Science and Art in Cognitive Behavioral Therapy

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SPECIAL REPORT: CREATIVITY & PSYCHIATRY

THE BECK INSTITUTE

Can creativity play a role in psychiatric treatment? Studies have shown that music and art therapy can be helpful for patients with schizophrenia, depression, dementia, and other mental disorders.^1-4 Creativity can also enhance the therapeutic alliance.⁵

Norman Cotterell, PhD, senior clinician at the Beck Institute for Cognitive Behavior Therapy, is no stranger to leveraging creativity when supporting patients. His interest in the arts stem back to his school days, when he was in the drama club, the Princeton University Gospel Ensemble, and the Princeton Inn Theatre. To help clinicians cultivate creativity in clinical practice, Cotterell shared insights with Psychiatric Times.

Psychiatric Times: It is often said that psychotherapy combines science and art. Where does the art come into play in your daily work with patients?

Norman Cotterell, PhD: It comes on the fly. I’m usually thinking of ways I can help the patient get to where they want to go in life, and that is much more personal than science. I suppose the science comes into play in the empirically validated tools we have, but the art comes in terms of relating to a person one-on-one.

PT: Do you think being a creative person helps clinicians better support patients?

Cotterell: I have patients who come to me because I share their enthusiasm for art, music, literature, and theater. I share in the enthusiasm that they bring to whatever artistic pursuit they might have.

I had a patient who thought visually and recorded her thoughts in pictures. If she could sketch out her negative thoughts, it wasn’t too much of a stretch to have her sketch her positive responses to those thoughts. She sketched responses that displayed her hopes, dreams, and aspirations. She sketched out the best that she saw in herself, the best that she saw in those around her, and the best that she saw in what the future might bring to her. Having her sketch that out in visual terms was incredibly powerful.

Another patient of mine thought in terms of music. She created a mixtape that represented those hopes, dreams, and aspirations in musical form through other people’s work. There’s room for that. There’s room in sessions for clients to bring their creative, artistic pursuits into therapy. But it has to serve the nature of their goals for therapy; what they want to accomplish in life outside the session.

PT: How can clinicians leverage metaphors, anecdotes, and humor to improve therapy and the patient-clinician alliance?

Cotterell: Metaphors and anecdotes can be especially powerful, particularly in helping patients see that what can be an obstacle in one situation could be an opportunity in another.

I sometimes use the example of [former] President Franklin D. Roosevelt. Many assume that being in a wheelchair would have been an obstacle to the presidency, but there is some indication it was an opportunity.

Prior to polio, Roosevelt was a rich kid who was perceived as never having had to struggle a day in his life. After polio, he had something in common with people who were struggling through the Great Depression. So there is some thought that it increased his chances for the presidency, because he had something in common with voters who were struggling.

I say to patients, “Well, you can’t walk. What can you do? You can lead your country in the highest office in the land.”

Often, what can be an obstacle in one frame of mind can creatively be turned into an opportunity in another frame of mind. That might be what we do in therapy: turn obstacles into opportunities. We turn obstacles in terms of internal experiences, thoughts, feelings, sensations, and urges into opportunities to live life well.

Humor is another powerful tool when used correctly. I have seen stand-up comedians in sessions, and they naturally think in humorous terms—for better or for worse. Often, the use of humor has a therapeutic impact. One patient told me that for him, doing stand-up comedy was tantamount to therapy. It’s just one form of language and one form of a coping strategy that helps patients.

But it depends on the person. For some patients, humor is really important. It’s the way they speak, think, and cope. But some patients don’t have the same need or desire, so tread gently when it comes to humor. This is an area in which I would really let the patient take the lead, because individuals differ on what they find funny and on what kind of humor is therapeutic for them.

PT: Can you give specific examples of creativity within the cognitive behavioral therapy (CBT) framework?

Cotterell: The root of the word create or creativity essentially means “to grow.” That is probably what lies at the heart of what patients really want; they want to grow in terms of their relationships, their abilities, their passions and interests, their health, and in terms of whatever dreams they want to achieve personally in their lives.

It is the old button-pushing question from David Burns: What kind of life would they be leading if they pushed a magic button and were totally, permanently healed? If they pushed the button and therapy was a smashing success, what would change on a day-to-day basis? What would they be doing? I have them create in their own minds a vision of that life. If they were healed, what would they do in the next 7 days?

If they felt great about themselves, their world, their future; if their anxiety was no longer a problem; and if they were able to take steps toward what’s important and valuable and meaningful in their lives, then what would they do for the rest of today? Tomorrow morning? Tomorrow afternoon? Tomorrow night?

The creative aspect is enabling the patient to create a vision of the kind of life they want. I suppose the tools that we provide serve as fertilizer to enable their dreams and aspirations to grow, and to enable them to move in the direction of the life they seek.

PT: What specific CBT interventions are especially well suited for utilizing a creative approach?

Cotterell: Action planning. Action plans could include what the patient wants to do in the next week for pleasure, what they want to do in the next week that could engage their mind, or what they want to do in the next week for connection. It could be building relationships with those they care about. It could be something that gives them a sense of meaning and purpose; something they do for growth, for love, and to contribute to the well-being of those around them.

I have them create that vision for the next week, then we figure out what kinds of thoughts, urges, or sensations inside their body would get in the way of doing those things. The intervention within the session is finding creative ways to get around, get through, or travel with those thoughts, emotions, urges, or sensations that otherwise could serve as obstacles to the things they want to do to lead their life in a more fulfilling and more meaningful way.

References

1. Brandão FMV, Silva CV, da Silva Gonçalves de Oliveira KR, da Silva Pedroso J. Art as a therapeutic tool in depressive disorders: a systematic review of the literature. Psychiatr Q. 2019;90(4):871-882.

2. Hu J, Zhang J, Hu L, Yu H, Xu J. Art therapy: a complementary treatment for mental disorders. Front Psychol. 2021;12:686005.

3. Lu SF, Lo CH, Sung HC, Hsieh TC, Yu SC, Chang SC. Effects of group music intervention on psychiatric symptoms and depression in patient with schizophrenia. Complement Ther Med. 2013;21(6):682-688.

4. Zilidou V, Petsani D, Billis A, Bamidis P. Creative art therapy as an efficient way to improve the well-being of people living with dementia. Stud Health Technol Inform. 2023;305:553-557.

5. Heynen E, Roest J, Willemars G, van Hooren S. Therapeutic alliance is a factor of change in arts therapies and psychomotor therapy with adults who have mental health problems. Arts in Psychotherapy. 2017;55:111-115.