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Forepart Psychol. 2018; 9: 1611.

How Art Therapists Find Mental Health Using Formal Elements in Fine art Products: Structure and Variation as Indicators for Residuum and Adaptability

Ingrid Pénzes

¹Faculty of Health Intendance, Department of Arts Therapies, Zuyd University of Applied Sciences, Heerlen, Netherlands

²KenVaK Research Centre for the Arts Therapies and Psychomotricity, Heerlen, Netherlands

Susan van Hooren

¹Faculty of Health Care, Department of Arts Therapies, Zuyd University of Applied Sciences, Heerlen, Netherlands

²KenVaK Inquiry Centre for the Arts Therapies and Psychomotricity, Heerlen, Netherlands

³Faculty of Psychology and Educational Sciences, Open up University of the Netherlands, Heerlen, Netherlands

Ditty Dokter

²KenVaK Inquiry Centre for the Arts Therapies and Psychomotricity, Heerlen, Netherlands

⁴Music and Performing Arts Department, MA Music Therapy and Drama Therapy, Anglia Ruskin Academy, Cambridge, United kingdom of great britain and northern ireland

⁵MA Dance and Music Therapy, Codarts Academy for the Arts, Rotterdam, Netherlands

Giel Hutschemaekers

⁶School of Psychology, Radboud University, Nijmegen, Netherlands

⁷Pro Persona, Heart for Mental Wellness Intendance, Nijmegen, Netherlands

Received 2018 Apr 29; Accustomed 2018 Aug thirteen.

Abstract

In clinical practice, formal elements of art products are regularly used in art therapy ascertainment to obtain insight into clients' mental wellness and provide directions for further treatment. Due to the multifariousness of formal elements used in existing studies and the inconsistency in the interpretation, it is unclear which formal elements contribute to insight into clients' mental health. In this qualitative written report using Constructivist Grounded Theory, eight art therapists were interviewed in-depth to identify which formal elements they observe, how they draw mental health and how they acquaintance formal elements with mental health. Findings of this written report prove that fine art therapists in this study observe the combination of movement, dynamic, contour and repetition (i.due east., primary formal elements) with mixture of colour, figuration and color saturation (i.e., secondary formal elements). Primary and secondary elements interacting together construct the structure and variation of the fine art production. Art therapists rarely translate these formal elements in terms of symptoms or diagnosis. Instead, they employ concepts such as remainder and adjustability (i.e., cocky-management, openness, flexibility, and creativity). They associate residuum, specifically beingness out of balance, with the severity of the clients' problem and adjustability with clients' strengths and resources. In the conclusion of the article nosotros discuss the findings' implications for practice and further research.

Keywords: fine art therapy observation, formal elements, art product, adult mental health, qualitative report, grounded theory

Introduction

Formal elements of art products such every bit line, color and shape are frequently used in art therapy observation in youth besides every bit adult mental wellness care. The art therapists' underlying supposition seems to be that formal elements reflect clients' mental wellness issues (e.thousand., 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 art therapists to codify their perspective on clients' functioning, strengths and challenges and support their contribution to the descriptive diagnosis. This could help the art therapist to determine whether fine art therapy and which art interventions may be beneficial. This interest in the use of formal elements is reflected in a large number of studies (e.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 wide range of opinions concerning which formal elements are relevant and how they are described and interpreted in art therapy observation and assessment. Besides, 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 art therapy scale (FEATS) (Gantt and Tabone, 1998) fourteen formal elements are incorporated, in the descriptive assessment of psychiatric art (DAPA) (Hacking, 1999) 5 categories, and in the Nürtinger Rating Scale (NRS) (Elbing and Hacking, 2001; Stuhler-Bauer and Elbing, 2003) 4 categories of twenty-four formal elements. Even if similarities in these formal elements can exist recognized, the style they are described differs largely. For example, 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 color, 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 discover and assess the formal elements. In some studies, open up ascertainment of formal elements is used to inquire into an in-depth understanding of the individual client (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 three different tasks, or the FEATS, in which a drawing made with markers is assessed.

The same kind of diversity is seen in the way formal elements are interpreted. In previous studies, formal elements are related to distinctive psychological features. In most 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 wellness (Huber et al., 2016) and recovery (Anthony, 1993). These perspectives have institute their way into art therapy ascertainment and cess (Betts in Gilroy et al., 2012; Wilkinson and Chilton, 2013).

Thus, until at present, literature has been far from consistent in presenting tools or suggestions directed toward the clinical apply of formal elements in fine art therapy observation and assessment. Despite this ambiguous evidence, formal elements are very often used in clinical exercise. Art therapists utilise existing fine art therapy assessment instruments in their ain way, oft developing their own assessment methods with their own favorite formal elements (Claessens et al., 2016). It is, however, unclear which formal elements art therapists observe relevant in their clinical do, how they observe and interpret them, and how fine art therapists relate formal elements to mental health. In this study, we will systematically investigate these aspects past interviewing art therapists with many years of experience in clinical do. If indeed art therapists in clinical practice utilise formal elements in a consistent way, the outcomes of the present study may contribute to the 'body of noesis' regarding if and how formal elements tin can exist used in art therapy observation and cess to estimate clients' mental health, and direct further treatment.

Materials and Methods

In this study, we used Constructivist Grounded Theory (Charmaz, 2014). This qualitative arroyo inductively generates theory grounded in empirical data. 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). See Figure 1 .

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Participants

In total eight art therapists were purposely selected from the existing professional network of a research centre of arts therapies in kingdom of the netherlands^{^one}. Participating art therapists were women with 15- >25 years experience with different populations and settings in developed mental wellness intendance. 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 art therapy perspectives. This diversity provided a disquisitional exploration and variation of the concepts investigated in this study. All art therapists gave written informed consent in accordance with the Proclamation of Helsinki.

Data Drove

Art Products

The participating fine art therapists were asked to observe six art products of five clients with diverse mental health problems (see Table four ). Ii art products (three and vi) were fabricated by one client. 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 Annunciation of Helsinki. All three paintings were made with acrylic paint on paper (size: 50 × 40 cm.) over a menses of 3 weeks. For the first and 2nd painting, the clients received standardized instructions to pigment a landscape; for the third painting clients were asked to create a painting without education. For all paintings, clients received the same paint, color palette, brushes and pencils. The sampled clients had merely started handling in art therapy in a range of mental health settings. In this stage of handling it is common in holland that the head of treatment (ordinarily a psychologist or psychiatrist) formulates a preliminary DSM-diagnosis that might change during the form of assessment. Art therapists do not formulate a DSM-diagnosis. In a later phase they formulate an art therapy diagnosis and contribute to a general descriptive diagnosis.

Table 4

Art therapists' ascertainment of the art products and mental wellness.

Art production, instruction and preliminary diagnosis by psychiatrist or psychologist	Art production		Mental health according to the art therapists in this study		Formulated focus and duration of treatment

	Combination of formal elements - > structure	Variation	(Im)balance	Adjustability
Open in a separate window Art product i Instruction: Painting free choice with acrylic paint; tertiary session Client i: Female person, age 48, panic disorder, eating disorder (bulimia), depressive disorder, personality disorder	All therapists mention and agree on the articulate loftier structure; contour and repetition are dominant present; the lines are placed straight to each other and the colors are, nearly symmetrical, repeated. Motion and dynamic are boss absent. The presence of color saturation and absence of mixture of color heighten contour and weaken motility and dynamic and enforce the loftier structure. Two therapists mention figuration (abstract).	All therapists mention and hold on the very limited variation; there is no differentiation.	Therapists find this customer to be out of remainder; very much thought; cognitive command and express/ no feeling; restriction of allowing and expressing emotions.	This customer is found to be the least adaptive (not open up to experiment, not flexible considering of the lack of variation and differentiation and not artistic considering of the demand for predictability, yet some therapists mention that they observe the art production powerful; a sort of argument related to self-determination). This client is described every bit anxious, neurotic and rigid. Overall, the therapists are not positive about treatment outcome and duration.	Therapists estimate that this customer may do good from melancholia experiences that allow access to and express feelings instead of controlling or avoiding them. However, they are cautious about how much the client needs the command of emotion equally a defense force. Therefore they look more time may exist needed in handling.
Open up in a dissever window Art product 2 Instruction: Painting a landscape with acrylic paint; first session Customer ii: Female, age 20, Anorexia nervosa purging type	The therapists agree on the high construction; all of them mention the presence of rhythm (repetition of horizontal lines/ motion), loftier color saturation, figuration, the calm dynamic and contour that is enhanced past express mixture of colour and color saturation.	All therapists mention and hold on the limited variation; monotonous and without differentiation.	Therapists detect this client to be out of balance; having tendency toward thought and cognitive control out of fear to loose control over emotions. 3 therapists find this art production a scrap alarming by the lack of vitality.	This client is found to be express adaptive (express open as she seems to vary and experiment, limited flexible by the strong repetition, monotone movement and lack of differentiation, no inventiveness by the standard/ obvious and realistic figuration and express even so some self-determination as the client seems to intentionally chooses this figuration and tries to piece of work precise, yet not making the effort to correct "mistakes").	To expand this client's adaptability, the therapists prioritize stabilization and reinforcement of self-determination past enhancing affective experiences. The therapists are cautious positive about this client'south power to alter (she seems to be less stuck/ rigid equally client one by the presence of some movement).
Open in a separate window Art production 3 Pedagogy: Painting a landscape with acrylic paint; commencement session	Art product 3 The therapists agree on figuration (stylistic with no detail), repetition (rhythm of upward movements), profile (not dominate, even so nowadays) and dynamic (seven therapists said to notice it mechanically, one lively). Therefore the structure of this product is relatively high. Half-dozen therapists mention in that location is almost no mixture of color. Four therapists mention color saturation (varying but mainly transparent). These elements enhance the structure.	All therapists mention and agree there is some, yet restricted variation (a trivial bit more in fine art product three as in art product iv).	The therapists are less explicit and utilize diverse terms with regard to rest. In full general this client is described as composed, tensed and tending toward idea; having the ability to regulate, only preferring to withhold from expressing emotion.	Therapists hold on this client'due south adaptability (some openness by lilliputian experimentation simply sticking to what is familiar, limited flexibility by lack of differentiation, no inventiveness by the very basic and obvious figuration which indicates no exploration and no diversion from the first idea, some self-conclusion past the option of figuration, yet, performed accidentally not seeing other possibilities).	The therapists are cautious positive about change; the limited amount of differentiation is seen as an opportunity to reinforce in handling. All the same, some therapists question the client's potential due to intellectual restrictions.
Open in a carve up window Fine art product vi Pedagogy: Painting a landscape with acrylic paint; second session Client 3: Female, age 33, Borderline Personality Disorder (main), depressive disorder recurrent moderate, bug related to upbringing children and work.	Art product 6 Seven therapists immediately mention that fine art product three and 6 seems to be made past the aforementioned client. They agree that art product vi tends to be highly structured, as contour is present by the distinction of the blocks of colour. Yet there is some overlap. At that place is repetition by the rhythm of movement. Movement and dynamic are not completely absent-minded. There is merely little mixture of color. Color saturation varies betwixt covered and dry. At that place is some figuration, mainly by the use of color. Six therapists have subjective associations, which are diverse just all related to the cloud.
Open in a divide window Fine art product 4 Instruction: Painting a landscape with acrylic paint; first session Client 4: Female, age 48, Personality disorder (main), depressive disorder recurrent moderate.	All therapists mention the presence of movement and dynamic in combination with presence of figuration and some amount of repetition. Vii therapists mention contour, v mention colour saturation varying between saturated and transparent/dry and iv mention the presence of mixture of colour. They concur that this art production is not completely chaotic or organized structured, yet slightly disposed toward chaotic.	All therapists hold on the presence of variation.	Compared with the other clients in this study, the therapists detect this client most balanced; despite having a trend toward feeling, yet showing aspects of idea..	Therapists agree on this client's adaptability (open up as she seems to be experimenting and exploring, flexible every bit she seems to differentiate, creative as she seems non to be restricted to what is familiar or obvious, some express cocky-determination equally her impulses may block her from cognitive control.	Therapists are optimistic about change. They judge that this client may benefit from cognitive experiences to develop the ability to cease and reflect and develop more than cognitive control over feelings in order to enhance autonomy.
Open in a separate window Art product v Instruction: Painting free choice with acrylic paint; third session Client 5: Male, age 34, addiction (cocaine, alcohol) (main), dysthymic disorder, borderline personality disorder	All therapists agree on all formal elements and the rather low construction, even though it not completely lacks structure. Movement and dynamic (characterized as impulsive/forceful and contained/ restricted at the same fourth dimension) are dominant present. These are enhanced by the presence of color saturation and mixture of color. Contour is not completely absent-minded; the white paper creates stardom betwixt the newspaper and the paint. As well repetition is present to some degree; horizontal and vertical lines are layered up, yet are less repetitive as the lines in art product one.	All therapists concord on variation; limited present, all though the effect of pigment seems to be repeated.	The therapists notice this customer out of residue toward feeling by the physically, all the same not completely chaotic or impulsive, expression of feeling and some cognitive command.	Art therapists are moderate positive about this client'due south adaptability (openness seems to be restricted by the repetition of the discovered effect of the pigment, which may withhold this client from being artistic, some flexibility past differentiation betwixt expressing and structuring, presence of self-determination	Art therapists question this clients' ability to change. They estimate that this client may benefit from experiences that expand the potential to regulate affect.

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 wellness. In particular how exactly they related formal elements to what aspects of mental health. The first six interviews took place in the work setting of the art therapist. Interview seven and eight were conducted on Skype. All interviews were videotaped. During the live interviews the art products were spread out randomly. During the Skype interviews the art products were discussed in numerical lodge. The interviews were conducted with an interview guide based on the research questions of this study. First, every art therapist was asked to look at the fine art products separately, describe the formal elements and describe the first impression she gained about the client. Second, more general questions were asked about how she would define the concept of mental health. Finally, every art therapist was asked how she would relate the formal elements of the art product to various aspects of mental health.

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

Data Analysis

Initial Coding

Later full transcription of the interviews, text fragments were organized co-ordinate to the topics of the interview guide. These topics, (1) formal elements, (2) mental wellness and (three) human relationship between formal elements and mental health, were used as 'sensitizing concepts' (Charmaz, 2014). First, incident-by-incident coding took place; within each interview, each art production separately was analyzed. This analysis resulted in a set of codes.

Focused Coding

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

Theoretical Coding

Theoretical coding conceptualized the interrelatedness between the categories. Comparative analysis over the viii interviews supported synthesizing and organizing the links between the theoretical categories. Within this process some of the main theoretical categories were merged into core concepts. For case, the primary and secondary formal elements (encounter Figure two ) became primary categories nether the core concept "construction." Of others, it became articulate that they were related -but separated- main theoretical categories, such equally flexibility and creativity nether the cadre concept of "adaptability." This led to a theoretical framework, conceptualizing the relatedness betwixt sub- and primary categories and core concepts. All were divers in item.

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Combinations of formal elements determining the amount of structure.

Quality

The whole process of assay was peer debriefed to ensure that the codes, categories and concepts fit the information. The results of analysis were fellow member checked with all fine art therapists on two occasions; (1) afterward initial coding; no additions or changes were made and (2) later on 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 fine art products. Focused coding clustered these codes into seven categories (see Tabular array 1 ). The formal elements "motility," "dynamic," "contour," and "repetition" were mentioned most frequently. "Mixture of color," "color saturation" and "figuration" were only mentioned by the art therapists when the chemical element was dominantly present or absent within the art product.

Tabular array one

Description and illustration of formal elements.

Categories	Illustration by quotes and frequently used words	Clarification
Formal elements
Movement	T2 (AP2): "The movement is longer, fluent, continued and fairly monotonous." (AP 5): "Coarse, pretty fast and brusque movements." Words with regard to the (1) amount: a lot, piddling, more, less, (2) character: compact, curt, long, circular, directly, fluent, sketchy, small, large and (3) Direction: upward, horizontal, vertical, diagonal	Movement refers to the corporeality, character and direction of the move. Movement becomes visible by the brush marks.
Dynamic	T1 (AP5): "There is a lot going on, it is very energetic and forceful. And at the aforementioned time it is somehow contained. By looking at the line and effect it, consciously or unconsciously, stopped." T4 (AP four): "I find this art product very turbulent. There is a lot of dynamic which gives me a restless impression." Words with regard to (i) A lot of dynamic: lively, busy, forceful, energetic, powerful, turbulent, and (two) Less dynamic: static, rippling, reserved, contained, restrained, calm, timid	Dynamic refers to tension (tectonic) within the art product. Dynamic varies between static, restrained and calm and fast, turbulent, energetic and forceful. It refers to the vitality of the movement made.
Contour	T8 (AP1): "No fluidity, absolutely boxed-off; rigid distinctions, no overlapping, and more than over; he keeps them [colors] very separate." T5 (AP2): "In this case, the structure consists of the combination of movement and profile […]." Words with regard to (1) A lot of profile: delimitation, line marking, outline, blocks of colors, boxed off, rigid distinctions, abrupt, direct lines, and (2) Less contour: fluent, overlap, impressionistic, pictorial, diffuse, loosely	Contour refers to the delimitation that emerges when shapes are outlined or are placed straight next to each other. This leads to rigid distinctions.
Repetition	T4 (AP1): "The repeated pattern of colors." (AP6): "There is rhythm by the twist of the brush that is repeated throughout the art product." Words with regard to (one) the presence of repetition: symmetry, mirroring, rhythm in movement, constancy, the same, design, and (two) Absence of repetition: no repetition	Repetition refers to the return of one or more formal elements in a pattern. A high amount of repetition leads to symmetry. Rhythm refers to the repetition of movement.
Mixture of color	T8 (AP1): "He is not mixing the colors, he is not playing with them, out of the canteen." Words with regard to (1) A lot of mixture: mixed, tone, mix on palette/ paper, hue, and (2) Absenteeism of mixture: straight from the bottle, carve up, distinct, pure	Mixture of color refers to the amount in which the colors are mixed inside the art product.
Color saturation	T3 (AP4): "The colors are not completely saturated". Words with regard to (i) High saturation: covered, thick, impasto, opaque, filled in/upward, texture, globs, dense, and (2) Low saturation: thin, dry, transparent, not covered, not filled, paper comes through	Color saturation refers to the density of color within the art production varying between transparent and impasto.
Figuration	T6 (AP3): "At that place is tried to make an actual prototype, positioning a tree in the foreground." Words with regard to (1) Presence of figuration: figure, background, realistic, figurative, image, naturalistic, use of semantic color, and (ii) Absence of figuration: abstract, basic, unrecognizable	Figuration within the fine art product exists when there is tried to make a figurative or realistic image. Semantic use of color enhances figuration. Absence of figuration results in an abstract art product.
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Structure	T8 (AP4): "There is organisation, structure, absolutely. Painting the mountain and than the buildings." Related words: Gestalt, Overall Character Words with regard to (1) High structure: organized, planned, sequence, layered, clear construction, controlled, and (2) Low construction: chaotic, unorganized, no structure, uncontrolled	Structure refers to the way the fine art product is synthetic and varies between clearly high and low structured. A highly structured fine art product is characterized equally organized and planned. An art production with low or no structure is characterized as chaotic.
Variation	T2 (AP4): "I meet various movements; long, short, bended and dissimilar ways of using the pigment; dry and moisture. In that location is diversity and intention in this product." Words with regard to (1) Presence of variation: diversity, differences, nuances, diverseness, divergence, differentiation, play, and (2) Absence of variation: no variation, limited, uniform, regular, equal, monotonous	Variation refers to the diversity that can be recognized in one or more formal elements within the art product.

Structure and Variation

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

uncomplicated

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 product."
simple

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 fine 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 absence of "movement" and "dynamic" (shown as "-" in Figure 2 ). Absenteeism of "mixture of colour" and presence of "color saturation" enhanced the corporeality of structure. "Figuration" contributed sometimes to a highly structured product (e.thousand., art product iii), at other times not (east.grand., art product 1).

Low structured fine art products consisted of the presence of "motion" and "dynamic" in combination with the absence of "profile" and "repetition." Low structure was further weakened by the presence of "mixture of color" and absenteeism of "figuration." "Color saturation" contributed sometimes to a low structured art production (e.g., art product 5), at other times not (eastward.g., art product 1 or 2).

The presence or absence of "move," "dynamic," "contour" and "repetition" determined the construction of the art product. These formal elements were mentioned almost frequently. "Mixture of color," "figuration" and "color saturation" reinforced or weakened this structure. To betoken the conciseness of "movement," "dynamic," "profile" and "repetition" in comparison with the other formal elements, the distinction between "main" and "secondary" formal elements was introduced (see Effigy ii ).

How formal elements are combined and how strongly they are present appeared to determine the corporeality of structure art therapists perceived in the art product. The more dominant a formal element was present or absent-minded, the more than clear the structure of the art product was high or low.

The fine art therapists were in agreement about clearly structured art products. The ascendant present or absent-minded formal elements were consistently mentioned first. The art therapists were less consistent nearly fine art products that were less clearly structured. It seemed as if the fine art therapists hesitated and needed more than time describing the formal elements. This was for case the case with fine art production 6 (see Table 4 ) that showed high structure but was far less structured than art product i:

simple

Therapist two: "Somehow the others [art products] are more than clear to me, here nothing jumps out. It is all the same, just the color is a chip different, and nada is placed in the foreground. Those flowers feel a chip strange. Information technology is not connected somehow."
simple

Therapist 5: "It has something threatening, almost as if it comes rolling toward me. It is a mountain, simply it rolls in my direction. Probably accidentally painted in this way…sort of. I don't know…there are really only four shapes with a deject and some dots. Kind of duality, contradiction within the art product."

Besides, articulate high or low structured art products demonstrated less variation. Variation emerged as a core concept by clustering categories related to the diversity inside the art product (see Table 1 ). Variation existed when a range of formal elements was present or when in that location was multifariousness within one or more formal elements (e.g., diversity in movement by the presence of short and long, bended and straight lines). All therapists mentioned the amount of variation in each fine art product explicitly.

simple

Therapist viii: Virtually fine art product ane: "There is lilliputian variation; no mixing of colors, not 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 Wellness

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

Clients' Mental State: Balance

The fine art products provided cues to the art therapists almost the clients' inner globe. They seemed to use an implicit conceptual model well-nigh the customer's residual. To describe this, they used a multifariousness of terms. Most of them were related to "feeling" or "thought" (encounter Table 2 ).

Table 2

Categories of balance.

Category	Illustration past quote and frequently used words	Description
Feeling	T5 (Customer 4): "It is made very fast so I wonder if this customer fabricated this from a feeling or a retention? Does this client pay attention to how it felt to brand this product? Does the client recognize to be in the "fast lane" often? Then it is about feeling. I imagine this was made by a more than disinhibited expressive person. It seems the client lost grip on itself a bit." Existence overwhelmed, feeling, lost in emotions, affective, not in control of emotions, uncontrolled, under regulation of emotions	Feeling refers to affects and emotions and the ability to allow experience and express these. Feeling can be differentiated between "impulsive expression" (physically interim on feeling) and "emotional expression" (allowing and experiencing feeling).
Thought	T2 (Customer 1): "The need to command, shape raised from an idea, it is planned, thoughtful, restrained." Ratio, cognitive, controlling emotions, need for predictability and structure, controlled, from the head, not feeling, analytical, thoughtful, over regulation of emotion, frantic, neurotic, planned.	Thought refers to cognitions and cognitive processes that are related to cognitive control.

With regard to feeling, all therapists mentioned emotion regulation and near all therapists focused on the customer's potential to regulate emotions. Art therapists extracted cues about feelings and emotions from the art products. Sometimes they referred to positive emotions (happy, lively), more oft to negative emotions (acrimony, sadness, fear). It was every bit if they scanned the fine art product for cues with regard to the content of the emotion likewise as the intensity of expression. Art therapists differentiated between clients who tended to limited impulsively, i.e., physical acted on feeling, and clients that tended to limited emotional, i.east., assuasive and experiencing feeling.

unproblematic

Therapists v: "Well, here [art product four] it is about expressing feeling by using variation in color and movement and it seems to be about a memory or a story, whereas here [fine art product 5] it seems to exist just near expressing emotions in an impulsive, more concrete manner."

Next, fine art therapists used words that could exist 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 mostly to a continuum of cerebral command (see Table 2 ).

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

Adjustability: Toward More than Rest

Ascertainment of a client'south tendency toward either "thought" or "feeling" enabled the art therapists to proceeds a perspective on clients' bodily residue. The art therapists stressed the importance to search for cues to gauge the customer'due south potential power to achieve balance. This was related to clients' "adjustability." Adaptability was amassed into four categories; "self-management," "flexibility," "openness," and "creativity" (run across Table 3 ).

Table iii

Categories of adaptability.

Category	Analogy past quote and frequently used words	Description
Self-management	T5: "Specifically that rest betwixt emotion and ratio determines the power to choose and self-determination. If someone only acts impulsive, that person is less able to decide." Making choices, attention, self-conclusion, autonomy, identity, intention, position taking, and confidence.	Self-direction refers to the power to choose. This requires the ability to distance and reflect, awareness of and paying attention to a present situation. Art therapists related self-direction to cocky-determination, identity and autonomy.
Flexibility	T7: "Someone that is mentally healthy is flexible: a person that is able and free to accept in information through many means; body, mind and emotions, without blocks, obstacles and disconnections. Someone who is not mentally salubrious is stuck in 1 fashion or non able to admission or flexibly modify betwixt ways of processing." Tuning, interact, being able to switch in response style adequate to a requite situation, being able to adjust, resilient, integration of knowledge and emotion, navigate, responsiveness to the situation, versatile Absence of adaptability: rigid, stuck, blocked, stock-still	Flexibility refers to the client's range of possibilities to react to given challenges, tasks, persons or situations. This requires the ability to switch between cognitive command and assuasive and expressing emotions. Therapists related flexibility to resiliency.
Openness	T5: "Some sort of curiosity, openness, the power to collaborate with the fine art material, to play with it, explore. Existence open up tells me something nearly the power detect and learn." Taking diverse perspectives, trying something new, experimenting, openness, not seeing a error as a disaster, exploring, differ from the known and familiar, taking risk	Openness refers to an mental attitude that allows taking various and new perspectives. It involves curiosity, risk taking, not seeing mistakes as a disaster and daring to experiment in unfamiliar situations.
Creativity	T1: "When someone wants to change, that ways he has to transform and move from A to B. That requires leaving what'southward familiar, expanding your horizon, facing and exploring the unknown." Discovering, anarchistic, combining things into something novel.	Creativity refers to the possibility to differ from the known and leave beaten paths in social club to create something novel. Art therapists related creativity to problem-solving.

The combination of cocky-management, flexibility, openness and inventiveness determined clients' adaptability. Art therapists were less positive well-nigh the adaptability of clients who were observed as struggling with being flexible, open up, self-managed and artistic (see Table 4 ).

uncomplicated

Therapist seven: "Persons that are willing in an unfamiliar situation, to put themself out, willing to acquire and make mistakes and learn grade their mistakes shows me something about their prognosis in therapy. Being able to face this task and adapt, that tells me something near their power to learn and accommodate in real life and that is a good prognosis."

Art therapists in this study agreed that gaining a perspective on the client'southward balance and the presence of adjustability gave direction to the conception of treatment goals (meet Table 4 ).

simple

Therapist 2: "When someone over overregulates his emotions, tries to control them, treatment then is often focused on losing a bit of that control, being able to play, move and act and allow to feel. When someone under regulates his emotions, treatment is often focused on creating structure and calming downward."

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' balance and variation was related to adaptability (run across Figure 3 ).

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Formal elements in art therapy ascertainment.

Structure and Balance

Based on the observed primary and secondary formal elements, the extent to which they were present/absent and in which combination, art therapists ascertained the structure of the art product on a continuum from loftier to depression. The structure was related to clients' balance; based on one art product, fine art therapists were able to estimate the customer's balance. Art therapists preferred to observe at least three art products to observe if each art products had like amounts of structure over time. If the construction of the art products did not change over time, their initial estimation of clients' balance was confirmed. The art therapists causeless that art products with clear high or low construction indicated that the client was more than out of balance. Three full general patterns could exist recognized; (1) highly structured art products were related to much "thought" and less "feeling", (2) low structured art products were related to more than "feeling" and less "thought" and (3) art products that alternated between high and low construction were related to much "idea" and much "feeling".

Variation and Adaptability

Art therapists observed the amount of variation of the fine art production, which they related to "adaptability". Variation was associated with experimentation, exploration, playfulness, taking risks, and discovery (see Table i ). These aspects were related to openness, self-direction, flexibility and creativity; the categories of adaptability. Generally, more variation was related to more adaptability until a "turning point". This ways that art therapists assumed an "optimum" amount of variation; absent or limited variation equally well as over- presence of variation was related to limited adaptability. Art therapists stressed their preference to discover at to the lowest degree three 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 learn and accommodate. If variation was nowadays over different art products art therapists were more than optimistic most clients' prognosis, as they associated adaptability with potential to alter in therapy.

Balance, Adaptability and Further Handling

The aim of treatment was to restore or develop remainder betwixt "thought" and "feeling" and to heighten adjustability. The art therapists in this report formulated the focus of treatment mainly on the estimated residual and potential adaptability. The focus of treatment directed the choice for fine art interventions. In general, the art therapists estimated that clients with a lot of cognitive control (i.eastward., thought) might benefit from more than "affective" interventions, whereas clients with difficulties regulating their emotions might benefit from more "cerebral" interventions. Art therapists stressed the importance of the ascertainment of clients' private position on the continuum of balance to choose the art interventions specific to the client'southward needs.

Art therapists institute clients' balance and adaptability indicative for treatment duration and prognosis. They were more optimistic nigh the treatment duration and prognosis of clients who were more balanced and adaptive. Art therapists were alert to clients lack of rest and adaptability. They emphasized the importance of clients' capacity to bargain with modify; they stated that a clear lack of balance and adaptability might have a office in survival and daily operation. Therefore, handling might take longer and prognosis, i.east., the expected amount of modify, might be more limited.

Word

Based on art products made with acrylic paint and the teaching to either pigment a mural or create a painting without instruction, all the art therapists in this study focus on 4 primary (motion, dynamic, profile, and repetition) and three secondary (mixture of color, figuration and colour saturation) formal elements in fine art therapy ascertainment. This implies that the art therapists in this study agree largely on the relevance of formal elements as well as their hierarchy. These vii formal elements evidence some resemblance to formal elements incorporated in existing studies on formal elements in art therapy eastward.k., "mixture of color" is likewise incorporated in the DDS, "color saturation" resembles "color intensity" of the DAPA, and "figuration" tin be related to "color fit" of the FEATS. Some existing studies point out that individual elements mean cypher 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 study add to these studies past conceptualizing specific combinations of formal elements that construct the "structure" of the fine art product.

The art therapists in this study employ the formal elements to estimate how clients make their fine art product. This is in line with existing studies in which it 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 explain why they provide data about clinically meaning 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 do 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., self-management, openness, flexibility, and inventiveness). Emphasis on adjustability, i.east., resources and strengths, is in line with the perspective of positive wellness (Huber et al., 2016) in which health is defined as "the ability to accommodate and self manage concrete, emotional and social challenges in life." This perspective shows resemblance to the "recovery approach"(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 change and growth.

The art therapists' perspective on mental wellness certainly influences the way the formal elements are interpreted. Non relating the formal elements to symptoms and/or disorders, transcends any nomenclature and is in line with other perspectives on mental health such equally those of Siegel (Siegel, 2010, 2012, 2017) and Cozolino (2017) who also stress the importance of integrating "thought" and "feeling" to achieve, restore or maintain mental wellness and well-functioning.

If the fine art therapists detect clients being out of balance - which is more or less e'er the case in health care situations- they actively commencement searching for the elements of variation. Variation is associated with making choices, play, experimentation and exploration of the 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-direction, openness, flexibility and inventiveness, i.due east., adjustability. Hinz (2009); Lusebrink (2010), and Bucciarelli (2011) besides pointed out creativity might be a sign of mental health, which emerged….notwithstanding, they did not explore this further.

Balance and adaptability are conceptualized every bit ii divide concepts; out of rest indicates the severity of the problems, whilst adaptability indicates present or potential resources which allow alter in therapy. Ane might say that being out of balance refers to "mental-affliction" and variation to "positive mental-wellness." Still, the therapists in this study often mention them together and bespeak out that these concepts are closely interrelated, i.eastward., the severity of the problem and the potential resources of the client are seen as two sides of the same coin. This raises the question whether and to what caste balance and adaptability are independent, distinct, concepts. Literature on this matter is divided. Some studies question the stardom between mental illness and mental health (adaptation) (Lukat et al., 2016; Van Erp Taalman Kip and Hutschemaekers, 2018). The seven formal elements that emerged in this study might enable art therapists to gain perspective on the strengths and resource as challenges of clients. The findings add to studies that chronicle formal elements either to specific disorders or clients' strengths and recourses in art therapy observation and assessment. The use of formal elements in art therapy observation provides a broader perspective on the customer every bit a person.

Critical Reflection and Implications for Practice and Future Research

This study conceptualizes 3 patterns of rest in combination with the variation in the art production. These patterns provide perspective on clients' strengths, resources and challenges. Information technology may be of interest in future enquiry to investigate if and how the formal elements may differentiate in the way they are present between clients with various mental health issues." Due to the express number of art products included in this study, future research might include more fine art products to investigate if the same patterns emerge or if these patterns can exist differentiated, specified or added.

Additionally, information technology may exist useful to contain more than i art product of each client in futurity research to investigate if that leads to a more precise and differentiated observation of variation and adaptability. Fifty-fifty though all therapists largely agreed on clients' variation and adjustability, they preferred more than i art product to estimate the variation.

Art therapists of three nationalities participated in this written report. 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 study could be a valuable starting signal to replicate the study in a broader international scope. Future research may accost the potential of these concepts in contributing to the international current literature.

Existing studies on formal elements show that the formal elements observed are likely to change in response to the given task and the art media used. One could question if other formal elements would accept emerged in this study when fine art products were made with a dissimilar task and art media. For example, the formal chemical element "filled space" might have emerged when art products would have been made on larger paper size, with smaller brushes and/or allowing more than fourth dimension.

Nonetheless, the backdrop of acrylic paint, allow the observation of those formal elements which enable the art therapists to find the structure and variation of the fine art product. The ability to observe the construction and variation related to the level of balance and adaptability may support fine art therapists to codify treatment goals to suit the individual needs and potential and to choose those art interventions that heighten or develop the client's balance and adjustability. Previous studies point out the therapeutic potential of diverse art material properties to achieve 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 (due east.g., Cozolino, 2017; Porges and Flores, 2017). Hereafter research may address the use of fine art interventions to generate different affective or cognitive experiences.

Conclusion

Formal elements are ofttimes used in clinical exercise. In this study, we addressed two questions, namely which formal elements art therapists detect, and how they interpret them in terms of mental health. Findings add to the electric current body of noesis. They prove that the combination of seven formal elements construct the construction and variation of the art product and are indicative of clients' level of balance and adjustability. Art therapists in this written report gain insight into clients' mental wellness through these concepts. This insight supports the art therapists in formulating treatment goals that adapt the individual needs and potential and to cull those art interventions that amend the client's residue and adjustability.

Ethics Statement

With regard to ideals blessing, this study was conducted in 2016 and an ethics approval was not required equally per our Establishment'due south 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 person method of observation of fine art products, their perspective on mental wellness and how they used the formal elements of the art product 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 procedure. The interviews had duration of i–one.v h, in which the art therapists were interviewed on a familiar and professional person topic. This research procedure was not considered equally a risk of bringing the art therapist whatsoever possible harm. Written informed consent was obtained from all therapists in accordance with the Declaration of Helsinki.

With regard to the inclusion of the clients' art products, written informed consent was obtained from all clients in accordance 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 every bit not harmful for clients.

Author Contributions

IP developed the inquiry design, conducted the research, and kickoff authored this commodity. SvH, DD, and GH supervised the development of the research blueprint and research process, and co-authored this article.

Disharmonize of Interest Argument

The authors declare that the inquiry was conducted in the absenteeism of any commercial or financial relationships that could be construed every bit a potential conflict of involvement.

Acknowledgments

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

Footnotes

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143814/