles of this approach in detail in our article what is art therapy. When it comes to people diagnosed with schizophrenia, it is thought that this work may contribute in the following areas:

• A space for non-verbal expression: For someone who finds it hard to put their thoughts into words in an orderly way, drawing, collage or clay can be another way of expressing themselves.
• Structure and routine: An activity carried out at regular intervals can give a framework to the flow of the day. On days spent at home for long stretches, inactive, this small structure is valuable.
• Social contact: Work carried out in groups can offer people who have withdrawn from social life the chance to be in the same space as others without feeling pressured.
• Making something: During illness, a person is often seen only as a "patient". Producing something can help the person remember their abilities and other aspects of their identity.
• Enjoyment and interest: The lack of motivation and inability to enjoy things that the illness brings makes daily life harder. An enjoyable activity can create a moment of interest and liveliness, however small.

Each of these contributions should be described with words such as "may" and "is thought to"; because, as we will see below, research findings that strongly support them are still limited.

Group or individual work?

Creative work for people diagnosed with schizophrenia is often carried out in groups, within hospitals, day hospitals or community-based services. A group setting offers opportunities for social contact; however, crowds, noise or other people's gaze can make some people uneasy. Especially where suspiciousness or anxiety is prominent, small, calm groups or more structured activities may be more suitable. Which format suits a person should be assessed together with the treatment team according to their condition and preferences at that time. The person's own wishes are decisive here; an activity someone is forced to attend can create more tension than benefit.

What Does Research on Art Therapy for Schizophrenia Say?

This is the question families most want answered, and it should be answered honestly: the research carried out in this area is limited in number and is not sufficient to draw firm conclusions.

A significant proportion of comprehensive reviews on creative therapies have focused on mental health problems other than psychosis. For example, a comprehensive health technology assessment published in 2015, which examined the effect of art therapy in adults, specifically limited its scope to non-psychotic problems. In other words, it would not be right to generalise positive findings from this field directly to schizophrenia.

In a closely related area, a Cochrane review of drama therapy (2007) reported that the reporting of studies was inadequate and that no conclusion could be reached about benefit or harm. We discuss the general framework of drama-based work separately in our article what is drama therapy.

The common limitations of research in this area are:

• Participant numbers are generally small.
• Blinding is not possible because participants know what they are taking part in.
• Measurements often rely on self-report.
• Follow-up periods are short.
• "Therapy" and general "art activity" are sometimes mixed up in studies.

What this means in practice is this: if a relative diagnosed with schizophrenia enjoys an art workshop or a creative group, that is a valuable experience and can be supported. However, any expectation that this work will reduce symptoms, prevent hospital admissions or take the place of treatment is not supported by current knowledge.

Realistic Expectations: What Might Happen and What Won't?

To avoid disappointment for families and for people diagnosed with schizophrenia, it is important to clarify expectations from the outset.

What might happen:

• By taking part in a regular activity, the person may give their week some structure.
• Spending time with others in a group may ease feelings of loneliness a little.
• The person may find a new way of expressing themselves and enjoy it.
• The work produced may create a topic of conversation between the family and the person that has nothing to do with the illness.

What should not be expected:

• Art work taking the place of medication or psychiatric follow-up
• Voices, suspicions or other symptoms disappearing through this work
• Every person benefiting from this kind of work to the same degree

One warning also needs to be stated clearly: some online content or commercial programmes may claim to cure schizophrenia "without medication" or through art, music or particular sounds alone. These claims are not supported by evidence, and stopping treatment can lead to serious deterioration. Every decision about treatment should be made together with the psychiatrist.

What making things can mean in the face of stigma

Schizophrenia is perhaps one of the most misunderstood mental illnesses in society. People who receive the diagnosis are often defined only by their symptoms and labelled as "dangerous" or "incomprehensible". This stigma makes it harder for a person to find work, make friends and believe in themselves. Creative work can remind the person and those around them that they are more than a diagnosis. Some people may feel proud to share their work in an exhibition. But this decision should always belong to the person themselves; displaying their work as "patients' pictures" or sharing it without permission can increase stigma rather than reduce it.

Can Symptoms Be Read from Drawings?

Pictures made by people diagnosed with schizophrenia can sometimes look unusual, intense or disturbing. Families may look at these pictures and worry, "Is the illness getting worse?" Yet no reliable conclusion about a person's mental state, the severity of their symptoms or the course of their illness can be drawn from a single picture.

Evaluations of projective drawing tests show that the evidence for the validity of tools such as human figure drawings is very limited. The content of a picture is influenced by the person's mood that day, the materials they used, their interests and many other factors. A picture is not an assessment tool, but a way of starting a conversation.

For this reason, it is more helpful to approach your relative's work with curiosity rather than reading meaning into it: "What were you thinking about while you made this?", "Why did you choose these colours?" It is also important not to insist if the person doesn't want to talk about it. The work belongs to the person; it should not be shown to others or shared on social media without their permission.

On the other hand, if you notice marked changes in behaviour, sleep, self-care or speech, it is important to share these observations with the doctor, independently of any pictures.

Ways Families Can Offer Support at Home

Families living with a relative diagnosed with schizophrenia often don't know how they can help. Creative activities can be one of the small ways of offering support at home without creating pressure.

• Make materials accessible: Keeping paper, paints or clay on the corner of a table serves as an invitation the person can take up whenever they want. Rather than saying "Come on, draw something", simply leaving the materials there is enough.
• Do it together: Draw, paint or make something yourself too. Creating quietly side by side can be less demanding than talking face to face.
• Value the effort, not the product: Instead of "That's beautiful", a sentence such as "You worked on that for a long time, it's good to see" recognises the person's effort.
• Look into outside resources: In Turkey, various occupational and social activities may be available at community mental health centres (TRSM), some municipalities and voluntary organisations. It is helpful to talk about these options with the doctor or treatment team.
• Make room for yourself too: The rest, social life and mental health of family members who provide care also matter.
• Ask about their preferences: Not everyone enjoys drawing. Some prefer listening to music, some taking photographs, some gardening or handicrafts. Asking your relative what they enjoy and respecting their choice makes the activity meaningful for them.

Let's say a father, during periods when he finds it hard to talk to his son, starts painting birdhouses with him on the balcony on Sunday mornings, as they used to do together. Their conversations are not long; sometimes they don't talk at all. But this hour becomes a time they both look forward to. It doesn't change his son's illness; but it helps them preserve the bond between them and remember that, beyond the illness, they also share a common world.

When Is Urgent or Additional Support Needed?

In the course of schizophrenia, some situations call for professional support without delay:

• If the person has stopped taking their medication or is taking it irregularly
• If voices, suspicions or fears have increased markedly
• If sleep patterns have broken down, or the person has stopped eating or looking after themselves
• If the person talks about harming themselves or others, or behaviour pointing in this direction is seen

If you think there is a risk of harm to the person or to others, do not wait; call 112 (emergency services) in an emergency.

While things are calm, it also helps to prepare a simple crisis plan together with the treatment team. This plan can include the early warning signs seen in previous episodes, such as disrupted sleep, withdrawal or getting stuck on particular topics, whom to contact and how, the nearest health facility and the person's own preferences. Preparing the plan together with the person themselves ensures that their voice is also heard at a difficult time.

Family members may also need support during treatment. Living with a relative diagnosed with schizophrenia can bring feelings of anxiety, guilt, grief and burnout. Individual therapy can help family members cope with these feelings, learn to set boundaries and make room for their own lives too. Structured approaches such as cognitive behavioural therapy (CBT) can be used to address the carer's difficult thoughts and stress. Psychosocial support for the person diagnosed with schizophrenia should be planned together with the treatment team.

Frequently Asked Questions

Can art therapy be used instead of medication for schizophrenia?

No. The foundation of schizophrenia treatment is assessment by a psychiatrist and regular medical treatment. At most, art-based work can be a supportive activity that accompanies this treatment. Any change to treatment should be decided together with the doctor.

My relative draws very intense and dark things. Is this dangerous?

The content of a picture is not on its own a sign of danger, and no reliable conclusion can be drawn from it. However, if alongside the pictures there are marked changes in behaviour, sleep or speech, it is important to share this with the treatment team.

Can someone diagnosed with schizophrenia join an art workshop?

If the person's condition is stable and they want to, many people can enjoy art workshops. Before joining, it is helpful to talk to the treatment team and assess whether the workshop setting suits the person.

Can creative work be done during a crisis?

In the acute phase, the priorities are the person's safety and their medical treatment. Creative work usually comes up when the situation is more stable, on the recommendation of the treatment team. The most valuable thing you can do as a family during this period is to provide a calm environment and support the continuation of treatment.

• #schizophrenia
• #art therapy
• #psychosocial support
• #family carer

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Eda Erkan Alapala

Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.

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