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Eating Disorders: The Journal of
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Arts-Based Therapies in the Treatment of
Eating Disorders
Maria J. Frisch
a
, Debra L. Franko
b
& David B. Herzog
c
a
University of Minnesota , Minneapolis, Minnesota, USA
b
Massachusetts General Hospital and Northeastern University ,
Boston, Massachusetts, USA
c
Massachusetts General Hospital and Harvard Medical School ,
Boston, Massachusetts, USA
Published online: 21 Aug 2006.
To cite this article: Maria J. Frisch , Debra L. Franko & David B. Herzog (2006) Arts-Based Therapies
in the Treatment of Eating Disorders, Eating Disorders: The Journal of Treatment & Prevention, 14:2,
131-142, DOI: 10.1080/10640260500403857
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131
Eating Disorders, 14:131–142, 2006
Copyright © Taylor & Francis Group, LLC
ISSN: 1064-0266 print/1532-530X online
DOI: 10.1080/10640260500403857
UEDI 1064-0266 1532-530X Eating Disorders, Vol. 14, No. 02, January 2006: pp. 0–0 Eating Disorders
Arts-Based Therapies in the Treatment
of Eating Disorders
Arts-Based Therapies in Treatment M. J. Frisch et al.
MARIA J. FRISCH
University of Minnesota, Minneapolis, Minnesota, USA
DEBRA L. FRANKO
Massachusetts General Hospital and Northeastern University,
Boston, Massachusetts, USA
DAVID B. HERZOG
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
Arts-based therapies are increasingly being employed, in conjunc-
tion with empirically valid traditional therapies, in the residential
treatment of eating disorders. A systematic database search of arts-
based therapies in the treatment of eating disorders was conducted.
In addition, program staff at 22 residential eating disorder treat-
ment programs were contacted to provide information regarding
arts-based therapy utilization rates. Of the 19 programs that par-
ticipated in this study, all incorporate arts-based therapies on at
least a weekly basis in the treatment of eating disorders. However,
while published narrative reflections on arts-based therapies and
eating disorders imply a generally positive outcome, no known,
empirically valid studies exist on this experiential form of therapy
within the area of eating disorders.
In the past several decades, a large variety of psychological treatments such
as interpersonal, cognitive-behavioral, family systems, and pharmacothera-
peutic therapies have gained popularity in the treatment of eating disorders
(Fairburn & Harrison, 2003; Garner & Garfinkel, 1997; Wilson, 2004). Along
with this trend has come the emergence of multidisciplinary approaches, such
as the incorporation of experiential therapies in combination with one or
This work was in part supported by Matina S. Horner, Phd. Summer Research Fellowship.
Address correspondence to Maria J. Frisch, Dept. of Psychiatry, Riverside Prof. Bldg, 606
24th Ave. S., Ste. 602, Minneapolis, MN 55454. E-mail: fris0039@umn.edu
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132 M. J. Frisch et al.
more traditional forms of therapy in the comprehensive treatment of eating
disorders. Some programs have even made the incorporation of alternative
and holistic therapies, such as arts-based therapies, part of their core treat-
ment philosophy. However, there is currently no published research to sub-
stantiate the claim that such therapies are useful in the treatment of eating
disorders.
In the most basic sense, arts therapy is the medicinal use of creative arts
such as drawing, dance, music, and drama. It is most often implemented by a
Master’s level trained therapist whom, according to the American Art Therapy
Association (AATA), is trained in both art and therapy through a nationally,
regionally, or state accredited program (AATA, 2002). Arts therapists utilize
psychological and developmental theories in combination with a form or
forms of creative arts to bring about personal growth and positive change in
clients. This distinctive form of therapy presents a unique avenue of adjunc-
tive treatment for the eating disordered client.
While arts therapy has been clinically used for over a century (Junge,
1994), much of the published work in this area consists of case studies and
theoretical discussions, with little emphasis on outcomes (Reynolds, Nabors,
& Quinian, 2000). Moreover, specifically within the area of eating disorders,
we were not able to find evidence of empirically valid studies conducted with
this population.
Despite the lack of treatment outcome studies specifically in the area of
eating disorders, some nonrandomized and randomized controlled trials with
trauma survivors and psychiatric patients exist in the area of arts therapy.
Chapman and colleagues (2001) looked at the effect of arts therapy on pediat-
ric trauma patients up to six months after treatment, but found no significant
reductions in post-traumatic stress symptoms between patients receiving arts
therapy and those receiving standard hospital treatment. In contrast, Green,
Wehling, & Talsky (1987) studied regular therapy versus regular therapy with
art therapy every other week in chronic psychiatric patients for 20 weeks and
found significant differences between groups in attitudes towards self and
getting along with others. On a broader scale, Koerlin, Nybaek, & Goldberg
(2000) investigated arts therapy in a group of 58 individuals with a wide range
of mental and behavioral impairments over a period of four weeks. Although
there was considerable variation in psychiatric symptom reduction between
participants, 88 percent of participants who completed an arts therapy pro-
gram showed significant improvements in symptom reduction, with a sub-
group of trauma patients obtaining significantly better results, implying that
research on arts therapy and trauma may differ from arts therapy outcome
studies in other areas. However, it is not entirely clear whether the positive
outcomes found by Koerlin et al. (2000) were the result of arts therapy treat-
ment since there was no control group used for comparison. In addition, it is
difficult to generalize the results of these studies to clients with an eating dis-
order, because the samples are very different.
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Arts-Based Therapies in Treatment 133
Research exploring arts-based therapy that specifically investigates and
addresses the unique characteristics of clients who have an eating disorder is
warranted. The purpose of this review is to highlight, summarize, and explore
the prevalence of primary types of arts-based therapies commonly used in the
residential treatment of eating disorders and to stimulate discussion regarding
future research in arts-based therapies and eating disorders treatment.
METHODS
Participants
Program directors at 22 residential eating disorder treatment programs from
across United States (see Table 1) were contacted. Programs were selected
based on the following criteria: 1) Offered residential treatment services; 2)
Offered treatment for anorexia nervosa (AN), bulimia nervosa (BN), or
binge eating disorder (BED); and 3) Location in North America. The 22
selected programs were the only programs that met the above criteria, from
a comprehensive national search of all residential treatment programs for
eating disorders. The comprehensive search was conducted by searching
the Internet, national eating disorder treatment referral databases, and on-
line yellow pages. Programs were not offered any form of compensation for
participation in this project.
Materials
An email survey used in a recent descriptive study of residential eating dis-
order treatment programs (Frisch, Herzog, & Franko, 2005) was used to col-
lect information from program staff regarding the incorporation of arts-
based therapies in residential programs. Data were collected during July
and August of 2004.
TABLE 1 Survey Questions Specifically Pertaining to Incorporation of Arts-based Therapies
•Do you incorporate any arts-based therapies into your program? Please check all that you offer:
_Arts-based Therapy ___Dance Therapy
_Music Therapy __ __
__
_Other(s):__________________
•On average, what percentage of your residential clients participates in arts-based therapies while
in treatment?
•On average, do your clients participate in arts-based therapies at least:
___Once p/day ___Once p/wk. ___Once p/mo ___Once in 3/mo ___Never
•Why do you offer/incorporate arts-based therapies into your treatment program?
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134 M. J. Frisch et al.
Procedure
All participating programs were asked to complete a 30-question survey
regarding their residential treatment program (Frisch, Herzog, & Franko, in
press). Of these 30 questions, four were specifically on the topic of arts-
based therapies (see Table 1), and an additional question asked about
weekly schedules for residential clients. The results of these five questions
will be presented here.
Websites and brochures produced by each program also were
reviewed as a secondary means of obtaining information.
Additionally, a systematic English-language only database search was
conducted using PsycInfo (1985–2004), PubMed (1966–2004), and AMED
(1985–2004) using the keywords eating disorders and arts therapies or arts
based therapies or creative arts therapy or music therapy or dance therapy.
Results were limited to only include papers on anorexia nervosa, bulimia
nervosa or binge eating disorder, excluding obesity. A total of 30 papers
were found, 17 on arts therapy, 8 on music therapy, and 5 on dance. Six
books containing chapters pertaining to this topic were also reviewed.
LITERATURE REVIEW RESULTS
What is Arts Therapy?
Arts therapy is an umbrella term for a diverse assortment of sub-specialty
experiential therapies that cross a wide variety of artistic disciplines. Based
on the literature, three major sub-specialties of arts-based therapies emerged
in the treatment of eating disorders: music therapy (MT), dance/movement
therapy (DMT), and creative-arts therapy (CAT).
Music Therapy (MT)
MT primarily utilizes music as a therapeutic tool. Music is used most
often in the treatment of eating disorders as a tool for self-discovery or
as a method for relaxation (Justice, 1994; Parente, 1989; Robarts & Sloboda,
1994). Some examples include using background music to facilitate
breathing, positive imagery or meditation. Alternatively, music may be
played during mealtime to alleviate anxiety. Examples of using music as
a tool for self-discovery include listening or singing along with a song
and then examining and discussing the lyrics, eventually using the
insight discovered through the lyrics to apply to oneself. For instance, an
arts or music therapist could facilitate a discussion on the theme of lov-
ing oneself unconditionally from the lyrics of India Arie’s “Supermodel”
or the desire to survive a battle with one’s eating disorder from Destiny
Child’s “Survivor.” A wide variety of songs may be used with this therapy
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Arts-Based Therapies in Treatment 135
and selection is typically based on the individual characteristics of a per-
son or a group.
One residential program employs a unique form of cognitive-behavioral
music therapy (Hilliard, 2001). Under this model, music therapy is used to
address “behavioral and cognitive issues in a non-threatening and support-
ive manner while challenging long-held cognitive distortions and destruc-
tive behavioral patterns” (p. 112). Hilliard (2001) illustrated this technique
by showing a “recovery rap” that clients had written and performed about
overcoming their eating disorders and reclaiming their lives. He also
emphasized the use of lyrics as a tool for personal insight and change.
Dance/Movement Therapy (DMT)
The body is a central battleground in eating disorders, making DMT a prom-
ising adjunctive treatment. DMT is often misunderstood because of its
name; this specialized form of therapy is not simply limited to dance and
movement. The majority of dance movement therapists base their therapeu-
tic art on the idea that the body and mind are unconsciously (or con-
sciously) connected and strive to impact the mind through some type of
direct work with the body. In other words, positive effects on the body may
often result in positive changes within the mind. Dance movement therapy
is defined in a broader sense by the American Dance Therapy Association
(ADTA) as “ . . . a process that furthers the emotional, cognitive, social and
physical integration of the individual” (ADTA 2001). Of the five papers
found on eating disorders and DMT, all were narrative depictions of a spe-
cific DMT method (and corresponding theory) and/or treatment model
developed from clinical experience with eating disordered clients. Most
methods incorporated some form of psychotherapy with DMT. Krueger and
Schofield (1986) developed what they termed “preverbal” (p. 326), dance-
therapist led DMT techniques developed to be directly followed with verbal
psychoanalysis, led by a trained psychiatrist. Intended for use with inpatient
and outpatient clients, the DMT technique was developed as a treatment for
emotionally stunted patients who were not yet inherently “. . . insightful
[or] verbal . . .” (p. 324) and included relaxation and centering, mirroring
another’s movement, facing a mirror, creating drawings that reflect the
experiences of the movement session, and videotaping of one’s body and
movement following self-critiquing and reflection. Another technique with
ties to psychoanalytic theory is that developed by Blanch Evan (Evan, 1991;
Krantz, 1999; Levy, 1988) who is known among dance-movement therapists
as a pioneer in the field of dance therapy. Her methods and theories are
closely intertwined with a unified goal of “psychophysical unity,” using the
body to link action with feeling through individualized DMT.
Other authors have incorporated DMT methodology into body image
therapy (Totenbier, 1994). Totenbier suggests a DMT model in which a
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136 M. J. Frisch et al.
positive change results from the exploration of one’s body. Specifically, a
client is asked to look in a mirror and draw a picture of herself. She is then
walked through a series of activities, such as creating an actual body tracing
and comparing it to her self-portrait, which encourages clients to challenge
distorted beliefs they may have about their body. By examining and experi-
encing different aspects of actual versus perceived body images, it is pur-
ported that the client is able to reach a more realistic perception. Another
similar technique embracing the use of a mirror and a body map was devel-
oped by Rice, Hardenbergh, & Hornyak (1989), although their work was
limited to clients with anorexia nervosa.
Creative-Arts Therapy (CAT)
CAT primarily utilizes drama, role-playing, drawing, painting, and sculpture
as therapeutic tools. Arguably the most widely employed of the three forms
of arts-based therapies, CAT may be found within inpatient units (Wolf,
Willmuth, & Watkins, 1986), day treatment programs (Jacobse, 1994), outpa-
tient programs (Bloomgarden, 1997), and residential programs for eating
disorders. Methods widely varied across papers, although a common theme
of symbolism as a tool for insight appeared throughout. Additionally, each
author stressed the importance of the creative arts as an alternative means
of expression and exploration of feelings. Techniques vary from diagnostic
drawing (Kessler, 1994; Levins, 1995), which is the examination or interpre-
tation of the structure and content of drawings, to improvisation (Kaslow &
Eicher, 1998). Wooley and Wooley (1985) described an improvisation tech-
nique where clients acted out getting fatter and fatter and then getting thinner
and thinner until they were unable to move because they were so thin. Sim-
ilar to verbal psychotherapy, improvisation allows free association through
the body instead of through words (Siegel, 1984).
Arts may be used to explore early developmental stages (Fleming,
1989) and root causes of eating disorders. For example, in the early stages
of therapy, the art therapist could focus on Piaget’s (Atherton, 2003) stage of
assimilation by mirroring the actions of a caring authority figure that empa-
thizes with the themes found within the client’s art and unconditionally
accepts the client’s artwork, often praising the client for her efforts. Rabin
(2003) pioneered a unique form of arts therapy called Phenomenal and
Nonphenomenal Body Image Tasks (PNBIT) that addresses self-esteem as a
root cause of eating disorders. Her technique involves participation in a
series of verbal and nonverbal arts-oriented tasks (many focused on body
image) designed to bridge the client’s self-image with reality.
Dramatherapy is another form of CAT. The National Association of
Drama Therapy (NADT) describes this treatment as “ . . . the systematic and
intentional use of drama/theatre processes and products to achieve the ther-
apeutic goals of symptom relief, emotional and physical integration, and
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Arts-Based Therapies in Treatment 137
personal growth” (NADT, 2004). Jacobse (1994) described a Dutch method
of dramatherapy where clients with anorexia nervosa and bulimia nervosa
were given theatrical roles in a fictional play. Through the process of acting,
they explored expression, imagination, and emotional involvement under
the safety of playing another character. This role-playing also allowed cli-
ents to improve means of communicating and functioning within a group
setting. Under the auspice of acting, clients experimented both “psychologi-
cally and physically” (p. 142).
SURVEY RESULTS
Twenty-two residential eating disorder treatment programs were contacted
for this study. Of these 22, 13 programs completed the survey through self-
report. Information was obtained about 6 programs through a combination
of publicly available information and verification telephone calls and 3 pro-
grams refused to participate.
Arts-therapy is frequently employed in the residential treatment of eat-
ing disorders. Of the 19 programs that participated in this study, all pro-
grams offered arts-based therapy at least once per week, with an average
weekly client participation rate (CPR) of 90.55% (SD = 26.64%) for BED
treatment programs and an average weekly CPR of 99.21% (SD = 2.08%) for
AN and BN treatment programs. Over twenty-six percent (26.32%) of the 19
participating programs offered arts-therapy once per day. These programs
boasted an average daily CPR of 99.38% (SD = 1.25%).
Based on a review of daily resident schedules for each program, there
was large variability in the amount of time per week devoted to arts-based
therapies (see Table 2). Controlling for outliers (two programs dedicating
over 10 hrs to arts therapy per week per patient were removed), programs
devoted an average of 2.8 total hrs (SD = 1.5 hrs, range = 45 min–5 hrs) per
week per patient to arts-therapy, not including dance or music therapy.
Programs offered a wide variety of reasons for incorporating arts-based
therapies, including self-discovery, self-exploration, and self-expression.
Others reported that arts-based therapies allowed clients to face and chal-
lenge issues such as self-esteem, body image, depression, and the tendency
TABLE 2 Arts Therapy Utilization: Average Time per Week per Patient Dedicated to
Arts-based Therapies
Type of therapy
Avg. time p/wk,
p/patient (SD) (Range)
Arts therapy 4.5 hrs (6.2 hrs) (45 min–22.2 hrs)
Dance therapy 25 min (44 min) (0–2 hrs)
Music therapy 32 min (1.1 hr) (0–3 hrs)
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138 M. J. Frisch et al.
to isolate by providing an alternative, healthy outlet for expression of emo-
tions and development of positive coping skills. Art activities were viewed
as non-threatening, alternative therapies wherein registered art therapists
worked to help clients identify feelings and integrate new awareness into
more positive coping behaviors. Many arts-based therapies were reported to
be particularly effective for patients who had difficulty with more traditional
forms of talk-oriented therapies.
DISCUSSION
While creative arts therapies are by all means intriguing and widely
employed in the residential treatment of eating disorders, based on a com-
prehensive review of the current literature, there are no empirical studies on
arts-based therapies with clients who have an eating disorder. Although
some studies in the area of trauma and general psychiatric disorders exist,
the outcomes are inconsistent between studies, most likely due to differ-
ences and problems in study design. Further, the results of these studies
may not be applicable to the unique characteristics of the eating disordered
client. It appears that the majority of residential eating disorder treatment
programs support and employ at least one form of therapy that has not yet
been shown to be an empirically valid primary, secondary or adjunctive
treatment for eating disorders. However, the concept of empirical validity
with respect to arts-based therapies is complex.
Based on a review of the literature, the practice of utilizing arts-based
therapies in the treatment of eating disorders has not been standardized.
Most narrative depictions offered a case study for illustration of basic con-
cepts, but stressed the unique, individualized nature of their process. Most
agree that the field of arts is quite individualized and difficult to measure, let
alone standardize. However, if art as therapy is frequently used in the resi-
dential treatment of eating disorders, perhaps we should consider scientific
study of standardized forms, in order to test whether or not arts therapy is
an effective adjunctive form of therapy. We suggest that a small series of
randomized, controlled studies in this area be conducted. In addition, we
support pursuit of short- and long-term follow-up data from basic outcome
studies.
The question of standardization within arts-based therapies must be
addressed. It is vital for purposes of replication that at least one standard-
ized, replicable arts therapy model is tested within a randomized, controlled
study. However, homogeneity for the sole purpose of “quality” or “correct”
scientific research may alienate a core concept in arts therapy, the process
of individualized expression. It is possible that standardization of arts-based
therapies for the purpose of study may undermine the inherent therapeutic
benefits. By requiring the standardization of arts based therapies for the
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Arts-Based Therapies in Treatment 139
purpose of empirical validation, are we in some sense changing the spirit of
this practice? Perhaps evidence-based practice and best practice are not
always the same (Driever, 2002).
According to the American Psychiatric Association (APA, 2000), type of
care selection for clients who have an eating disorder is not only based on
empirical evidence, but on clinical judgment and availability of care
(Vandereycken, 2003). It is possible that arts therapy is not a therapy in a
traditional sense, but is in fact a basic standard of care (Aldridge, 2003).
Specifically, it may be that arts therapy is an important addition for eating
disordered patients that allows for an alternative means of expression and
communication within the context of traditional milieus of therapeutic care
and treatment. However, it remains important to better understand the
effectiveness of arts therapy.
This study has some limitations. First, while this review presented
revealing information regarding arts-based therapies in the treatment of eat-
ing disorders, the limited scope of the survey does not allow for generaliza-
tion to inpatient, partial or outpatient treatment programs for eating
disorders, even though generalization may be implied. Second, the survey
did not ask whether each program utilized a standardized curriculum for
arts-based therapies. While a review of scientific literature did not reveal a
widely accepted or employed, standardized form of arts-based therapy in
the treatment of eating disorders, it is not clear whether any residential
programs have developed and/or tested effective forms of standardized arts-
based therapies. Therefore, it is possible that the standardization problems
outlined within this discussion are less significant than suggested.
Several questions were raised by the study. How do scientists validate
and support the use of such individualized forms of experientially oriented
therapies? If arts therapies are indeed only one small aspect of complex,
multimodal client care, does it make a difference whether or not arts ther-
apy has a positive impact that leads to progressive client change? Arts ther-
apy does not cause any known harm to patients; it has been used on
inpatient units at psychiatric hospitals for decades (Junge, 1994), long
before its application to the treatment of eating disorders. Yet without sys-
tematic study, important questions remain unanswered.
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