Child art psychotherapy (CAP) is a form of psychotherapy that uses the medium of art, which can be helpful to children and young people in communicating difficult issues verbally. It is an effective short-term, early intervention, treating young people experiencing mild to moderate mental health issues.

Little has been published on the role and value of child art psychotherapy in primary care in Ireland. Many GPs are unaware of the profession and its success as a treatment, since CAP is often grouped under the umbrella of ‘psychological therapies’. It is generally thought that art, as a form of expression, encourages resilience, personal growth and emotional development in young people.¹

Early intervention and developmentally appropriate supports are critical in promoting the long-term health and well-being of children and adolescents experiencing psychological difficulties.^2,3 Easy access to these supports is vital, particularly when treating mental health difficulties, where delay and long waiting lists can prohibit early recovery.⁴ Timely access is not always possible, coupled with the lack of development in primary care, and has necessitated secondary referrals.

GPs have identified a greater need for short-term, focused counselling services to meet the needs of young people in their communities, and are increasingly collaborating with psychological services.⁵ This approach is regarded as best practice and is internationally supported.⁶

Through our experience of implementing the CAP method with young people presenting with mental health issues to CAMHS (Child and Adolescent Mental Health Services) and in private practice, we propose that some cases with early presentation of emotional behaviour disorders could be treated within primary care, if access to child art psychotherapists is available. Currently, CAP is delivered through private practice, schools, in many CAMHS teams, and as a pilot with TUSLA, the state’s Child and Family Agency. It is also offered in a day hospital and inpatient unit.

The model of child art psychotherapy 

The CAP method devised by the art therapist Vera Vasarhelyi has been developing over the past 30 years and provides a way of communication that is uniquely appropriate for children and adolescents.⁷ 

It is a form of psychotherapy that uses the medium of art to facilitate children and young people to communicate difficult issues verbally in a safe, non-judgemental environment. Through the process of image-making, it allows children to express and explore their inner world in new ways which can help them come to terms with difficult feelings, in the presence of a trusted and trained professional.

This can result in positive behavioural change, improving physical, mental and emotional well-being. This form of therapy can be helpful to a range of many mild, moderate and severe mental health related problems including; attachment disorders, self-harm, anxiety issues, suicidal ideation, psychosomatic problems and trauma issues.⁸ It is especially beneficial if treated early before behaviours and symptoms escalate, requiring secondary or tertiary care.⁶

The CAP method follows existing principles of adult psychotherapy in terms of boundaries, confidentiality, predictability and reliability of both therapist and sessions. However, it introduces several key aspects: 

• Three semi-structured assessment sessions

• The development of a pictorial language which is unique to the child and interpreted by them

• The formulation of the image created as a snapshot of the inner unconscious world

• The provision of a safe space where the child can engage without the immediate presence of the therapist. 

It differs from other psychological therapies in that it is a three-way process between the client, therapist and image. This positive therapeutic alliance can act as a catalyst in tapping into the well of resilience that lies dormant in the child.⁹

Sessions are approximately an hour long and delivered weekly in a dedicated art room where the child or young person is invited to make an image. The therapist withdraws to allow the child to create freely and on completion the therapist and child talk about the image. The role of the therapist is to facilitate the child in finding their own meaning, and support them in resolving their own difficulties, thereby enhancing self-esteem and autonomy.

Confidentiality is paramount between the child and therapist. Prior to the sessions, the child’s parent or guardian is informed about the boundaries and importance of confidentiality to ensure that the welfare of the child is central. Where disclosure occurs, the child is informed by the therapist that this information is given to the relevant people for the child’s protection. 

The CAP process begins with the three semi-structured assessment sessions: a self-portrait; a family portrait or depiction of significant people in their life; and finally their earliest memory. The latter can reveal the source of the current presenting issue.^10,11 Subsequent sessions are non-directive where the theme is decided by the child. 

In the CAP method, the three assessment sessions are crucial as they empower the individual to explore deep-seated feelings safely through the visual medium from the very beginning of the therapeutic process, which can lead to early resolution of behaviour and symptoms in some cases. As Vasarhelyi states, “internal changes are always the first ones to occur,”¹¹ suggesting that CAP may be an effective short-term therapy for some children. 

Short-term therapy or brief therapy refers to any therapy that is tailored between six and 10 sessions.¹² Proposing a time-limited intervention for mild or emerging mental health problems, the treatment plan is always discussed with all participants including the child at the introductory meeting.

After the assessment sessions, the parents/guardian, child and therapist collaborate to review progress and discuss continuing treatment or plan discharge. The length of treatment varies depending on symptoms, attitude and supportive environment. Not all children and adolescents respond in the same way or require the same level of intervention. Each has their own history and may present differently. Their wish to end therapy at any stage must be respected, a central tenet of CAP, which is child-centred and child led.

Evidence

Art psychotherapy as an effective intervention in treating stress and levels of depression in adults has been well documented.^13,14,15 A recent study examining creative counselling and GP practice found that adult patients responded positively to short-term therapy.¹⁶ The substantive evidence for short-term and creative therapies is currently based on adults; however, there is a growing body of studies showing positive results in short-term engagement with children and young people.^17,18

The more creative child-friendly approaches such as play therapy, art therapy and art psychotherapy have in some cases been successfully offered as short-term interventions. This applies particularly for adolescents, who may prefer shorter interactions with the therapy.¹²

Internationally, many studies confirm the positive impact of art psychotherapy among children coping with trauma and somatic issues, as well as some autistic spectrum disorders.^9,19

Discussion

Advocating for the availability of CAP as an early intervention is challenging in an environment where primary care services are underdeveloped and where CAP as a profession is not widely known. Each year secondary services receive thousands of referrals from GPs, a very high proportion of which include depression and anxiety disorders.²⁰

Studies have shown that early clinical intervention and a supportive environment offered to children and young people can lead to better mental health outcomes later in life.^19,21 Since 2013, the NHS in the UK has launched CYP – the Children’s and Young People’s access to psychological therapies, which aims to support existing CAMHS in treating children when they need care and which can address obstacles such as lengthy waiting times.

In Ireland, GPs recognise and indicate that anxiety, depression and emotional disorders could be managed in primary care, but seldom are because of a lack of resources.⁵ People want alternatives to medication.¹³

The introduction of National Counselling in Primary Care (CIPC), which seeks to improve the delivery of mental healthcare in the primary setting for adults in Ireland, is a positive move towards providing early access to psychological therapies.⁵ The UK’s National Institute for Health and Clinical Excellence (NICE) guidelines, recommend the use of psychological interventions with young children in a stepped care approach as the first line of treatment for mild to moderate mental health issues.⁶

A stepped care model of service in counselling and psychotherapy is already in existence in Irish universities where a walk-in service is available for all students. 

Recommendations

The clinical experience of delivering CAP across different healthcare settings and a review of case work suggest that a number of mild to moderate presentations could potentially be treated earlier in primary care, if there is better integration of services with mental health professionals which could facilitate a speedier recovery in line with NICE recommendations.⁶

Working therapeutically with young people through images and the creative process is a powerful, yet very gentle, non-threatening way of processing distressing material. Positive behavioural changes can occur after the implementation of the three initial assessment sessions which can lead to early resolution of symptoms resulting in shorter treatment. This suggests that a positive effect can rapidly manifest through the process of short-term engagement with CAP. These changes have been backed up by reports from schools and parents. It was noted in such cases that having supportive families and guardians was central towards the alleviation of symptoms and well being. 

Improving access to psychological services such as CAP at a community level is significant for early intervention. The pivotal role that GPs and primary care practices occupy at the centre of communities is core to meeting the needs of children and young people with mental health issues in a timely manner. 

Situating the discipline of CAP within primary care, or as an adjunct service to GP practices, may potentially help alleviate waiting lists in the already overwhelmed secondary services; relieve the burden on GPs and possibly encourage young people to actively seek help. 

The modality of CAP has been developing as a mainstream treatment for more than 30 years, and is now a four-year postgraduate training course. Its employment and continued integration through interdisciplinary practice in secondary and tertiary services in Ireland is testimony to its efficacy. However, to encourage its wider use as a short-term early intervention, observations from small case samples, though encouraging, are not substantive. More rigorous, well-designed evaluation methodologies are required to build the evidence base in order to inform practice and improve policy.

Building and strengthening alliances between primary care, secondary services and service users will be key to this end, raising the level of awareness and appropriateness of using CAP as a clinical short-term intervention. 

References 

1. McLean J, Maxwell M, Platt S, Harris F, Jepson R. Risk and Protective Factors for Suicide and Suicidal Behaviour: a Literature Review. Scottish Government Social Research, 2008. Available from: http://www.scotland.gov.uk/Publications/2008/11/28141444/0. Accessed July 6, 2013
2. Cleary A, Nixon E. Early Adult Outcomes for Irish Children with Behavioral Difficulties. Sage Journals, 2011. http://isp.sagepub.com/content/58/6/643. Abstract. Accessed February 3, 2013
3. McAvoy H, Purdy J, Mac Evilly C, Sneddon H. Prevention and Early Intervention in Children and Young People’s Services: Child Health and Development, Dublin: Centre for Effective Services, 2013
4. Kerin L. National & international literature review of good practice in child & adolescent mental health services. Research commissioned by Mental Health Reform for distribution to the Children’s Mental Health Coalition, Ireland, 2014
5. Jeffers A. Mental Health in Primary Care – What do Health Professionals Believe is the Best Model of Care. 2005. Available from: http://www.doc.ie/publications/vision_ for_ change _ 6th/ submissions/CPI_Mental _ Health _ in _ Primary _Care.pdf [Accessed April 9, 2013] 
6. NICE. Depression in children and young people: Identification and Management in Primary, Community and Secondary Care, 2015.  Available at: https://www.nice.org.uk/guidance/cg28/chapter/1-Recommendations 7. Vasarhelyi V. Video: Child Art Psychotherapy at UCD, 2012. Available at: http://www.ucd.ie/medicine/studywithus/graduatestudies/psychotherapy/mscchildartpsychotherapy/ [Accessed July 6, 2015]
7. ACAP Association for Child Art Psychotherapists, 2014. Available at: http://acap.ie/ [Accessed August 16, 2015]
8. Malchiodi C. Medical Art Therapy with Children, London: Jessica Kingsley, 1999
9. Vasarhelyi V. Time Aspect of Pictorial Thinking, London: EGO, Bulletin of the Division of Psychiatry, UMDS, University of London, 1986 
10. Vasarhelyi V. “Visual Psychotherapy – the Hungarian Challenge”, Winter issue, Inscape, Journal of the British Association of Art Therapists, London: Routledge, 1992
11. Scheffler G. Time Limited Psychotherapy with Adolescents, Journal of Psychological Practice. 2000; 9(2): 88-99
12. Mental Health Reform. Mental Health In Primary Care in Ireland: A briefing paper, 2013
13. Bell C, Robbins S. Effect of Art Production on Negative Mood: A Randomised Controlled Trial. Art Therapy: Journal of American Art Therapy Association, 2007; 24: 71-75
14. Riley S. Contemporary Art Therapy with Adolescents. London: Jessica Kingsley, 1999
15. Murphy G. Short Term Psychotherapy, IAHIP Inside Out 2012; 66
16. Koss M, Shaing J. Research on Brief Psychotherapy in Bergin A, Garfield S. (eds) Handbook of Psychotherapy and Behaviour Change, Fourth Edition, England: Wiley and Sons, 1994
17. Elvins R, Green J. “The Conceptualization and Measurement Therapeutic Alliance: An Empirical Review.” Journal of Clinical Psychology Review, 2008
18. Harvey B. The Case for Prevention and Early Intervention: promoting positive outcomes for children families and communities. Prevention and Early Intervention Network, 2014. Available at https://www.tcd.ie/Education/assets/documents/PEIN%20A4%20Report-April%202014.pdf [Accessed September 20, 2015]
19. Health Service Executive (HSE), 2013. Fifth Annual Child and Adolescent Mental Health Service Report. Available from: https://www.iasw.ie/attachments/6c0a78b4-25ea-44e3-bb40-145e638543ca.PDF [Accessed June 14, 2015]
20. Evans E, Hawton K, Rodham K. In what ways are adolescents who engage in self-harm or experience thoughts of self-harm different in terms of help seeking, communication and coping strategies? Journal of Adolescence, 2005; 28(4): 573-587