Trauma Informed
Pluralistic Art Psychotherapy & Psychotherapy

'Trauma Informed Pluralistic Art Psychotherapy'
& Trauma Informed Pluralistic Psychotherapy

- an integrative framework for practice  

(Sibbett, 2003, 2014, 2016, 2019). Drawing on: (Cooper & McLeod, 2011, 2015; McLeod, 2015, 2018; McLeod & Sundet, 2016; Cooper & Dryden, 2016)
and (Harris & Fallot, 2001; Fallot & Harris, 2009; SAMHSA, 2014; Sweeney et al, 2016).

We have seen that Psychotherapy and Art Psychotherapy practice needs to be ethical, legal, characterized by good governance and evidence-based. This needs to be guided by a coherent approach which enables the practitioner to be able to articulate a sound therapeutic rationale. The capacity in Art Psychotherapists to understand theory and apply it to practice is a requirement of the Health and Care Profession’s (HCPC, 2023) Standards of Proficiency – Arts Therapists and the British Association of Art Therapists’ (BAAT, 2019) Code of Ethics and Principles of Professional Practice for Art Therapists. The HCPC specifically requires that art therapists should “employ a coherent approach to the therapeutic process” (HCPC, 2023: 12.10) and “understand that while art therapy has a number of frames of reference, they must adopt a coherent approach to their therapy, including the relationship between theory, research and practice and the relevant aspects of connected disciplines” (HCPC, 2023: 12.16), such as visual arts, aesthetics, anthropology, psychology, psychiatry, sociology, psychotherapy, and medicine (HCPC, 2013). In psychotherapy, a coherent approach that enables the inclusion of various frames of reference and theories is known as an integrative framework.

Evolving from my initial trauma informed approach in Art Psychotherapy originating in the 1990s in NI, I have proposed an integrative framework in Art Psychotherapy, specifically: ‘Trauma Informed Pluralistic Art Psychotherapy’ (Sibbett, 2014, 2016, 2019) and also Trauma Informed Pluralistic Psychotherapy. This offers “a coherent approach” (HCPC, 2023: 12.10) that synthesises pluralistic practice, an evidence-based contemporary integrative psychotherapy framework, mapped to trauma informed care principles and to Art Psychotherapy.

This framework, which I proposed and adhere to, is grounded in and committed to an integrative model of health that is grounded in the biopsychosocial paradigm (Engel, 1977) and biopsychosocial-spiritual (Sulmasy, 2006) and eco dimensions of healthcare. It features a pluralistic commitment to respecting and promoting diversity and practice that is relational, systemic and ethical.

This paper explores how pluralism, trauma informed care, Art Psychotherapy and Pluralistic Psychotherapy interact. For me, a pluralistic approach encompasses a number of dimensions that inform the integrative framework and guide my relational systemic practice.

1. Firstly, a pluralistic way of being is a way of regarding and valuing others, celebrating diversity and promoting rights, such as choice and agency. Pluralistic art psychotherapy and psychotherapy features an ‘I-Thou’ stance (Buber, 1958) relating to the person and their art, characterised by reverence.  I also extend this reverence to our other companion life-forms on Earth and to the “more-than-human world” (Abram).

2. Secondly, a pluralistic professional attitude honours all other bona fide theories and orientations of helping; and features an openness to signposting to these, based on client needs and preferences. This respects diverse therapies, including talking therapies, creative therapies, and nature-based modalities, as well as wider health and social care. Multidisciplinary practice, therapeutic teamwork, and interprofessional learning are also all valued. Openness to referring to evidence-based trauma specific support is consistent with contemporary trauma informed care principles.

3. Thirdly, underpinned by the above two, pluralistic practice is a holistic, biopsychosocial, inclusive, and collaborative approach to clients and their creativity. It is a coherent approach where pluralism is practised across orientations, clients, and perspectives.    See also Sibbett (2019).

The core components of the ‘Trauma Informed Pluralistic Art Psychotherapy’ and Trauma Informed Pluralistic Psychotherapy integrative framework are summarised and elaborated on below in Figure 1. This depicts the underpinning Trauma Informed Care principles which guide the 3 pillars of pluralistic practice and the overarching values and research informing practice.

Figure 1 (below) depicts an overview of ‘Trauma Informed Pluralistic Art Psychotherapy’ and Trauma Informed Pluralistic Psychotherapy, i.e. synthesised with the trauma informed care principles.

The core components of ‘Trauma Informed Pluralistic Art Psychotherapy’ and Trauma Informed Pluralistic Psychotherapy are outlined in more detail below.

⭐ PLURALISTIC - The pluralistic approach is a philosophical and ethical stance and is a major contemporary framework in psychotherapy (Cooper & McLeod, 2011, 2015; McLeod, 2018). My proposal is that this is relevant in, and can be applied to, Art Psychotherapy and can provide a useful integrative framework for practice. Applying a pluralistic framework is consistent with Burt’s (2011: 236) assertion that “Postmodern art therapy is particularly sensitive to pluralism”. It is also consistent with Hogan’s (2003: 191) view that “The art process within the art therapeutic relationship has the capacity to hold a polytheistic view of the clients’ inner world. Thus, the process of healing has many sources of meaning, direction and value. … Integrated and pluralistic art therapy approaches will create an inclusive, flexible and receptive environment for an increasingly multicultural population.” A pluralistic approach is also relevant to art therapy research (Waller, 2015, p.x) and, in art therapy, Gilroy (2011) proposes that a pluralistic evidence base should be developed which, whilst systematic and particular to client population, is neither prescriptive nor constrained by diagnostic criteria.

The ‘Trauma Informed Pluralistic Art Psychotherapy’ & Trauma Informed Pluralistic Psychotherapy integrative framework is founded on a relational orientation, and can be informed by humanistic / existential, psychodynamic, attachment, mentalization, object relations, compassion-focused, neuroscience, social justice, transpersonal, systemic and ecopsychological understandings, trauma informed care principles, and evidence-based research. This is consistent with BAAT’s (2019) approach which promotes relational attachment and mentalization based practice informed by wider modalities. The framework is underpinned by abiding within ethical and professional standards and good clinical governance. Art Therapy is underpinned by psychodynamic, humanistic and existential models (Wood, 1998: 7-8) and the psychoanalytic / psychodynamic model is vital in the development of Art Psychotherapy (Wadeson, 1987; Fuller, 1983; Simon, 1999), as are contemporary holistic theories. The integrative pluralistic framework is consistent with the view that:

“Although influenced by psychoanalysis, art therapists have been inspired by theories such as attachment-based psychotherapy and have developed a broad range of client-centred approaches such as psycho-educational, mindfulness and mentalization-based treatments, compassion-focussed and cognitive analytic therapies, and socially engaged practice.”  (Galassi et al, 2022; BAAT, 2021 website)

Pluralism is both a way of thinking about the world and psychotherapy and a specific approach to practice (Cooper & McLeod, 2011, 2015). Pluralistic therapy “comprises a ‘meta-theory’ or practice framework that functions as a means of harnessing the ideas, knowledge and experience of both the client and the therapist.” (McLeod, 2018, p.2). Cooper (2021) states that the pluralistic approach is

“a collaborative, integrative perspective, deeply rooted in humanistic and person-centred values. Its fundamental premise is that each client is unique, and therefore may need different things from therapy. On this basis, the pluralistic approach creates a framework in which practitioners can integrate a wide variety of understandings and methods into their practice.”

A key element of this pluralistic approach is shared decision making: communicating with clients about what they want from therapy, and how they might most effectively be helped to get there. Therefore, one aspect that “is distinctive about a pluralistic perspective, is that it consists of integration ‘in the room’ rather than ‘on the therapist’s desk’ or ‘in the therapist’s head’.” (McLeod, 2015: 7). Pluralistic integrative practice draws on contemporary Art Therapy, psychotherapy, neuroscience. It is also grounded in and informed by “common factors” research (Asay & Lambert, 1999, 2008; Cooper, 2008; Norcross, 2011; Wampold, 2015; Wampold & Imel, 2015). This promotes evidence-based practice (EBP), informed by practice-based evidence (PBE) and underpinned by values-based practice (VBP).

In psychotherapy, pluralism adopts “a pluralistic stance in relation to knowledge and practice” (Dryden, 2013: 51) and is a “meta-model of therapy integration” (McLeod & Sundet, 2016: 160), underpinned by three “pillars” (Cooper & Dryden, 2016: 3-4):

1.    Pluralism across orientations –

• This features having an integrative approach and an openness to considering a variety of ways clients are affected by issues and a variety of ways of helping them (Cooper & Dryden, 2016: 3). This involves reflexive practice and an openness to, and critical evaluation of, multiple sources of knowledge including research, theory and personal experience (Cooper & Dryden, 2016: 4). It involves “taking a ‘both/and’ perspective, rather than an ‘either/or’ one”, thus challenging traditional ‘schoolism’ in therapy (Cooper & Dryden, 2016: 4). This is consistent with the HCPC's (2023) statement that: while art therapy "has a number of frames of reference", art therapists "must adopt a coherent approach to their therapy”. It is consistent with the BACP's (2024) requirement for a "coherent approach". 

• Pluralism across orientations features an openness to the diverse ways that clients can be affected and prefer to be helped. Pluralistic art psychotherapy draws on diverse theoretical orientations within one’s scope of practice, consistent with our professional body’s (BAAT) integrative approach, informed by person centred, psychodynamic, and other diverse theories. Here, there is an embracing of the diverse non-verbal, verbal and multi-sensory creative media and methods, guided by client needs. Pluralism in art therapy values multi-sensory knowing through making and symbolising, as well as knowing through thought and language. It aligns with the HCPC’s standards which stipulate that ‘while art therapy has a number of frames of reference’, art psychotherapists ‘must adopt a coherent approach’. Pluralistic art psychotherapy notes the diverse ways that creative practice can help, and also can harm, thus managing psychological and/or physical ‘arts-based risk’ and injury (Springham, 2008). This is supported by adherence to the ethical principle of non-maleficence (BACP).

• The pluralistic lens is also applied to the artworks and opens us to how a client's artwork may have fluid and multiple meanings for the client. In art therapy, this pluralistic openness across orientations is consistent with the view in art therapy that “All creative art is symbolic… a work of art retains this potency, and any attempt to interpret symbolic images totally can only end in ‘and – and – and’.  This is the essence of art as therapy and the therapist must beware of defining symbols as fixed signs” (Simon, 1997). McNiff (1992) writes that “Artistic images are never fixed and are incapable of being described absolutely.”

• Pluralistic art psychotherapy across orientations is also consistent with trauma-informed care principles  (SAMHSA, 2014; Sweeney et al, 2016) in that the relationship to clients and their art aims to ensure safety and ‘see through a trauma lens’. This is guided by trauma awareness, the minimisation and management of retraumatisation and vicarious traumatisation, and awareness of pathways to trauma-specific care – signposting, referral, co-ordination. It is grounded in a biopsychosocial approach. Practice is adapted according to clients’ needs, informed by diverse integrative and trauma sensitive frameworks. Pluralistic practice can be tailored across the spectrum of ways clients have been affected and how they use art and experiential processing, guided, for instance, by the ‘expressive therapies continuum‘ (Kagin & Lusebrink, 1978; Lusebrink, 2010; Hinz, 2020). This continuum maps diverse developmentally relevant ways of creative processing through sensory/kinaesthetic, perceptual/affective and cognitive/symbolic levels. In this way, pluralistic art psychotherapy aims to adapt to best fit a client’s trauma history, current functioning, and needs, guided by developmentally sensitive and neurobiologically informed trauma models (Beacon House, 2024; Perry, 2006; Perry & Dobson, 2013).

2.     Pluralism across clients –

• Recognising, valuing and celebrating diversity and client uniqueness (Cooper & Dryden, 2016: 3-4). Pluralistic practice involves “an ethical commitment to valuing diversity” (McLeod, 2017: 3). This is founded in a relational Humanistic/Existential way of being, characterized by adopting an “I-Thou” (Buber, 1958) stance (Cooper & Stumm, 2015: 140), a humanising attitude that values the presence of the parties in the encounter. This is also characterized by the communication of the following Person-Centred core conditions (Rogers, 1957, 1961): congruence, acceptance and empathy - and associated skills (Hanley et al, 2016: 101) which can facilitate therapeutic change (Cooper & McLeod, 2011). In pluralistic Art Psychotherapy, such conditions and skills are communicated both to the client and in relation to their art. The pluralistic approach is consistent with the HCPC’s (2023, 2024) requirements to promote respect and to be non-discriminatory and by adherence to the laws on non-discrimination.

• The provision of a bespoke approach tailored to specific client needs and goals, and maximising client strengths and creative resources (Cooper & Dryden, 2016: 3). The Art Psychotherapy is adapted to the needs and preferences of the client, as appropriate.

• Pluralism across clients refers to a prizing of the diversity of clients and their art, abiding within ethical commitments. Building on Rogerian core conditions, communicated in relation to the client and their art, the art psychotherapist acts as an informed ‘bricoleur’ adapting and tailoring practice. This is guided by client aims, choice, resources, and cultural beliefs and practises, including their cultural and individual symbolic language and meanings. The creative expression in art psychotherapy can offer a ‘pluralistic microcosm’ in which the client can engage in a dynamic process in which symbolic and metaphorical expression opens up multiple meanings and possibilities.

• Consistent with trauma informed care principles, the approach to the diversity of clients and their art is guided by: cultural awareness  / competence and sensitivity to the various complex types and effects of trauma, recognising historical & community-specific trauma, the impact of intersectionality, cultural healing potential, gender responsivity, and prizing diversity.

3.     Pluralism across perspectives –

• Adopting a collaborative partnership approach, advocating that both psychotherapist and client are active participants, sharing decision-making concerning goals, tasks and methods (Cooper & Dryden, 2016: 3). The Art Psychotherapist collaboratively co-creates a safe and effective therapeutic alliance. “Clients should be fully involved at every stage of the therapeutic process” (Cooper & Dryden, 2016: 4). The therapist invites metatherapeutic communication (e.g. about the therapeutic process, relationship, needs, goals and methods). This also involves collaborating with clients in gathering systematic feedback on the Art Psychotherapy, including using appropriate outcome measures and therapeutic alliance measures. 

• This is consistent with the HCPC’s (2023: 8.1; 2024) requirement that art therapists should “work in partnership with service users, carers", colleagues and others. A collaborative partnership approach is consistent with the drive for ‘co-production’ (DoH, 2016, 2018). Co-production is “a genuine partnership approach which brings people together to find shared solutions, In practice co-production involves partnering with people from the start to the end of any change that affects them. It works best when people are empowered to influence decision making and care delivery processes.” (DoH, 2018, p.9). “Fundamentally co-production is a deeply person centred approach and is based on ‘No decision about me without me’. It recognises the knowledge of people with lived experience is of equal value to staff experience and knowledge.” (DoH, 2018, pp.28, emphasis in original). A collaborative approach is also in line with the HCPC’s (2023) advocacy for “collective leadership” and compassionate leadership. and the need for “…a new leadership culture, a culture that recognises service users and carers also as leaders and moves away from command and control to collective leadership responsibility” (DoH, 2017, p.5). The pluralistic approach is consistent with the HCPC’s (2023, 2024) requirements to promote respect, and to work in partnership with service users and carers.

• In psychotherapy where art is made, pluralism across perspectives features a collaborative ‘triangular’ partnership between client, therapist, and art, all actively interacting. The art acts as a space-within-a-space, offering a ‘trialogue’ where topics can be approached directly and indirectly. Conscious and unconscious dynamics can operate, with multiple layers of processing. Conscious, voiced, unvoiced, multi-sensory, and unconscious goals and issues can be processed across the transference/countertransference triadic matrix. A topic that can feel too difficult to approach directly may be approached through the art and therapeutic relationship. It can be a space for processing that which is perceived to be unthinkable, unspeakable, unseeable, unhearable, untouchable... In the triadic space, clients can consciously focus on something, whilst the art process and later artwork reviews may reveal that something else was being processed more unconsciously. Pluralistic art psychotherapy engages in verbal/non-verbal/symbolic metatherapeutic communication, enabling clients to indicate their views and preferences, allowing adaptation of therapy. Where possible, systematic feedback is integrated into practice, co-creating the alliance. Ruptures and repairs across the triadic space are worked on. Within training, supervision and beyond, the HCPC (2023) requires art psychotherapists to engage in self practice, to develop insight through personal art therapy and to maintain ‘fitness to practise’ through ‘engagement in their own arts-based process’.

• Consistent with trauma informed care principles, across the triadic space, pluralistic art psychotherapists and psychotherapists work to maximise collaboration, mutuality, hope, empowerment, voice, choice, control, trustworthiness, transparency, and wider supportive partnerships. 

⭐ TRAUMA INFORMED – 

My trauma practice in art psychotherapy and counselling / psychotherapy began in the early 1990s in Northern Ireland, practising in community and forensic settings. In the mid and late 1990s I had trauma training, including training by Dr Charles Figley on trauma, working with PTSD, vicarious trauma and compassion fatigue. Trauma theory informed my practice (Figley, 1985, 1992; Herman, 1992; Felitti et al, 1998). Theories of Trauma Informed Care emerged from a seminal Adverse Childhood Experiences (ACE) study in the US (Felitti et al, 1998), work by Harris and Fallot (2001a&b), and subsequent international (SAMSHA, 2014) and UK research (Sweeney et al, 2016). My practice was guided by these  theories and findings and further guided by SAMSHA's (2014) outlining of Trauma Informed Care (TIC) assumptions and principles. 

• TIC Assumptions (SAMSHA, 2014): "a basic realization about trauma and understand how trauma can affect families, groups, organizations, and communities as well as individuals." Ability "to recognize the signs of trauma." "The program, organization, or system responds by applying the principles of a trauma-informed approach to all areas of functioning." "A trauma-informed approach seeks to resist re-traumatization of clients as well as staff." 

• TIC Principles (SAMSHA, 2014): "Six key principles of a trauma-informed approach: 1. Safety.  2. Trustworthiness and Transparency.  3. Peer Support.  4. Collaboration and Mutuality.  5. Empowerment, Voice and Choice.  6. Cultural, Historical, and Gender Issues." (SAMSHA, 2014).

Consistent with this, the ‘Trauma Informed Pluralistic Art Psychotherapy’ & Trauma Informed Pluralistic Psychotherapy integrative framework aims to promote and develop trauma informed care and practice (Evans & Coccoma, 2014; Steele & Malchiodi, 2012; Sweeney et al, 2016). This is grounded in the trauma informed care core principles, adapted from: Sweeney et al (2016) and SAMHSA (2014):

1.   Trauma awareness – recognise prevalence, types, levels & impacts of trauma;

2.   Eliminating retraumatisiation – managing power & avoiding retraumatising practices;

3.   Cultural awareness / competence – recognising historical & community-specific trauma, impact of intersectionalities, cultural healing potential, gender responsive, prizing diversity;

4.   Trustworthiness, transparency – fidelity, building trust, openness;

5.   Collaboration, mutuality - power aware & sharing, shared decision-making, respect, connection, hope;

6.   Empowerment, choice, control – strengths-based approaches,
  building strengths & skills, individualised approach, promoting voice & autonomy;

7.   Safety – physical psychological, moral & cultural safety;

8.   Partnerships – survivor self/peer help;

9.   Pathways to trauma-specific care – signposting, referral, co-ordination.

This includes the application of attachment theory, particularly as applied in Art Therapy (BAAT, 2018; Malchiodi, 2008, 2011, 2014; Malchiodi & Crenshaw, 2013), and such as in clay work (Elbrecht & Antcliff, 2014). This draws on research showing how adverse childhood experiences (ACEs) (Felitti et al, 1998) and trauma can impact negatively on development and mental health (Van der Kolk, 2006, 2013, 2015). It also draws on neurodevelopmental research (Perry, 2008) showing the value of symbolic and sensory-based “bottom up” approaches (Grabbe & Miller-Karas, 2018) and synthesising “bottom up” and “top down” processing when addressing trauma (Ogden et al, 2006).

Trauma informed care (TIC) involves: building an understanding of the prevalence and impact of trauma and avoiding re-traumatisation (Harris & Fallot, 2001a); making a paradigm shift from dependence on the medical model (Harris & Fallot, 2001b); viewing symptomology and risk-taking behaviours as normal in the sequelae of trauma, rather than pathologizing them. It also involves understanding the complex pathways to healing, managing vicarious trauma through professional self-care, supervision and art process, and being committed to safety and ‘do no harm’ (Beauchamp & Childress, 1994).

Trauma informed care is particularly relevant in view of Northern Ireland ‘post-conflict’ setting and current understandings of types and levels of trauma and vicarious trauma, adverse childhood experiences, developmental trauma, abuse and conflict-related trauma. It has been suggested that NI has the highest levels of mental health problems, self-harm and also suicide in the UK.

“Northern Ireland has catastrophic levels of mental ill health. … our society is blighted by transgenerational trauma. … As we mark the twentieth anniversary of the Belfast Agreement in April 2018, the message from mental health organisations is clear: there can never be real peace in Northern Ireland until we have peaceful minds. The collapse of the Northern Ireland Assembly has worsened Northern Ireland’s mental health crisis.” (Action Mental Health, 2018)

I believe that a core aspect of pluralistic art psychotherapy and psychotherapy is communicating to the other person that they and their creative potential matter; as do their unique experiences, needs, preferences, creations, future aims, and power of choice. Building on these values, the approach is one of benign, caring, creative collaboration and empowerment. Pluralistic art psychotherapy encompasses verbal, multi-sensory, symbolic, non-verbal, and unconscious projective processes; featuring a collaborative and bespoke co-creative matrix and ‘trialogue’, offering creative opportunities for constructive change.

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