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Riding the wake: Detailing the art therapy delivered in the MATISSE study

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Riding the wake: Detailing the art therapy delivered

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Sue Patterson, Diane Waller, Helen Killaspy & Mike J. Crawford
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To cite this article: Sue Patterson, Diane Waller, Helen Killaspy & Mike J. Crawford (2015) Riding the wake: Detailing
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Vol. 20, No. 1, 28–38, http://dx.doi.org/10.1080/17454832.2014.993666

Riding the wake: Detailing the art therapy delivered in the MATISSE study

SUE PATTERSON, DIANE WALLER, HELEN KILLASPY & MIKE J. CRAWFORD

Abstract
Art therapists have been unsettled by the findings of a pragmatic randomised controlled trial testing the addition of group-
based art therapy to standard care for people diagnosed with schizophrenia. Arguments that the therapy tested was not
that routinely delivered in the UK have been fuelled by the arguably scant descriptions of therapy published to date. To
inform the important debate about implications of findings, we provide a comprehensive description of therapy delivered in
MATISSE. Drawing on accounts of therapists, their supervisors and participants and study documents, we articulate the
three models used to deliver therapy. Described as modified studio, phased group and potentially interactive art therapy,
the models were differentiated by structure and the degree of interpersonal and types of therapeutic interaction encouraged.
Therapists, it seems, began with their ‘usual’ practice and while remaining true to their ethos, modified that to fit the trial
context and participants’ needs. Such adaptation is consistent with the principles of pragmatic trials which seek to test
interventions in circumstances approximating the ‘real world’. MATISSE provides a piece of the puzzle but a plurality
of evidence is needed before ‘calling time’ on the debate about the usefulness of art therapy for people diagnosed with
schizophrenia.

Keywords: Art therapy, models, group, randomised controlled trial, process evaluation, qualitative
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Background effectiveness—whether an intervention does

Internationally, policy and clinical guidelines are
grounded in the view that mental health care
should be ‘evidence based’. A number of
research methods can generate evidence but not
all evidence is valued equally within the prevailing
evidence-based approach. Consistent with the
positivist scientific paradigm within which
evidence-based medicine (EBM) emerged, valid
and reliable quantitative evidence of cause and
effect is accorded the greatest weight. Thus, the
randomised controlled trial (RCT), deemed the
most robust way to test hypothesised
relationships, is regarded as the ‘gold standard’
research method. Archie Cochrane’s view that
evidence from RCTs was ‘key to a rational health
service’ (Cochrane, 1979) has become
normative.
Use of the RCT, introduced to medicine to test
streptomycin in the treatment of tuberculosis in
the 1940s, has grown exponentially with the rise
of EBM. The method has evolved over time such
that the contemporary RCT is multifarious,
applied in complex settings including mental
health services, to test diverse interventions
(such as psychotherapies) which are much more
complex than a simple pharmaceutical. While
arguments for dimensional rather than categorical
descriptions of trials are made (Tansella,
Thornicroft, Barbui, Cipriani, & Saraceno, 2006),
a fundamental distinction is drawn between trials
designed to test efficacy—whether an
intervention can work—and those concerned with
© 2015 British Association of Art Therapists
more good than harm in the circumstances of
usual care (Cochrane, 1979). Following Schwartz
and Lellouch (1967/2009), who described how
attitudes towards the purpose of trials governed
design, the former are commonly referred to as
‘explanatory’ and the latter as ‘pragmatic’.
Pragmatic trials are the approach of choice
where investigators are concerned with practical
outcomes. The tight controls (which characterise
trials of efficacy) are relaxed: sample, intervention
and environment are standardised to approximate
the conditions within which findings are likely to
be applied as closely as possible (Wells, 1999).
Findings of pragmatic trials thus have more
external validity; the increased generalisability,
however, comes at a price. Reduction of internal
validity compromises the cause-effect chain,
making interpretation and application of findings
difficult. This is especially challenging with multi-
component interventions where mechanisms of
action are difficult to identify (complex
interventions) (MRC, 2008). While the method
provides information to answer ‘what works’, it
does not explain for whom, or how. It has thus
been argued extensively that findings of RCTs of
complex interventions must be interpreted and
applied cautiously (Hawe, Sheill, & Reiley, 2004;
Oakley, Strange, Bonnell, Allen, & Stephenson,
2006; Weaver, Ritchie, & Tyrer, 2003). If the null
hypothesis (i.e. that the intervention has no effect)
being tested is rejected, indicating that the
intervention works, a lack of clarity about active

ingredients, mechanism(s) of action and
contextual influences on outcome hinders further
implementation. If findings are marginal or
‘negative’, it may be difficult to differentiate
between problems with the intervention and the
design or conduct of the evaluation (type III error).
In such circumstances stakeholders may contest
interpretation; rather than providing a blueprint for
the way forward, the evidence then represents a
dilemma (Glasby & Beresford, 2006).
Such is the situation ‘in the wake of’ MATISSE
(Wood, 2013), a pragmatic RCT that tested the
effectiveness of the addition of group-based art
therapy to standard care for people diagnosed
with schizophrenia (Crawford et al., 2010, 2012a,
2012b). The conclusion of MATISSE investigators
that ‘referring people with established
schizophrenia to group art therapy as delivered in
this trial did not improve global function, mental
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health or other health related outcomes’
(Crawford et al., 2012b, p. 4) has, as predicted
(Kendall, 2012), ‘unsettled’ the profession of art
therapy. Asking ‘does art therapy really have
nothing to offer people with a diagnosis of
schizophrenia?’ Holtum and Huet ‘studied the
MATISSE reports to determine whether radical
changes were needed in art therapy or whether
the trial’s conclusion should be challenged’
(2014). Among the areas of concern identified by
these authors and Wood (2013) has been the
apparent failure of investigators to explicate
mechanisms of action and active ingredients of
art therapy and sufficiently describe art therapy
delivered and thus ‘tested’ in MATISSE.
We have previously described, from the
perspective of art therapists, the complex process
of art therapy, theories employed and potential
mechanisms of action in people with
schizophrenia (Patterson, Crawford, Ainsworth, &
Waller, 2011a). We have also described the
impact of slower than anticipated recruitment and
limited uptake of art therapy on establishment of
groups (Patterson, Kramo, Soteriou, & Crawford,
2010; Patterson, Crawford, et al., 2011a;
Patterson, Borschmann, & Waller, 2013).
However, as noted by Holtum and Huet (2014),
the descriptions of MATISSE art therapy
published to date have not detailed the nature
and format of therapy; more information is sought
on the structure and degree of interpersonal
interaction encouraged. To support further critical
interpretation of, and conversation about
MATISSE findings, we now redress these
perceived gaps.
MATISSE: Riding the wake 29
Methods
Findings derive from a process evaluation
conducted in conjunction with MATISSE.
Endorsed by MATISSE investigators, the study
had separate ethics approval (07/MRE12/27).
The process evaluation employed grounded
theory underpinned by constructivist propositions
as set out by Charmaz (2006). Rather than
assume an objective stance, constructivist
grounded theories acknowledge the ‘temporal,
cultural and structural contexts’ (Charmaz, 2000,
p. 524) within which the theory is developed.
Designed to explain the generation of
MATISSE findings, the process evaluation
underpinned a PhD thesis (Patterson, 2010)
critiquing the use of RCTs of complex
interventions in mental health care. The emergent
grounded theory ‘Practicing Pragmatism’
modelled the influence of socio-political,
contextual and personal variables on the
commissioning, design, implementation and
‘outcomes’ of MATISSE. Contextualised
description of study recruitment, and organisation
and delivery of art therapy and control
interventions (activity groups and treatment as
usual), were central concerns.
As is typical with grounded theory studies
(Charmaz, 2006; Glaser & Strauss, 1967), the
investigation evolved as data were iteratively
collected and analysed. Data were collected by
SP through face-to-face interviews and focus
groups with diverse stakeholders (n=110) and
through participant and non-participant
observation of diverse MATISSE activities and
management meetings. Relevant policy,
commissioning and study documents were also
reviewed. (A detailed description of data used
including source, type and timing of collection is
available from the authors on request.)
The findings presented here draw on analysis
of study documents (protocol, fidelity proforma
from every MATISSE art therapy session,
transcripts of art therapy supervision sessions)
and accounts of MATISSE art therapists,
MATISSE art therapy supervisors and
participants collected in interviews and focus
groups (therapists only) over the course of
MATISSE. Recruitment for interview/focus groups
and data collection were undertaken by SP. All
MATISSE therapists (known to SP as a member
of the MATISSE team) were invited to participate
by email or in person during the course of
MATISSE activities (e.g. attendance at meetings).
MATISSE participants were contacted by phone
after they provided permission to be contacted in
relation to the process study to either a MATISSE
therapist or research associate. Interviews/focus
 30 S. Patterson et al.
groups were conducted in English in venues
chosen by participants, using topic guides
relevant to the participant’s role. Therapists were
asked to describe, inter alia, experiences
providing and views about art therapy (theoretical
orientations, models employed, potential
mechanisms of action, role of image-making),
generally and in MATISSE. Influences on practice
in MATISSE and experience of being part of the
study were explored in detail. Therapists were
asked specifically about group work,
management of interaction and structure of
sessions. MATISSE participants were
encouraged to describe and explore their
experience of participation in the study and
allocated intervention, reasons for taking part and
perceived outcomes. Art therapy participants
were asked about relationships with the therapist,
other group members and art-making. Interviews/
focus groups were audio-recorded and
transcribed for analysis. Analysis involved using a
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constant comparative process to support multi-
level coding. As described by Charmaz (2006),
coding operated at three levels: initial, focused
and theoretical. Initial coding, undertaken as data
were available, involved allocation of descriptive
data-based codes to ‘chunks’ of text containing a
single idea. In focused coding, initial codes were
grouped thematically to form concepts. Data
under each concept were compared to identify
divergences and similarities. Theoretical coding
involved deeper analysis using constant
comparison and analytic questioning to abstract
categories and formation of networks in an ‘if…,
then…’ format.
While the account below represents an
integration of data from various sources, specific
sources are cited where possible. Documents are
named and quotations are attributed to MATISSE
participants, individual therapists (e.g. AT1) or to
the focus group (e.g. FG n) at which it was
collected. To avoid repeated publication,
reference is also made to previously published
papers as necessary.
Results
MATISSE therapists and usual practice
Art therapy was delivered in MATISSE by 16 art
therapists aged between 26 and 56, including 11
women, with varying experience. Registered with
the Health Professional Council for between one
and 23 years (median 12 years), therapists
reported working with various patient populations
in a range of settings. Experience of working with
people with a diagnosis of schizophrenia varied
widely, ranging from ‘none’ for newly graduated
therapists to decades for more experienced
therapists.
As described elsewhere (Patterson, Crawford,
et al., 2011a), therapists employed various
theoretical models in their practice but shared the
view that creation of images was communicative;
the process and content of images were
symbolic. The consensus among therapists was
that art therapy was a function of a tripartite
relationship involving therapist, participant and
image. Therapists all accepted responsibility for
containment and processing of individual and
group affect but their usual practice varied widely,
influenced by training and theoretical orientation.
With a single therapist reporting only providing
therapy to individuals, some form of group was
the most commonly employed therapy delivery
mechanism. Therapists reported using ‘open’ and
‘slow-open’ groups and studio-based models.
Open groups, commonly used on inpatient units,
afforded an opportunity for interested patients to
engage with art materials and therapists at given
times. Slow-open groups had a fixed number of
places (between five and nine), with new
members, selected using eligibility criteria and fit
with the group, introduced as places became
available. Two forms of studio-based therapy
were described. In one, participation involved art-
making during a scheduled session commonly in
a community studio, in the presence of a
therapist. In the second, participants used studio
space at their convenience during ‘opening
hours’; a therapist may or may not be present.
Created images would be explored subsequently
in scheduled individual sessions. Except where
art therapy was a component of time-limited
programmes, therapists argued that there was no
‘usual’ treatment duration. Participation was
typically ‘open-ended’, extending from a single
session to more than 10 years; periods of two to
three years were considered not uncommon.
Despite the apparent diversity, and although none
had prior to MATISSE provided time-limited art
therapy with groups comprised solely of people
diagnosed with schizophrenia, therapists
confirmed, when agreeing to take part in
MATISSE, that their usual practice was congruent
with MATISSE therapy guidelines (see Crawford,
et al., 2012) and that they could practise within
these.
Therapists reported being motivated to
participate in MATISSE by their ongoing
commitment to art therapy and the belief that
developing an evidence base was essential to the
professionalisation and credibility of art therapy.
For most, especially those who had worked within
the National Health Service (NHS) for extensive

periods, there was a sense of urgency which
contributed to a sense of ‘pressure’ to facilitate
successful conduct of MATISSE:
Because I’ve been an art therapist for 20 years
and been part of it expanding, I’m very aware of
what’s happening at a government level,
organised guidelines and the need for research
and how art therapy is potentially being squeezed
out because things that are just guidelines quite
quickly become rules and so, [MATISSE] is
extremely important. (FG3)
Others, however, acknowledged the tensions
involved and considered the process rather than
the outcome important:
[MATISSE] is risky. We could come out
demonstrating no benefit whatsoever, but
whatever we find is going to be very valuable …
we will know a lot more at the end than we did at
the beginning. If we get stuck on outcome we
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really are in trouble. We're going put ourselves
under awful pressure about running the groups
because you’ll want to do it right. (FG3)
As described previously (Patterson, Crawford,
et al., 2011a), therapists agreed that art therapy
had the potential to help people with experiences
consistent with a diagnosis of schizophrenia.
Underpinning this view was the understanding
that schizophrenia arose from psychotic anxiety
or psychotic mental structure, breakdown of ego
boundaries and identity fragmentation. In that
context, the adaptability of art therapy was
perceived as particularly valuable. Therapists
who typically considered a desire to connect
innate, unanimously endorsed the role of image
as a ‘space-holder’ (enabling safe therapist–
participant engagement) in working with people
with psychosis. They expressed divergent views,
however, about the extent to which interpersonal
interaction could be tolerated and should be
encouraged. These were reflected in therapy
delivered in MATISSE.
MATISSE art therapy
Schedules, setting and materials
MATISSE therapy was delivered, as scheduled,
in mental health and community facilities in
spaces of varying size and perceived suitability.
While some therapists ran groups in dedicated art
rooms with which they were familiar, others
experienced difficulties securing facilities, or with
the quality of the facilities they could find.
Relatively ‘minor’ problems reported involved
working in ‘unsuitable’ settings, for example in a
multi-purpose room that had to be ‘set up’ and
MATISSE: Riding the wake 31
cleared before and after each session. More
challenging issues included experiencing
intrusions during groups and having to repeatedly
negotiate access to space, and working with
facilities considered inadequate. A minority of
groups (in one centre) were convened in multiple
spaces over the 12-month study period. In
addition to the logistic challenges involved,
therapists were concerned that ‘transience’
potentially undermined the needed sense of
continuity, and thus worked hard to engender this
at an interpersonal level.
A range of materials were available in all
settings. While use depended on participants’
preferences, all groups had access to 3D
materials (clay/plasticine), paints, pencils and
crayons, collage materials, paper of various sizes
and textures, and resource books and
magazines. Proforma suggest that while in some
groups participants (individually and collectively)
consistently used the same materials, a wide
range was used in others.
The format of MATISSE art therapy and
interpersonal interaction
Delivery of art therapy within MATISSE was
multiply influenced; in addition to rate and uptake
of referral, contextual factors, therapist beliefs
and participant characteristics were important
influences on practice. Therapists, concerned to
maintain authenticity in practice while being
responsive to the needs of participants, began
with their own ‘usual practice’, modifying that to
varying degrees to fit the trial context.
Therapists’ accounts, supported by those of
participants, demonstrate the use of three models
of art therapy in MATISSE. Differentiated by
structure and the degree of interpersonal
interaction encouraged, these can be categorised
as: (1) the modified studio model; (2) the phased
group model; and (3) the potentially interactive
model.
(1) THE MODIFIED STUDIO MODEL
Off the back of a studio model really, the patients
come in, try and stay throughout, for the 90
minutes, and not a formal discussion period at the
end. But for us to be working together and I go
round and gently chat about how they were and
on the work they were making. (AT6)
‘Modified’ differentiates delivery in MATISSE
from the traditional studio-based interventions
from which ‘modern art therapy’ developed
 32 S. Patterson et al.
(Waller, 1993). Participants were welcomed and
invited to commence work individually, and
encouraged to stay for the duration of the
session. Each participant consistently occupied
an identified position, at either a shared or an
individual table, dependent on venue, over the
course of engagement. Described as ‘individual
art therapy in a group’ by one therapist, and
likened to gardening by another, participants
made art ‘in a space of their own’, establishing
personal terms of engagement with the materials
and the therapist. The degree to which
interpersonal communication was encouraged
varied, but therapists using this model agreed that
interaction between participants was not ‘social’.
There may be some interaction but no formal time
when the group comes together to, if you like,
experience itself as a group and its processes,
share looking at the imagery. (FG2)
As described by a participant:
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Ground rules are we don’t start chatting to one
another and socialising … we work as individuals;
there are other social groups if we want to talk,
but this is our own individual space to work on the
art therapy, and talk to [therapist].
Identifying the image as the focus of therapy,
therapists described minimising interpersonal
demands:
… a partial human relationship; there’s other
people, but not conversational or relationship
expectations. (AT5)
They reported ‘doodling’ or appearing to draw to
minimise participants’ awareness of being
observed, but described this image-making as
superficial. Their focus, they said, was on
participants’ process with interactions based on
the perceived ‘capacity of the individual’ to
tolerate this. Typically therapists began by
employing reflective ‘concrete’ language.
Like ‘isn’t that a bright picture?’ or ‘I like the way
you’ve drawn that’, ‘that seems very calm or
relaxing, I’d like to be there’ if it’s a picture of a
tropical island. (AT9)
Such image-mediated interactions were designed
to encourage intrapersonal work, with responses
used to gauge each participant’s capacity to
tolerate interpretive work which would be used as
deemed appropriate.
… work at a pace and a level the person felt
comfortable with; so you’re kind of assessing
people’s ability to engage … making comments,
interpretations and see how they’re picked
up. (AT2)
Participants and therapist were described as
sharing an identity as artists. Indeed, this was
considered the primary ‘therapeutic ingredient’ in
the modified studio model.
If someone says ‘I’ll swap you mental illness for
an identity as an artist instead of being mentally
ill’. Art will take them outside the illness. (FG3)
(2) THE PHASED GROUP MODEL
Art was from quarter past one until quarter to
three. We’d stop at quarter past two and talk
about our art…about colours we used, how
bright, and how dull some of them were, and what
did we think of our pictures? Chat about our art,
and our problems.
Used by the majority of therapists, across sites,
the ‘phased group model’ comprises three
phases: (1) coming together; (2) image-making;
and (3) sharing time. Some therapists used this
model from the outset but for others it evolved as
groups formed and matured. One therapist
reported adopting a modified studio model when
‘gathering didn’t seem to achieve anything’.
(1) Coming together: establishing a safe and
defended space
The brief (5–10 minutes) coming together period
was used by therapists to establish ‘presence’. To
ground participants in the therapeutic space,
therapists reported acknowledging and thanking
participants for attending and noting absences
before inviting participants to move to the image-
making area, select materials and begin work.
(2) Image-making
Image-making occurred at a communal table on
which therapists had placed a range of materials.
Therapists sat with participants; some made
images but their primary role was to observe.
Therapists described using observation of
material selection, image-making, content and
management to develop understanding of
individuals and the group.
I sit a bit off the table but still part of the group.
The art-making, it’s up to them. If they want to ask
questions, and often people do talk, and
interaction might happen individually with me but
it’s still heard in a group. (AT1)
There’s always periods when perhaps one person
really needs to take more from the group than the
others, but I still try and make it so that other
people don’t feel like they’re being cut out or they
don’t have a space. (AT4)
Therapists described different approaches to
interaction. Most viewed image-making as a time

for independent work in a ‘culture of quiet’,
although interaction would be tolerated. For
example, in relation to a discussion with
participants about comics they enjoyed as
children, one therapist wrote:
I permitted the interaction to continue as
[participant] still had ample time to re-engage with
art-making. (proforma)
Others reported supporting dialogue for various
reasons. For instance, participant comments
might be used by the therapist to encourage
connections between participants:
So, [participant] you said this, does that feel
similar to what [participant] was just saying?
Therapists emphasised that while such
interactions might ‘appear kind of social’, that was
not the intent.
Therapists who were more pro-interaction
facilitated this by offering observations about the
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qualities of images, typically pointing up
commonalities:
There is a lot of blue being used today.
There seems to be something about new
beginnings in the images.
Therapists reported occasionally moving around
the table engaging participants in individual
‘discrete’ conversation, enquiring for instance
about their week and current feelings, with a view
to exploring common issues further in
sharing time.
Therapists typically allocated 45–60 minutes for
image-making but managed time differently.
Whereas some had fixed timetables, others were
responsive to group process, drawing image-
making to a close when participants appeared
ready. Transition to the next phase—
contemplation and sharing—was managed in
various ways. In some groups a refreshment/
cigarette break was taken in a space away from
the art table to demarcate image-making from
verbal/social interaction.
(3) Sharing time
Gathering round, moving from being alone where
people are separate making art in their own
worlds, and then in discussion they
connect. (FG3)
In this phase, therapists worked to facilitate
participants’ movement from the separateness
and internal focus of image-making to
‘groupness’. This was organised differently by
each therapist using the model, influenced by
group dynamics and venue. Commonly,
MATISSE: Riding the wake 33
participants were invited to ‘display’ images, on
the art table, wall or floor. One therapist described
displaying images on a ‘wonderwall’ with
participants seated side by side to minimise the
need for eye contact, which was thought to hinder
communication. In some groups participants were
invited to comment on their image(s) in turn. In
others, an invitation to contemplate and comment
was made to the group collectively. Therapists
maintained that participants determined their level
of interaction:
If people want to say something about the art
then they can and you work with that, but I don’t
necessarily say could everyone comment
because the image is very personal. (AT5)
Interactions were generally image-centric and
mediated through the therapist, but therapists
reported spontaneous participant–participant
dialogue emerging as groups matured. Therapists
described adopting a bridging role, linking
participants, images and processes involved in
their making with each other and ‘real world’
experiences.
Sessions concluded with therapists thanking
participants for attending, providing reminders in
relation to any programme changes and
encouraging ongoing attendance.
Potentially interactive art therapy
Two therapists described providing the
opportunity to make images and engage in
conversation for the duration of the session.
A free-flow group, very amorphic. Haven’t split
painting and talking … some people don’t want to
stop, they want to paint. While people are
collecting materials or painting, talking might be
happening, I might interrupt or not … some
people join with what I’m saying, others don’t.
Sometimes nobody’s painting or talking and we
bring that up and say ‘oh this is … how does that
feel for you?’ Somehow they seem to be able to
paint and listen. (FG3)
However, this format was not always
‘comfortable’ for art therapists—‘It feels a very
awkward way to do it’ (AT8)—and interaction
quantity and quality was, it seems, somewhat
unpredictable. Data including therapists’ accounts
and proforma indicate that, in practice, these
sessions were similar to the modified studio model.
I’m not here to kind of develop the interaction
between other people, if it happens I’m delighted
but I don’t think it’s a, it’s not at all
necessary. (AT7)
 34 S. Patterson et al.
If there wasn’t time where you actually facilitated
some interaction, there wouldn’t be any. They will
spend an hour happily working in silence,
absolute silence. (FG3)
There’s a sense of separateness even though
they’re sat round a sort of a group of tables
together. It can be like drawing teeth trying to get
people to interact or whatever; takes a lot of effort
to do that, because it’s such a non-verbal
group. (FG3)
Group formation
Use of the term ‘group’ reflects the intention
rather than the actuality. While the protocol
envisaged groups with approximately eight
members commencing and completing 12
months of art therapy together, this was not
achieved. Formation, maintenance and cohesion
of groups were problematic to varying degrees
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across centres and sites, frustrating therapists
who were trying to achieve trial guidelines.
I was reluctant to start with only three people …
I’ve had experience of community groups before
… and they didn’t work out, starting with a small
number … but I appreciated it was important to
get started … felt very much as if I’ve been trying
to sort of make a group when it hasn’t been one.
More like a series of two individual relationships
really. (AT7)
However, as described by AT7, such difficulty was
not uncommon in routine practice. Acknowledging
the practical and personal challenges associated
with engaging fully in 12 months of weekly
therapy sessions, therapists generally adopted a
proactive but flexible approach to engagement
and attendance. From proforma:
MD arrived late, said he should have rung to let
me know … talked of punishment, a cane (‘you
must have one’) or writing lines. I told him that this
is his time; I am not imposing any kind of
punishment.
A asked to leave after 50 minutes. I offered a
short break with option to come back … reminded
him there was 35 minutes left. He replied with
finality ‘done enough’.
P stayed half an hour (20 minutes more than last
time) … felt that by suggesting half an hour, P
may settle, in due course, for the whole session.
They reported repeatedly phoning or writing to
motivate attendance at given sessions or
incremental engagement. Participants were
encouraged to attend for the duration of sessions
but therapists accepted that late arrival and early
departure were ‘par for the course’.
Therapeutic stance
Whichever model was employed, therapists
reported taking responsibility for the structure and
format of sessions and development of the
protected emotional space within which therapy
occurred. All reported working to meet the
expressed and perceived needs of participants
drawing on concepts of both art-in and art-as
therapy. Using their models of schizophrenia (see
Patterson, Crawford, 2011a) and their firm belief
in the potential of art therapy to help people with
psychotic mental structures, they tailored their
interventions to ‘meet people where they are’.
Without exception, therapists understood
communication in the broadest sense to
encompass verbal and artistic expression as well
as physical actions (e.g. leaving the room or
sitting passively). Within this context, therapists
endorsed understanding of their therapeutic
stance as ‘non-directive’ and reported
encouraging spontaneous engagement with art
materials rather than structuring sessions around
themes or activities.
I don’t set a theme, tell people what to do or set
up certain art materials. If people are stuck with
how to use something, a pen, or crayon, I might
show them a little, so it’s non-directive. (AT7)
Where therapists reported providing guidance
regarding technique or choice of materials, such
advice was described as a therapeutic
intervention rather than direction.
If somebody says I’d like to get this particular
effect, I wouldn’t blindly jump into that, I’d be
mindful of what’s happening and why they’re
asking, but if I felt they had a clear image in their
mind, and really wanted to put it down, I’d help
them but it would depend on them. (AT6)
As evident in the descriptions of the models of
therapy above, therapists’ views regarding the
role of verbal interaction within groups and the
degree to which group-interactive processes were
encouraged varied. Therapists all described
having deep respect for participants’ choices in
relation to engagement in verbal communication
and sharing of images, which are understood as
communication. Proforma indicate that therapists
were, at times, directive in their management of
specific situations, but in the main demonstrate
therapists’ approach as enabling participants’
verbal interaction, gently guiding the direction of

discussion and maintaining control of the
process.
Therapists’ accounts and data from supervision
sessions indicate attention to group process,
whichever format was followed, and that this
informed therapeutic intervention. However, while
therapists reported drawing attention to group
feeling or themes in images, group processes
were seldom explicitly addressed. There were
only occasional references in data to links made
between happenings or feelings in the group to
‘real world’ experiences.
Participants’ and therapists’ care of the art work
All therapists understood art work as clinical
material, to be respected, treated confidentially
and kept safe, and acknowledged their
responsibility as caretakers.
They agreed that participants should not
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damage another’s work and that disposal/
destruction of an image by its creator was
‘communication’. However, they managed the
latter differently; some ‘allowed’ permanent
disposal but others proposed storage in a ‘throw-
away’ folder, so that the image and symbolism
could be used in therapy.
Sometimes you might find somebody who does
something gets really frustrated with it and wants
to tear it up, destroy it, and that opens up the
possibility of thinking about frustration and how
they might deal with frustration in another
situation in their lives … an opportunity to work
through, make changes and adaptations. (AT6)
Everybody has an awareness of the importance
of what they are creating and … whether you
choose to trash that or not also has a kind of
significance. (AT13)
Overall, boundaries were implicit and managed
responsively by therapists. Although no therapists
had discussed boundaries or established ‘ground
rules’ with participants, they reported commitment
to the ‘principles of consistency’ inherent in this
guideline. Therapists’ establishment of their own
boundaries was described as fundamental to
creation of the safe space that provides the
context for therapy.
Art therapy in MATISSE
Analysis of therapists’ accounts, proforma and
transcripts of supervision sessions (see also
Patterson, Crawford, et al., 2011a) demonstrated
that while the format and theoretical approaches
of therapists differed, the art therapy delivered in
MATISSE: Riding the wake 35
MATISSE was underpinned by common values,
processes and practices, namely:
. The therapist provides and defends a space
within which participants’ emotional safety is
protected;
. The therapist is accepting and empathic,
containing and processing each participant’s
emotions as needed;
. Participants are enabled to titrate
engagement with therapist, art materials,
group members and group;
. Therapists titrate engagement and intervene
with participants according to their perceived
capacity to tolerate, and the potential benefit
of the relationship;
. The therapeutic relationship is a tripartite
comprising therapist, image and participant
and is attended to by the therapist;
. Art materials, art-making and created images
have agency and are integral to therapeutic
process: image creation is understood as
communication;
. Interpretation of transference and counter-
transference and symbolism of images are
internal processes of the therapist, only
rarely made visible;
. Therapy occurs in the here and now, in the
‘being with’ and witnessing;
. Therapy is process- rather than goal-
oriented, making definition of ‘outcomes’
problematic.
These principles provided the framework within
which specific interventions, tailored to match the
strengths and problems of each participant, were
delivered. Art therapy as provided in MATISSE
clearly resonates with Winnicott’s description of
psychotherapy as
[a]n activity that takes place in the overlap of two
areas of playing, that of the patient and that of the
therapist … where playing is not possible, then
the work done by the therapist is directed towards
bringing the patient from a state of not being able,
to play. (Winniccott, 1971, p. 38)
Discussion
With the aim of supporting generalisation and
rigorous discussion of MATISSE findings, we
have described the art therapy delivered in the
trial. Drawing on accounts of MATISSE therapists
and participants, and study documents, we have
outlined three distinct models of practice. Using
these models, grounded in their usual practice,
therapists worked within MATISSE guidelines to
deliver art therapy that was congruent with their
values. Therapists employed art both ‘as’ and ‘in’
therapy, dependent on the perceived needs of
 36 S. Patterson et al.
participants. Despite differences in structure and
contextual variability, each model was
underpinned by key principles enabling
encapsulation of the tested therapy with due
respect to flexibility of the approach. Before
considering the implications of these findings, we
acknowledge vulnerability to critique on the
grounds of bias and subjectivity inherent in
qualitative research.
Data were collected and analysed by a single
researcher making decisions about where and
how data would be collected in response to
questions developed with the story of MATISSE.
Personal qualities, professional training and
circumstance necessarily shaped decisions and
data in ways both knowable and implicit. Similarly,
subjectivity, the ‘garment that cannot be removed’
(Peshkin, 1988, p. 17), is inherent in participants’
accounts and informed interpretation of these
accounts. We also note that although data were
collected from various sources over the course of
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MATISSE, each interview, document or
observation reflects a point in time construction. It
is possible that those interviewed would have
reported different experiences at different times.
These concerns, however, are mitigated by the
longitudinal nature of analysis and the reflexive
approach taken. Use of multiple data sources
over the course of MATISSE enabled thorough
investigation of processes (including
development of therapeutic models) over time.
The account of MATISSE therapy presented here
was scrutinised as it was developed by MATISSE
therapists and MATISSE participants. Not least
because findings demonstrated that therapy
delivered differed from Interactive Group Art
Therapy described in the MATISSE protocol, they
were subject to robust interrogation by members
of the MATISSE team, including MC and DW.
Limitations notwithstanding, our comprehensive
description of MATISSE therapy provides
important information, the absence of which has
fuelled some critique of MATISSE. To allow
further interpretation of MATISSE findings, we
briefly examine the interlinked issues of
standardisation and similarity of therapy with
routine practice before examining implications for
research into art therapy.
Pragmatic RCTs are designed to test whether
an intervention effects change in a predetermined
outcome in circumstances approximating routine
care. Standardisation of the intervention is central
to the validity of the test; it behoves trialists to
know who is doing how much of what, to whom
and in which circumstances. However, because
pragmatic trials are designed to answer questions
of real world relevance, standardisation
particularly of complex interventions (such as art
therapy) may be of function rather than form
(Hawe, Shiell, & Riley, 2008). To enhance
generalisability, practitioners, who may have
varying skill levels, may be granted freedom to
use clinical judgement and treat patients
‘normally’ (Tansella et al., 2006).
Such was the case in MATISSE. While offered
in varying formats, the art therapy available to
MATISSE participants was as defined by the
British Association of Art Therapists: ‘a form of
psychotherapy that uses art media as its primary
mode of expression and communication … art is
not used as a diagnostic tool but as a medium to
address emotional issues which may be
confusing and distressing’. It was also, counter to
Woods’ assertion, consistent with art therapy as
currently practised in the UK (see Patterson,
Debate, Anju, Waller, & Crawford, 2011b). It may
also, given the identification of principles applied
across the study, be understood as
‘standardised’. Despite the inevitable differences
related to contextual, therapist and participant
variables, the therapy available to participants
was fundamentally similar. Therapists began with
their ‘usual’ practice and, exercising clinical
judgement, provided person-centred art therapy,
adapted to the needs of participants and setting.
Participants were offered the opportunity to
engage, at a level appropriate to them, in a
tripartite relationship within which the therapist
accepts responsibility for safety. Given art
therapists’ contention that the infinite variability of
art therapy is a key strength of the approach,
attempts at further prescription may be
unproductive.
Conclusion
Although the MATISSE study demonstrated that
the offer of art therapy had no impact on the
global function of people diagnosed with
schizophrenia who took part in the study, the
investigators have never claimed that art therapy
has nothing to offer, as suggested by Holtum and
Huet (2014). Indeed, as reported elsewhere,
those who engaged with art therapy reported
deriving substantial benefits from it. With
increasing pressure on finite resources, RCTs
such as MATISSE (and meta-analysis of findings
of multiple trials) may usefully inform resource
allocation at a population level. However, where
psychotherapy is concerned, a robust case can
be made that a fundamentally different kind of
evidence is needed to inform provision to
individuals. Recalling Bradford Hill’s wise
injunction that ‘if we ever believed that RCTs were

the only method to evaluate a treatment that the
pendulum would not only have swung too far, it
would have come off its hook’ (1965, p. 108), we
urge that ongoing consideration of MATISSE
findings be informed by rigorous study of for
whom, and how, the potential benefits of art
therapy can be realised.
Acknowledgements
This work would not have been possible without the support of
the MATISSE study team, including the art therapists whose good
will and cooperation, even as I critically examined their practice,
is gratefully acknowledged. We are also indebted to the
MATISSE participants who generously shared of their
experiences of the study and art therapy.
Funding
Research reported in this article was completed while Sue was
employed by Imperial College London as a research associate on
MATISSE. MATISSE was supported by the National Institute for
Health Research: Health Technology Assessment [grant number
04/39/01]. No separate funds were provided for process
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evaluation reported in the PhD.
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Biographical details
Sue Patterson is a health services researcher
currently working with health professionals,
managers and service users to integrate research in
mental health care. Trained as a psychologist, she
 38 S. Patterson et al.
worked clinically and in management of services in
Australia before moving to the UK to pursue a
research career. Her PhD, ‘Evidence for mental
health care: A grounded theory reconstruction of the
randomised controlled trial’, was based on a
comprehensive examination of the design and
conduct of MATISSE. Sue’s work is grounded in
critical theory and social constructionist views of
‘evidence’. Email: Susan.patterson@health.qld.
gov.au
Diane Waller is Emeritus Professor of Art
Psychotherapy, Goldsmiths, University of London
and Principal Research Fellow, School of Applied
Social Science, University of Brighton. As Honorary
Visiting Professor at Imperial College, she chairs the
International Centre for Research in the Arts
Therapies. She is the author of publications,
including ones that focus on art and design and
ethnography. Diane is an art psychotherapist and
group analyst and was recently on the Health and
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Care Professions Council. She is Honorary
President of the British Association of Art
Therapists. Her research interests are in mixed
methods, multidisciplinary projects to explore the
usefulness or not of art therapy, currently with
people with dementia, in stroke rehabilitation, with
substance abuse and eating disorders. Diane was
joint PI on the MATISSE study.
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Mike Crawford is Professor in Mental Health
Research at Imperial College London, an Honorary
Consultant Psychiatrist with Central & North West
London NHS Foundation Trust and Director of the
Centre for Quality Improvement at the Royal
College of Psychiatrists. Mike’s primary academic
interest is in mental health services research,
particularly the development and evaluation of
psychosocial interventions for people with complex
mental health needs, such as those with personality
disorder and psychoses. Current projects include
clinical trials of creative therapies, brief intervention
for alcohol misuse and problem-solving therapy. He
was joint PI on the MATISSE study.
Helen Killaspy is Professor of Rehabilitation
Psychiatry at University College London and
Honorary Consultant in Rehabilitation Psychiatry
with Camden and Islington NHS Foundation Trust.
Her research focuses on the development and
evaluation of mental health interventions and
services for people with complex psychosis. She is
currently leading two national programmes of
research in England into mental health rehabilitation
services and specialist supported accommodation
services for people with mental health problems.
She was joint PI on the MATISSE study.