The Arts in Psychotherapy 33 (2006) 3758

The treatment of aggression using arts

therapies in forensic psychiatry:
Results of a qualitative inquiry
Henk Smeijsters Ph.D.
a,
, Gorry Cleven RDT
b
a
KenVaK, Centre of Expertise for the Arts Therapies, Zuyd University, the University
of Professional Education Utrecht, and Saxion University of Professional Education Enschede,
PO Box 69, 6130 AB Sittard, The Netherlands
b
GGzE, the Institute for Forensic and Intensive Psychiatry, Eindhoven, The Netherlands
Abstract
The article describes the body of knowledge of arts therapies in forensic psychiatry based on recent
practice, theory and research. The rst part gives an overview of observational details, interventions,
effects and rationales of drama therapy, music therapy, art therapy and dance-movement therapy in
general and more specically in the Netherlands. It shows that arts therapies can help to decrease
recidivism. In the second part the results are presented of a qualitative naturalistic inquiry with 31
experienced arts therapists working in 12 institutions in the Netherlands and Germany. The arts ther-
apists have been involved by means of semi-structured questionnaires, interviews and focus groups.
Their implicit knowledge about indications, goals, interventions, effects and rationales have been
compared and integrated into consensus-based treatment methods. The research reects the Dutch
tradition where all arts therapies are developed and researched within the same methodological for-
mats. The results of one of the problem areas that have been researched, destructive aggression,
are presented. Finally a comparison has been made between all arts therapies for the treatment of
destructive aggression.
2005 Elsevier Inc. All rights reserved.
Keywords: Arts therapies; Forensic psychiatry; Qualitative research; Aggression

Corresponding author. Tel.: +31 46 4207262; fax: +31 46 4207279.

E-mail address: h.smeijsters@hszuyd.nl (H. Smeijsters).
URL: www.smeijsters.nl, www.kenvak.hszuyd.nl.
0197-4556/$ see front matter 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2005.07.001
38 H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758
Introduction
In the Netherlands health care system, arts therapies are a regular part of treatment in
psychiatric and forensic psychiatry. Nowadays there is strong pressure to become evidence-
based. For this reason there is a need for arts therapists, and other therapists as well, to
develop treatment protocols and treatment guidelines based on research. To start with,
arts therapists describe their observations, goals, interventions, effects and rationales when
working with specic problems. What prompted this research, which lasted several years,
was the lack of a research-based overview of these aspects of treatment for all arts therapies
in forensic psychiatry. Because arts therapists had started describing their work individually,
the authors decided by means of questionnaires, interviews and focus groups to accumulate
and analyze this material further.
All arts therapies (drama therapy, music therapy, art therapy, dance-movement therapy)
were included. The research reects the Dutch tradition where all arts therapies are united
in one national association and arts therapies are developed and researched within the same
methodical formats and compared to each other.
The rst part of this article describes the context for forensic psychiatric treatment and
the status of arts therapies in forensic psychiatry. A summary of the published research
is included, which gives an overview of the state of the arts in forensic psychiatry. The
second part of the article describes the research method and results.
Forensic psychiatric treatment in the Netherlands
Forensic psychiatry is an important concern in the Netherlands. Many forensic patients
are treated in special forensic mental health institutes and will be released to the community
sooner or later. For offenders who, at the time of the crime, had a psychiatric disturbance, for
instance psychosis, personality disorder or addiction, it is agreed that they need treatment
rst before theycanbe released. These offenders are treatedas clients inpsychiatric hospitals
that are closed from the community. Patients are imprisoned, but within the institution there
is a psychiatric, not a prison culture.
Although these patients are diagnosed using the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV; American Psychiatric Association, 1994), in several psychi-
atric hospitals the focus of treatment is on so-called problem areas. Problem areas are
related to the DSM-IV and the chain of offense. Broek (2000a, 2000b) distinguishes the
following problem areas: lack of impulse control, aggression, grief, lack of empathy, low
social functioning and lack of structure. H orschl ager (2000a, 2000b), in her follow-up of
the research by Damen (2000, 2001), mentions problem areas such as tension, aggression,
impulsivity, power, control, lack of boundaries, lack of structure, lack of expression and
inadequate perception. Factor analytic research with the Behavioural Status Index (Woods,
Reed, & Collins, 2001) shows that there are factors for social perception, assertiveness and
non-verbal behavior as problem areas for this population.
Arts therapies in forensic psychiatry in the Netherlands
In the Netherlands arts therapies are a regular part of multidisciplinary treatment in most
psychiatric institutions. The number of arts therapists working in forensic institutions is
H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758 39
about 10% of the working population of arts therapists. However, there is no difference
in the relative frequency of art therapists working in forensic and general psychiatry. In
general and forensic psychiatry arts therapists from different modalities (drama, music, art,
dance-movement) work together in teams and take part in the overall treatment plan. Based
on their observations, they collect supportive information for the process of diagnosis,
which is determined by the psychiatrist. Treatment in a forensic institution is made up
as an integrated program in which several professionalspsychiatrist, psychologist, arts
therapists, and otherstake part. Within the treatment program, arts therapists focus on
specic treatment goals.
In the Netherlands the arts therapies in the last decade developed from insight oriented
therapy that takes the personality as a focus, to changing the way the patient feels, thinks and
acts in concrete, here-and-now situations. The arts therapies became more re-educative,
which means that the patient is trained to change specic cognitions, feelings and behaviors
related to one problem area. This makes arts therapies valuable ingredients in the treatment
of forensic patients. An important rationale for arts therapies in forensic psychiatry is
their orientation to action (Douma, 1994; Hakvoort & Emmerik, 2001). The experiential
and active nature of the arts therapies makes concrete goals like regulation of tension,
impulse control, regulation of aggression, the planning and structuring of behavior and the
development of interaction competencies possible.
A general theory of arts therapies, for psychiatry as well as forensic psychiatry, has been
articulated by Smeijsters (2003a, 2003b, 2003c, 2005). In line with Sterns developmental
psychology (Stern, 1985, 1995), Smeijsters describes the analogy between the vitality
affects of the psyche and the dynamic processes during the expression in the art form,
which both are characterized by equal basic parameters like dynamics, tempo, rhythm and
form. The therapeutic process is possible because the change of expression in the art form
is experienced as a change of vitality affects. By experiencing vitality affects in art forms
forensic patients canworkthroughunarticulatedlayers of experiences andgraduallybecome
conscious of cognitive schemes (Johnson, 2002; Kampen, 2004; Timmer, 2004).
Drama therapy in forensic psychiatry
Forensic patients in dramatherapy are unable to improvise, to take roles and to distinguish
betweentheir ownpoint of viewandsome elses point of view(Thompson, 1999). Thompson
(1998, 1999) developed workshops like Joe Blaggs and The Pump. The Joe Blaggs
workshop involves a ctitious offender about whomthe patients ask questions like: Who is
Joe Blaggs?, What is he doing?, What are his thoughts?, Who is inuenced by him?.
By means of these questions the patients develop a story with characters and events. The
story is played, and by means of stop-rules, it is possible to reect and explore alternative
behavior. The Pump is a workshop in which patients learn to distinguish between Knocks
(facts that cannot be changed), Wind-ups (provocations, threats by others) and Pumps
(inner thoughts and interpretations that increase anger). Patients are trained howto decrease
pumping thoughts and to manage their anger.
Timmer (2000a, 2000b, 2000c, 2003, 2004) uses the chain of offense developed by
Mulder (1995) in drama therapy. Together with the patient she develops a play in which
crucial moments of the chain of offense are incorporated. The patient reects on these
40 H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758
Table 1
Recidivism 2 years after patients have been dismissed from supportive treatment
Length of treatment Recidivism (%)
No more than 6 months 67
712 months 56
1318 months 45
1924 months 21
More than 2 years 17
Source: Teasdale (1997).
moments with words like who, where, and when. We see that typical aspects of drama
therapy are perfect ingredients to be incorporated in a cognitivebehavioral treatment. What
makes drama therapy a strong primary treatment is the fact that the behavior is trained in
concrete play situations.
Landers (2002) starts from the perspective that people who have been victims in society
choose the role of offender because this role is easily available. By means of playing the roles
of offender and victim, by changing scenes, and commenting on scenes patients acquire a
more varied role pattern. Cleven (1998a, 1998b, 1999, 2003, 2004) developed interventions
in which patients play different stages of life, including the stages that lead to the offense.
Teasdale (1997) describes psychodrama and art therapy as part of a supportive treatment
modality within a forensic therapeutic community in which the whole community and
also smaller groups have group therapy sessions. This community as a whole leads to a
remarkable decrease of recidivism (see Table 1).
This shows that the success of treatment increases with the length of treatment. Although
it is not possible to infer from this data the specic contribution of art therapy and psy-
chodrama, the characteristics of these therapies are closely connected to the rationale of the
therapeutic community: decreasing individual impulsivity and crime.
In drama therapy playing situations form daily life and using role changes to enhance
the ability to see things from the perspective of another person led to a decrease in offenses
of 50% during the follow-up measurement of a treatment group compared to a placebo
and control group (Chandler, 1973). Therapeutic theater for persons who committed armed
robbery and abuse led to the decrease of anxiety, the increase of empathy and the ability to
handle conicts (Cogan & Paulson, 1998).
Thompson (1999) takes the similarity between cognitivebehavioral therapy and the
process of the actor who changes his cognitions to play his role. He tells us that everyday
life is staged, and that it is a matter of rehearsing and playing the appropriate role in real
life that saves patients from getting into an offense. A patient can leave the role of the
bad guy and choose the role of the good guy. The combination of reecting and rehears-
ing the performance of the good guy is how drama therapy works. Because pathology in
forensic psychiatry is complex, Cleven (2004) uses several rationales adopted from Gestalt
psychology, transactional analysis, self-psychology and developmental psychology.
Music therapy in forensic psychiatry
Flower (1993) and Santos (1996) describe how forensic patients in music therapy are
unable to improvise. These patients either control themselves to the extreme or are unable
H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758 41
to stop their acting out behavior and act aggressively. Anger can be heard in the tempo, the
dynamics, and the sound of the patients play (Hakvoort, 1996, 2002a, 2002b).
There are many goals that are listed by music therapists working in forensic psychiatry
such as relaxation, self expression, mood change, emotional development, self-esteem,
respect for others, social interaction and adjustment, release of tension and anxiety, anger
management, decrease of aggressive behavior, self-control and coping skills (Codding,
2002; Fulford, 2002; Gallagher & Steele, 2002; Rio & Tenney, 2002; Thaut, 1987, 1992;
Watson, 2002). Thaut mentions that for these patients short-term therapy in the here-and-
now with realistic goals is appropriate.
The music therapist can use the monochord, background music, music listening, song
selection, song parody, song composition, lyric analysis, group singing, drumming, and
vocal and instrumental improvisation with themes your competencies, your beliefs,
your identity (Daveson & Edwards, 2001; Gallagher & Steele, 2002; Hakvoort, 2002a;
Reed, 2002; Watson, 2002; Wyatt, 2002; Poel, 1997).
Flower (1993), in her work with delinquent adolescents, focuses on their helplessness
and negative identity. To increase the patients control of his or her environment, Flower
takes destructive family situations as a theme and together with the patient explores musical
territory during which the patient can experiment with levels of control. The patient reaches
a balance when he or she is able to take initiatives and lead the improvisation and also is
able to give space to another person, which he or she supports and follows. Flower uses
thematic improvisations like The giant and the dwarf and The spider and the y. Wagner
(1997), Argante (1999), and Peeters (2003) developed interventions based on three themes:
the development history, the offense and empathy for the victim.
Music therapists report effects of music therapy on anxiety, tension, hostility, ghting
behavior, frustrationtolerance, impulse control, attentionspan, realityperception, awareness
of others, and self-perception (Codding, 2002; Hoskyns, 1988; Thaut, 1989a, 1989b, 1992).
A review of session documentation by Gallagher and Steele (2002) of 188 patients showed
that 91%actively participated, 82%expressed thoughts and feelings and 68%had a positive
change in affect.
The drum improvisation between patient and music therapist leads to a control of
anger (Drieschner, 1997). Watson (2002) reports the following effects of drumming: self-
expression and awareness of emotions, appropriate social interaction and cooperation, and
coping skills.
Research of Daveson and Edwards (2001), a self-report study after 12 sessions, shows
that ve female delinquents in a prison reported being more relaxed and experiencing less
tension and stress and were able to express themselves better after music therapy. All patients
reported that music therapy was pleasant and helpful. Song composition and song parody
led to more self-expression. Listening to songs and singing songs led to more relaxation.
Singing, song composition, song parody and listening to songs decreased stress, anger and
frustration.
The effect of music in forensic psychiatry can be explained by referring to its possibilities
for interaction, communication, expression and exploration of feelings, as well as its ability
to stimulate goal-oriented behavior and create possibilities for controlling emotions and
behaviors (Codding, 2002; Gallagher & Steele, 2002). Theoretical concepts that are used
may be related to psychodynamic theories, behavioral approaches, and cognitive procedures
42 H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758
(Rio & Tenney, 2002). An explanation for the effect of drumming with patients who have
themselves been traumatized is given by Skaggs (1997), who argues that trauma is imprinted
in the body, and that drumming by inuencing the body can evoke emotions. Drieschner
describes that the effect of the drum improvisation can be explained by referring to the
theory of analogy (Drieschner, 1997, and in Smeijsters, 2003c, 2005).
Other music therapists also stress the analogy between offensive and manipulative
impulses and behaviors, and the behavior during the musical improvisation (Hakvoort,
2002a; Hakvoort & Emmerik, 2001; Poel, 1997, 1998). By changing the parameters of the
musical expression, the behavioral, emotional and cognitive parameters of the offense can
be changed.
Art therapy in forensic psychiatry
In art therapy assessment instruments are used, such as the House-Tree-Person Test
(Buck, 1987), the Expressive Therapy Continuum and the Media Dimension Variables
(Lusebrink, 1990), and the Draw a Story Test (Silver & Ellison, 1995). Research by Lev-
Wiesel and Hershkovitz (2000) with the Machover Draw-A-Person Test shows a statistically
signicant difference in signs of violent behavior between violent and non-violent offenders.
Lopez and Carolan (2001) with the House-Tree-Person Test found a similar difference.
Goals which are used in art therapy in forensic psychiatry are self-expression, self-
esteem, coping mechanisms, social competencies, breakthrough of defenses, openness
for the offense, insight in thoughts, feelings and actions that triggered the offense, self-
control, alternative behaviors and empathy for the victim (Bennink, Gussak, & Skoran,
2003; Gerber, 1994; Kampen, 2001). The patient can work through childhood experiences;
compare thoughts and feelings while being a victim and offender, and express feelings to
others. The patient can reect on the form, the content, the emotional expression and the
cognitive distortions in the artwork.
Bennink et al. use collages that are constructed with journals, objects trouv es and oil
pastels to balance the planning, controlling and expression by means of cognitive and
behavioral instructions. The art therapist (and co-therapist) acts as a model, and together
with the patient rules are described that shape behavior. The use of simple steps of progress
helps to minimize the patients frustration and to maximize success experiences. Giving
patients the opportunity to make choices prevents opposition.
Art therapy in forensic psychiatry often takes place within the framework of
cognitivebehavioral psychotherapy in which the problem is explored and then the search
for a solution is undertaken (Kampen, 2001). Artistic expression of emotions instead of
acting out aggressive behavior can serve as a coping mechanism. Haeyen (2004) shows
that it is possible for patients to express emotional polarities in art, and gain insight into
inner contradictions from the perspective of dialecticalbehavioral therapy in line with
Linehan (1996). It is possible to integrate these contradictions in a work of art and decrease
aggressive and destructive impulses. By doing this, patients can prevent their levels of
increasing emotional tension from getting out of control and ultimately culminating in an
offense.
There are few research results of art therapy in forensic psychiatry (Bennink et al.,
2003). Several authors report that art therapy increases the insights patients have into
H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758 43
their personal thoughts, beliefs and behaviors as well as the thoughts, beliefs and behav-
iors of others (Gussak, 1997; Gussak & Cohen-Liebmann, 2001; Gussak & Virshup,
1997; Liebmann, 1996a, 1996b, 1998). The case vignettes described by Bennink et al.
show that patients, by drawing a volcano, express their anger symbolically if they are
unable to express it verbally and cognitively. After feelings have found an expression in
the artwork patients are enabled to talk about it. The feedback of others increases self-
esteem.
Riches (1998) reports a 29% reduction of disciplinary measures in a prison as a result
of 13 months of art therapy. The amount of transgressions requiring disciplinary measures
as a result of art therapy decreased 7581%. Two years after patients were dismissed 69%
of the persons who took part in art therapy did not re-offend compared to the control group
without art therapy, which in 42% did not re-offend (Brewster, 1983; Peaker & Vincent,
1990).
Art therapists in forensic psychiatry have used two prominent rationales. One is based on
the premise that patients can communicate in art in a symbolic way that cannot be verbalized
(Liebmann, 1998). This may be linked to Freuds or Jungs psychoanalytic concepts of the
manifest and latent meaning of images and Winnicotts concept of symbolic play (Murphy,
1998; Winnicott, 1971). In these rationales the patients artwork refers to content behind
the image. The goal of therapy is nding these latent meanings to reach insight in fragmented
psychic content and conicts (Hagood, 1998).
Froma different perspective, the art process and art formas an expression of the patients
thoughts, emotions and behaviors is used rather than the symbolic meaning of the patients
images (Baeten, 2001, 2005; McCourt, 1998; Riches, 1998). Important in this perspective is
howthe patient uses the brush and color, arranges the space on the paper, works with details
and the whole, makes transfers, and so on. These actions show how the patient experiences
and acts. The goal of therapy is then to help the patient nd new ways of experiencing and
acting.
Dance-movement therapy in forensic psychiatry
In Europe dance-movement therapy is not very well represented in forensic psychiatry.
Although this section does little justice to the possibilities dance-movement therapy might
have in forensic psychiatry it is included to show its potency.
In dance-movement therapy Laban Movement Analysis (Laban, 1998) forms the
basis for a variety of different assessment measures that can be used to analyze the
body and movement parameters of forensic patients. Presenting yourself through move-
ment increases individuation. Moving synchronously in the same rhythm increases social
behavior and bonding (Milliken, 2002). Dance-movement therapy makes it possible to
work with tension increases and decreases. Slow movements, conscious relaxation and
eye contact counteract impulsive, brusque, uncontrolled and antisocial behavior. In her
study DiGiorgio (1988) describes several theoretical perspectives when working with
aggression.
Currently, there are no published studies of the effect of dance-movement therapy with
the forensic psychiatric population. However, there are meta-analyses that showthat dance-
movement therapy is effective with psychiatric populations (Cruz & Salbers, 1998).
44 H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758
Dalessi (1997) describes how in dance-movement therapy movement games can be used
that show almost no difference from the offensive act. The patient can use his body to hunt
the therapist or another patient into a corner of the room. The same physical, emotional and
behavioral processes are evoked as have been experienced in the offensive act. But there is
analogy because in therapy this is play and not a real offensive act. The dance-movement
therapist by means of rules can offer the opportunity on the one hand to experience the
same physical, emotional and behavioral processes, and on the other hand to put these into
play where they can be controlled and where there is no harm done to others. Suddenly
increasing tension in movement followed by releasing this tension is an example how in
dance-movement therapytensionincrease andtensionrelease canbe exploredandcontrolled
(Milliken, 2002).
Research question and research method
The research reported here focused on nding which problem areas are important in
actual clinical practice, how they can be dened, and which observations, indications,
goals, interventions, effects and rationales arts therapists use when working with one
particular problem area with the population of interest. We also addressed the issue of
consensus about the treatment of any particular problem area within and between the arts
therapies.
The aim was to develop treatment methods with a sufcient amount of clinical trust-
worthiness. The research methodology was based on qualitative data, naturalistic (on site)
inquiry, and dialectical knowledge-building. This implies an authentic dialogue between
practitioners and researcher, in which treatment methods are developed, by reconstructing
tacit knowledge of experienced arts therapists (Polanyi, 1967). The outcome represents
subjective meanings that have been negotiated.
Specic research techniques used were repeated analysis of transcripts, iterative member
checking with respondents, peer debrieng with independent experts, triangulation (multi-
ple respondents with different training and experience, multiple data collection techniques
such as open questionnaires, interviews and panels, multiple theoretical perspectives), con-
cept development and categorizing fromgrounded theory, and content analysis as described
in the work of Lincoln and Guba (1985, 2000), Smeijsters (1997), Strauss and Corbin (1998),
Charmaz (2000), and Schwandt (2000).
Problem areas were conceptualized as diagnostic categories. Within these problem areas
the researcher asked questions such as: How would you describe this problem area?
Do you have a diagnostic theory about the problem area? How is the problem behavior
reected in drama, music, art, dance or movement? Which aspects of the problem area
do you focus on during therapy? What are your goals? Which method, play forms and
techniques do you use? Which effects did you see? Do you have a rationale why drama,
music, art, dance or movement has a positive effect? These questions reect the fol-
lowing framework: problem area, observation, diagnosis, indication, goal, intervention,
effect, and rationale, which can be understood as a way of axial coding (Strauss &
Corbin, 1998). Within the framework concepts were developed by means of the con-
stant comparative method: comparing data from the same individuals with themselves,
H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758 45
comparing data from different people, comparing incident with incident, comparing data
with category, and comparing a category with other categories (Charmaz, 2000; Glaser,
1992).
Respondents were 31 members of the network of arts therapists in forensic psychiatry.
They were working in 12 forensic clinics in the Netherlands and Germany. As data collecting
techniques questionnaires, interviews, and expert panels were used. Several arts therapists
participated in more than one data collecting technique. Nineteen arts therapists received
by e-mail an open questionnaire with a set of problem areas and the listed framework above
and were asked to write down their tacit knowledge.
All written descriptions were analyzed by comparing, selecting, relocating, combining,
and integrating content (Mayring, 1990). Smeijsters acted as the researcher, Cleven as co-
reader. The researcher analyzed each individual questionnaire and also made cross-analyses
of all questionnaires for a specic problem area and modality. There were several cycles
in which the results of analysis went back and forth between (new) respondents and the
researcher.
Because of gaps in the data, ve arts therapists were interviewed to ll these gaps using
theoretical sampling (Charmaz, 2000). The researcher used the same framework while
discussing the tacit knowledge of the therapist when working with specic problem areas.
During these interviews, by taking his own understanding into the dialogue, the researcher in
a dialogical encounter tested the arts therapists understandings, and thus critical involve-
ment produced understanding on both sides. During the interviews the researcher wrote
down the therapists answers into the framework. The transcripts of the interviews were
compared with the results of the questionnaires.
Finally 15 arts therapists participated in expert panels in which they discussed with
colleagues the trustworthiness of the researchers cross-analysis of the questionnaires and
interviews. Some people participated in several stages of the research process, but in total
31 different persons were involved (11 drama therapists, 9 music therapists, 8 art therapists
and 3 dance-movement therapists).
During all stages in the research process member checking, peer debrieng, the triangu-
lation of theoretical perspectives, and the use of several data collection techniques increased
credibility and dependability. Peer debrieng with the members of the KenVaK research
team was used to secure conrmability.
Results
The project began using the preliminary denitions of 11 problem areas by H orschl ager
(2000a) were used (see also H orschl ager & Cleven, 2002). The outcome resulted
in seven consensus-based problem areas and treatment models. Within the scope of
this article it is only possible to describe one problem area. A complete descrip-
tion of the research results (in Dutch) can be found in Smeijsters and Cleven
(2004).
Table 2 gives an overview of treatment possibilities for the problem area of destructive
aggression. This table is the result of the researchers content analysis of all open question-
naires, interviews and panel discussions as described above.
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Table 2
Consensus-based results of the treatment of destructive aggression by means of arts therapies (selection of data)
Drama therapy Music therapy Art therapy Dance-movement therapy
Indications Regular aggressive behaviors Lack of contact with own aggressive
feelings
Being irritated quickly Uncontrolled aggressive
outbursts during which the
patient cannot control his body
Lack of insight in own aggression Avoiding conicts Suppressed anger that explodes in
uncontrolled destructive aggression
Screaming and expressing
anger in interaction
Unable to regulate aggression Unable to regulate aggression Unable to regulate aggression Unable to control aggression
Goals Insight into ones personal
aggression history
To make contact with ones
aggressive feelings
Insight into the process of aggression
development
Insight in the process of
aggression development
Insight into stimuli that evoke
aggression and the process of
aggression development
To permit and express aggression Recognizing risky events To handle power and lack of
power, being big and small
Recognition of ones personal
aggression thermometer and
ones non-verbal signals of
aggression
Aggression regulation To handle cognitions and feelings
during events that might lead to an
offense
To handle frustration, tension,
anger, anxiety, aggression,
violence
Being able to use techniques of
aggression to decrease aggression
Being able to handle conicts Developing self control during risky
events
Being able to reconstruct risky
events
Being able to handle stimuli that
evoke aggression
To handle aggression To accept that suppressing
feelings leads to uncontrolled
outbursts
Being able to stop aggression
immediately
Sublimation of destructive aggression
into constructive aggression
To learn how to express
feelings without hurting oneself
and other people
Sublimation of destructive
aggression into constructive
aggression
Sublimation of destructive
aggression into constructive
aggression
Interventions General line of treatment: General line of treatment: General line of treatment: General line of treatment:
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Reach insight into and change
aggressive behavior
Reach insight into and change
aggressive behavior
Reach insight into and change
aggressive behavior
Reach insight into and
change aggressive behavior
Activities Activities Activities Activities
Going through the aggression
history in several life times
Together with the music therapist
play The cat that hunts, and kills the
mouse, exchanging roles
Working with water paint, using
another color before the rst one is
dry
Learn how to experience the
increase of aggression through
body signals
Scene work to explore: Express feelings like anger and
aggression; one person is playing, the
other is guessing which feeling has
been expressed
Alternating between constructing
and deconstructing (destroying,
burning, tearing apart)
Learn how to decrease the
increase of aggression by
means of changing body
reactions
Sorts of aggression Choosing on a scale from 0 to 100
which level of aggression the patient
wants to express. Rising the level
aggression from 0 to the level that
has been chosen and going back
Exploding within borders When aggression increases
focusing on functional
movements
Cognitions and emotions A ght on musical instruments Gradual exposure to materials with
resistance (hardness, weight, format):
Using strength in controlled
situations and movements (tug
of war) where you can hurt
nobody
Role-play of events where the
patient acted aggressively
YES/NO plays Working with stones Thematic techniques: power
and lack of power, big and
small, anger, aggression,
violence, anxiety, hyperactivity,
tension, frustration
Playing:
Using an aggression
thermometer (010) to schedule
events linked to levels of
aggression
Improvisation on percussions Working with strong physical
efforts
Hunter and hare
Role-play low risk events from
daily practice and increasing the
tension level, then:
Using words including feelings,
destructive coping behavior
(aggression, drugs abuse)
Depicting how the patient looses
control in the offense (sudden
changes in the art process)
Defending your territory
Confronting, looking for the
most frustrating stimulus of the
event
Giving structure to aggression by
learning how to play the drums
Painting stop signals Catch and free
4
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3
(
2
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5
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Table 2 (Continued )
Drama therapy Music therapy Art therapy Dance-movement therapy
Learn how to stop the
behavioral outburst
Researching the cognitions,
feelings and behaviors during the
offense
Painting lack of power Pretended ghts (hitting
at a distance)
Exploring alternative
behaviors
Playing the victim on the musical
instrument
Painting ones mist between
inner power and outer burdens
Fighting with sticks
against the wall and with
cushions
Connecting the low risk
event with the offense
Painting ones pitfalls Techniques of distancing
Learn to anticipate high risk
situations in the future
Learn how to behave different Using rules during play and
stops
The boxing ring
Scene work with high status
roles
Pretended ghts
Theatre of statues, tableaux
vivants
Joe Blaggs
Effects Insight in ones personal
aggression increases
Less experience of stress, anger
and frustration
Openness to the offense Admitting ones anger
Acting differently in conict
situations outside therapy
A decrease of anger Feeling responsible for the offense To understand and control
ones anger
For instance: Supporting others Perceive risk factors Expressing power in a
controlled way
Not hitting Insight into ones cognitive
distortions
Express aggression at the
right moment and in the right
way
Staying at a distance Reecting ones personal
development and experiences
Being more relaxed
Using a time out (visiting
ones room)
Experiencing the victim as
innocent
To understand ones borders
and stop behavior at an early
stage
Not slapping with doors Behaving differently
Not screaming
H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758 49
The consensus-based rationales that were developed as a result of the research are
described below.
Rationales
Drama therapy
Drama therapy allows distancing so it is possible to analyze cognitions before and during
aggression. Because of ctive dramatic play the patient can explore aggressive scenes and
reach insight into stimuli and his or her cognitions. The patient can reach insight into his
or her inner conicts concerning status and respect. Dramatic play gives the opportunity
to develop the ability to regulate aggression. This ability can be transferred to realistic
role-play.
Music therapy
Musical instruments and parameters offer the opportunity to express aggression in a
constructive way. The aggressive energy can become a part of the musical process. The
music therapist can take part in the aggressive outburst, contain it and help the patient to
express and regulate his aggression. Working in the music and being contained by the music
therapist gives the patient a feeling of security when exploring his aggression.
Art therapy
In art therapy materials and techniques can be used to evoke and release aggression.
Expressing aggression in art material safely helps to explore ones aggression. Using art
materials makes it possible to be in contact with ones cognitions, feelings and behaviors.
Visual art forms make it possible to picture the events, cognitions, feelings and behav-
iors that went along with the persons crime. By reecting on the image the patient can
be confronted. Behaviors like grasping, hitting or petting can be transformed into artistic
behaviors.
Dance-movement therapy
Aggressive behaviors have strong body and movement characteristics. Dance-movement
therapy works with body and movement and therefore can evoke destructive bodily and
movemental powers. Patients are afraid of their destructive behaviors, which are suppressed
but suddenly can come to an outburst. They did not learn to symbolically express power
less destructively. In dance-movement therapy, dance and movement are used to express
suppressed destructive aggression in an acceptable way, and to nd alternative behaviors.
Comments
All arts therapists sampled chose a lack of aggression regulation as an indication for treat-
ment. Drama, art, and dance-movement therapists mentioned aggressive behavior. Drama
therapists also focused on a lack of insight, music therapists on a lack of contact with
personal feelings and avoiding conicts, and art therapists on the saving up of anger.
All arts therapists used reaching insight as a goal. Learning how to control aggression
stimuli was used in drama, art, and dance-movement therapy. Drama, art, and dance-
movement therapists also took the transfer of destructive into constructive aggression as
50 H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758
a goal. Music and dance-movement therapists mentioned accepting and releasing aggres-
sion. Drama and art therapists focused on stopping aggression. Drama therapists also chose
relaxation as a goal, music therapists handling conicts, art therapists controlling thoughts
and feelings, and dance-movement therapists handling power and lack of power.
There were many interventions. All modalities used playforms for power and status, pre-
tended ghts and quarrel in the art form. Drama, music and art therapists explored thoughts,
feelings, and behaviors during the offense. Drama, art, and dance-movement therapists used
stop rules. Drama and music therapists worked with an aggression thermometer. Art and
dance-movement therapists worked with control giving way to power. Drama therapists
went into the aggression history, and also played little risk situations from daily life. Music
therapists worked with frustration tolerance training and used play forms to express feelings.
Drama and dance-movement therapy indicated as an effect the ability to react differently.
Music and dance-movement therapy led to a decrease of anger. Music therapy resulted in a
change of feeling, art therapy in the decrease of cognitive distortions, and dance-movement
therapy in expressing anger in a more controlled way.
Drama therapists saw as a rationale for the effect of drama therapy the possibility to
explore by distancing and ctive role cognitions and to explore and train alternative behav-
iors. Music therapists sawthe musical instruments, the musical parameters, and the musical
interaction as an opportunity to express aggression in a social context and to learn how
to control it. Art therapists mentioned the characteristics of the art material as a possibil-
ity to experiment with the expression of aggression. Depicting the offense in an image in
their opinion was a means to decrease cognitive distortions. Dance-movement therapists
stressed the fact that in dance and movement the physical aspect of destructive aggression
are expressed and changed.
Table 3 gives a summary of all therapeutic categories for all arts therapies.
In Table 3, in most cases a coherent clinical reasoning process can be seen, which means
that all aspects of treatment (indication, goal, intervention, effect, rationale) were connected
to each other. Sometimes, however, the link between treatments aspects was not manifest.
Table 4 based on Table 3, shows how the clinical reasoning process can become explicit for
all treatment aspects. The authors additions have been put in italics.
Discussion
From the literature it can be seen that arts therapies strongly focus on behavior and
emotions. The play forms are aimed to go into life history, to express emotions, to interact,
and to strengthen social, emotional, physical and cognitive competencies. Arts therapies
work with a combination of experiencing and acting; with a stable structure in the art form.
Patients learn how to think, feel and act differently as well as give different meanings to
their experiences. This is possible because in arts therapies concrete scenes are explored in
which it is almost impossible to hide ones thoughts, emotions, and behavior.
Arts therapies explore the onset and characteristics of the offense and help patients to
recognize and inuence the thoughts, feelings and behavioral signals that are linked to the
offense. Through structured play formswith roles, scenes, listening exercises, improvi-
sations, art images and forms, body exercises, and movement arrangementsbehaviors,
H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758 51
Table 3
Summary of the treatment of destructive aggression by means of arts therapies
Drama Music Art Dance-
movement
Indications
Lack of aggression regulation X X X X
Aggressive behaviors X X X
Lack of insight X
Lack of contact with ones feelings X
To avoid conicts X
Suppressing anger X
Goals
To reach insight X X X X
To control aggression stimuli X X X
To transform destructive in constructive behavior X X X
To express aggression X X
To stop aggression X X
Relaxation X
To handle conicts X
To control cognitions and feelings X
To handle power and lack of power X
Interventions
Playforms with power and status X X X X
Pretended ghts X X X X
Exploring cognitions, feelings and behaviors X X X
Stop rules X X X
Aggression thermometer X X
Controlled strength X X
Aggression history X
Low risk events X
Frustration tolerance training X
Expression of feelings X
Effects
Behaving differently X X
Less anger X X
Change of feeling X
Less cognitive distortion X
Expressing anger differently X
Rationales
Distancing in ctive scenes and roles X
Musical instruments, parameters and interaction X
Obstinate art material X
Imaging X
Expression in body and movement X
feelings and cognitions are transformed. Attachment problems, developmental and psychi-
atric disturbances are positively inuenced by strengthening self-expression, self-esteem
and empathy. A shared rationale of arts therapists is that by expressing thoughts, feelings
and actions in art forms it is possible to inuence these expressions hands on and explore
and develop new thoughts, feelings and actions.
5
2
H
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S
m
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s
,
G
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l
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/
T
h
e
A
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t
s
i
n
P
s
y
c
h
o
t
h
e
r
a
p
y
3
3
(
2
0
0
6
)
3
7

5
8
Table 4
Examples of coherent clinical reasoning process
Indication Goal Intervention Effect Rationale
Drama Aggressive behaviors To control aggression stimuli Low risk events Behaving differently Distancing in ctive
scenes and roles
Music Lack of contact with
ones feelings
To contact personal feelings Expression of feelings Change of feeling Musical instruments,
parameters and
interaction
Art Lack of insight To reach insight Exploring cognitions,
feelings and behaviors
Less cognitive distortion Imaging
Dance-movement Lack of aggression
regulation
To transform destructive into
constructive behavior
Controlled strength Expressing anger
differently
Expression in body and
movement
H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758 53
The research resulted in several consensus-based areas of treatment such as patients
limited perception, compulsive control, lack of emotional expression and empathy, high
emotional tension, impulsivity, lack of interpersonal boundaries, and destructive aggres-
sion. These problem areas form a bridge between disturbances and offensive behaviors.
Impulsivity for instance is related to addiction; limited perception is related to psychotic
disturbances. Other problem areas are related to personality disorders, attention decit
hyperactivity disorder, and mental handicaps. When the offense has been committed by
a patient with a particular disturbance, the problem areas that are connected to this dis-
turbance will be the focus of treatment. Interventions in drama, music, art, dance, and
movement show the psychological limitations and possibilities of patients. The arts thera-
pies confront forensic patients with their lack of emotions, dysfunction of cognitions and
behaviors. By experiencing and acting it is possible to increase tension regulation, impulse
control, aggression regulation, empathy, interaction, and the strengthening of boundaries.
This research makes explicit the tacit knowledge of a group of arts therapists. By
doing this it is possible to analyze, compare and integrate the implicit body of knowledge
this group of arts therapists developed while working with their patients. This research
made a cross-analysis of tacit knowledge of several arts therapists, which resulted in a
consensus-based body of knowledge, the collective sense of the profession so to speak.
The effects listed in this research study reect the effects as perceived by the surveyed arts
therapists. These effects are consensus-based, but not experimentally researched. Therefore,
we are planning another research study of effects that is closely linked to clinical practice,
but is more experimentally oriented, in which baseline phases, treatment phases and control
conditions are precisely observed and correlated with other assessment scales like scales
for recidivism. The results of this qualitative study will act as an input for the next research
study and we hope to transform these data into an assessment scale and treatment plan.
The arts therapists reported experiencing this interaction with the researcher as very
fruitful because they were stimulated to reect on their experiences and conceptualize what
they were doing. For them, this led to empowerment that they hoped would strengthen their
future treatment interventions and also their rationales within their multidisciplinary teams.
Hopefully, due to this research where respondents at several stages were confronted with
analyses of data, the reective practitioner could develop into a scientic practitioner
who not only acts as an individual respondent, but also as a co-researcher. Because the
respondents acted as co-researchers, this may have led to an increase of their scientic
competencies.
The information gathered by this research can be used in everyday clinical practice when
the goal is to inuence destructive aggression of forensic patients. The body of knowledge
is consensus-based, as listed in Table 2. However, this information should not be used as a
protocol without variation. Eachindividual art therapist shouldreect onthe transferability
of these data to his or her own setting and patients.
Acknowledgements
Thanks to all arts therapists and students who participated in this research. Thanks to the
members of the KenVaK team who were involved with peer debrieng. This research is a
54 H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758
joint project by KenVaK, and the GGzE, the Institute for Forensic and Intensive Psychiatry
in Eindhoven. The research results have been published as a book by the EFP, the national
Centre of Expertise for Forensic Psychiatry in Utrecht. Thanks to Cheyenne Mize at the
University of Louisville for her advice in preparing this article.
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