Trauma Informed
Pluralistic Art Psychotherapy & Psychotherapy

A coherent approach - an integrative framework for practice

Practice in art therapy / art psychotherapy and counselling / psychotherapy requires "a coherent approach" (HCPC, 2023, BACP, 2022).  This is necessary also when supervising therapy or teaching therapy. 

In its Standards of Proficiency - Arts Therapists, the HCPC (2023) states that: while art therapy "has a number of frames of reference", art therapists "must adopt a coherent approach to their therapy”. Art therapy / art psychotherapy is a form of psychotherapy (BAAT, 2024). The British Association for Counselling and Psychotherapy (2024), in its accreditation requirements, states that practitioners need to: 

"show a clear link between your way of working and the theory or theories that inform your approach... explain how you bring these together to form a consistent way of working. Consider the different theories that underpin these concepts and how they sit together with your main theoretical base. Explain what prompts your use of interventions from these different approaches and how you bring them together into a coherent approach. ... how you bring these two very different approaches together to make a coherent whole."

The word coherent means that something is "logically or aesthetically ordered or integrated" (Merriam-Webster Dictionary), and "is clear and carefully considered, and each part of it connects or follows in a natural or reasonable way" (Cambridge Dictionary). In counselling / psychotherapy, "integrative counselling is a combined approach to psychotherapy that brings together different elements of specific therapies" (Counselling Directory). Therefore, for me, consistent with HCPC and BACP requirements, 'a coherent approach' needs to feature a coherent whole (BACP) with an integrative framework which connects and guides its diverse elements, i.e. its theories and interventions (BACP) or frames of reference (HCPC). The integrative framework explains how the elements are brought together to form a consistent way of working.

The coherent approach I have adopted is a coherent whole with a CORE of good governance, ethics and laws and related standards. This core supports and nourishes an integrative framework guiding the diverse ELEMENTS of evidence-based theories and associated interventions and other competences. My integrative framework is 'trauma-informed pluralistic art psychotherapy' (Sibbett, 2003, 2014, 2016, 2019) and Trauma Informed pluralistic counselling / psychotherapy (Cooper & McLeod, 2011, 2015; McLeod, 2015, 2018; McLeod & Sundet, 2016; Cooper & Dryden, 2016), i.e. synthesised with trauma awareness (Herman, 1992; Felitti et al, 1998) and the trauma informed care principles (Harris & Fallot, 2001; Fallot & Harris, 2009; SAMHSA, 2014; Sweeney et al, 2016)

I mainly use a metaphor or symbol of a tree to represent this coherent approach featuring a coherent whole with its CORE and integrative framework guiding its diverse ELEMENTS. This coherent approach grows in the earth of the eco-biopsychosocial paradigm, earth-caring values, and common factors research. 

This is expanded on below.

A coherent approach in
Art Psychotherapy / Art Therapy / Psychotherapy / Supervision / Training.

Tree metaphor:
a coherent whole
with a GOVERNANCE CORE
supporting an
INTEGRATIVE FRAMEWORK guiding 
diverse ELEMENTS

CORE: The roots represent the governance core supporting the integrative framework guiding all its elements. This core features sound governance, ethics and laws and related standards, e.g.: HCPC's Standards of Proficiency (2024) and Standards of Conduct (2016/2024), BAAT's (2019) Code of Ethics and practice guidance, BACP's (2018) Ethical Framework and BACP's competence frameworks. The HCPC's (2023) Standards of Proficiency requires that art therapists practise “safely & effectively within their scope of practice”, in a way that is “ethical” and “legal”, and ensuring that there is explicit and valid “informed consent”. HCPC's (2024) Standards of Conduct require obtaining "valid consent, which is voluntary and informed" and state that practitioners "must keep up to date with and follow the law". This also requires that a clear contract is made with clients (BACP). BAAT (2019) also advocates that art therapy must ensure “a clear contract”, “informed consent”, risk management, records, data governance. Adherence with sound governance, ethics and laws requires ensuring “confidentiality”, “risk management”  and ensuring safeguarding. It is mandatory to ensure good record-keeping, information governance, “data governance”, adherence to GDPR requirements or equivalent, and non-discriminatory practice. Further requirements include:  “quality control, quality assurance” and “clinical governance” (HCPC, 2023). Governance also includes academic governance and research governance.

ELEMENTS: The leaves / foliage represent the diverse elements which are various theories & interventions used in Counselling/Psychotherapy and in Art Psychotherapy / Art Therapy. Integrative Counselling/Psychotherapy can draw on theories such as person-centred, psychodynamic, cognitive behavioural, etc (BACP). Art Psychotherapy can draw on diverse theories and also employs a wide range of art media: multi-sensory, drawing, painting, clay, fabric, natural and found objects, sandtray, play and performance art, digital, virtual reality, etc. Like Psychotherapy, Art Psychotherapy features a broad spectrum of practice: individual or group, from promoting health to mild or moderate or acute and complex care, in the community and third sector and statutory settings, indoor or outdoor, etc. Across the spectrum of practice, the practice must be grounded in good governance and be able to have a rationale for the interventions. 

INTEGRATIVE FRAMEWORK: The trunk & branches represent the integrative framework guiding all these elements. Therapists must have a sound clinical, theoretical evidence-based rationale for drawing on theories, interventions and uses of media. This requires having a guiding coherent integrative framework. My integrative framework is 'trauma-informed pluralistic art psychotherapy' (Sibbett, 2003, 2014, 2016, 2019) and pluralistic counselling / psychotherapy (Cooper & McLeod, 2011, 2015; McLeod, 2015, 2018; McLeod & Sundet, 2016; Cooper & Dryden, 2016) which I have synthesised with the trauma-informed care principles (Harris & Fallot, 2001; Fallot & Harris, 2009; SAMHSA, 2014; Sweeney et al, 2016). This framework embraces pluralism and pluralistic practice and features diverse evidence-based theories and practices. A key feature of this coherent approach is that it is collaborative, tailored and promotes co-production, consistent with the Department of Health NI (2018) direction. It features working "in partnership with service users and carers", empowering them, consistent with the HCPC's Standards of Conduct (2024) and Standards of Proficiency (2023). The framework is evidence-based, i.e. grounded in research including common factors research. The integrative framework ensures that there is a rationale and  explanation for what prompts the use of theories and interventions from different approaches, and it explains how they form a consistent way of working and are brought together into a coherent approach (BACP).

The integrative framework has a relational foundation, informed by a range of theories: humanistic, attachment, mentalization, psychodynamic, transpersonal, social justice, systemic, environmental, neuroscience, anthropology, art theories etc. Art Psychotherapy / Art Therapy features a broad spectrum of practice using diverse art media: multi-sensory, drawing, painting, clay, fabric, natural and found objects, sandtray, play and performance art, digital, virtual reality, etc.

'Trauma Informed Pluralistic Art Psychotherapy'
& Trauma Informed Pluralistic Counselling / 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 Counselling / 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). The British Association for Counselling and Psychotherapy (2024), in its accreditation requirements, states that practitioners need to show "a coherent approach." 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.

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. In Art Psychotherapy, this is consistent with BAAT’s (2019) approach which promotes relational attachment and mentalization based practice informed by wider modalities. 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)

The framework is underpinned by abiding within ethical and professional standards and good clinical governance.

 

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

 

2.     Pluralism across clients

 

3.     Pluralism across perspectives

 

 

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 with people affected by various types of trauma, including conflict-related trauma. 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 (2014) and Sweeney et al (2016) outlining Trauma Informed Care (TIC) assumptions and principles. 


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 awarenessrecognise 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 Counselling / Psychotherapy and 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 trauma informed pluralistic counselling / psychotherapy and trauma informed pluralistic art psychotherapy is communicating to the other person that they matter and their creative potential matters; 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.


Co-production

Professor Elinor Ostrom coined the term 'co-production' in the 1970s and described it as ‘…the process through which inputs used to produce a good or service are contributed by individuals who are not in the same organisation’ (Ostrom, 1996: 1073), further clarifying that "We developed the term co-production to describe the potential relationships that could exist between the ‘regular producers’ (street–level police officers, school teachers, or health workers) and ‘clients’ who want to be transformed by the service into safer, better educated or healthier persons." (Ostrom, 1996: 1079). The concept of co-production was further developed by Cahn (2000). In the UK, the New Economics Foundation (NEF) defined co-production as "A relationship where professionals and citizens share power to plan and deliver support together, recognising that both have vital contributions to make in order to improve quality of life for people and communities." (Social Care Institute for Excellence, 2015: 7). NEF also outlined six principles of co-production:

"Building on people’s existing capabilities
Mutuality and reciprocity
Peer support networks
Blurring distinctions
Facilitating rather than delivering
Recognising people as assets" (Boyle et al, 2010: 5). 


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