Art therapy in the promotion of mental health: an experience report

Objective: to report the experience of the use of art therapy as an instrument to promote mental health. Methodology: this is an experience report about the practice of art therapy carried out by nursing students in July 2019. The activity took place in a day hospital (partial hospitalization regime) and counted on the participation of 20 adult patients from 20 to 45 years old. The action was organized following the stages of planning, implementation, and discussion of the group activity. Results: the action aimed to provoke the participation of patients with mental disorders to favor clarifications, reduce distress, anxiety, and induce self-reflection. Patients participated in the activity in an effective way, expressing their feelings, emotions, or indicating some fact of their lives and routines that was in their production and meant happiness to them, as to promote their mental health. Conclusion: art therapy is important to provide a direct interaction between the therapeutic group and the professionals, since emotions and feelings were shared, in addition to the perception of patients about their own reality. Descriptors: Mental Health. Health Promotion. Psychiatric Nursing. Psychotherapy, Group. Occupational Therapy. RESUMO Objetivo: relatar a experiência da utilização da arteterapia como instrumento de promoção da saúde mental. Metodologia: trata-se de um relato de experiência de uma ação sobre a prática da arteterapia desenvolvida por acadêmicas de Enfermagem em julho de 2019. A atividade aconteceu em uma unidade de semi-internação de um Hospital-Dia e contou com a participação de 20 pacientes adultos com faixa etária entre 20 e 45 anos. A ação foi organizada seguindo as fases de planejamento, implementação e discussão da atividade em grupo. Resultados: a ação visou despertar a participação dos pacientes com transtornos mentais para favorecer esclarecimentos, reduzir inquietações, ansiedade e autorreflexão. Os pacientes participaram de forma efetiva da atividade, expressaram seus sentimentos, emoções, ou relataram algum fato da sua vida e cotidiano relacionado à sua produção que lhes significasse felicidade, de maneira a promover a sua saúde mental. Conclusão: conclui-se que a arteterapia é importante para fornecer interação direta entre o grupo terapêutico e os profissionais, visto que houve partilha de emoções e sentimentos, além da percepção dos pacientes sobre sua realidade. Descritores: Saúde Mental. Promoção da Saúde. Enfermagem Psiquiátrica. Psicoterapia de Grupo. Terapia Ocupacional. RESUMÉN Objetivo: informar sobre la experiencia en la utilización de la terapia artística como instrumento para promover la salud mental. Metodología: este es un informe de experiencia a respecto de una acción con práctica de terapia artística, desarrollado por académicos de enfermería en Julio, 2019. La actividad ocurrió en un hospital de día para hospitalización parcial, envolviendo 20 pacientes adultos entre 20 y 45 años. Se organizó a la acción siguiendo las etapas de planeo, implementación y discusión de la actividad en grupo. Resultados: el objetivo de la acción fue llevar a la participación de los pacientes con trastornos mentales y favorecer esclarecimientos, reducir inquietaciones, ansiedad, y provocar autorreflexión. Los pacientes participaron de la actividad de manera efectiva, expresando sus sentimientos, emociones, reportando algún hecho de sus vidas y cotidiano asociado a su producción artística que para ellos significaba felicidad, para promover su salud mental. Conclusión: la terapia artística es importante para fornecer una interacción directa entre el grupo terapéutico y los profesionales, ya que hubo la partilla de emociones y sentimientos, para allá de la percepción de los pacientes sobre su realidad. Descriptores: Salud Mental. Promoción de la Salud. Enfermería Psiquiátrica. Psicoterapia de Grupo. Terapia Ocupacional. ISSN: 2238-7234 Jansen RC, et al. Art therapy in the promotion.. 2 English Rev Enferm UFPI. 2021 10:e805. DOI: 1026694/reufpi.v10i1.805 INTRODUCTION In the mental asylum model, which predominated in Brazil for many years, people with mental disorders were isolated and institutionalized, undergoing many types of violence. In the 1970 decade, with the Psychiatric Reform, there were many changes in care, management, and health practice models. Based on the principle of deinstitutionalization and organization of a psychosocial care network, a new perspective was developed with regard to care as a tool of assistance.


INTRODUCTION
In the mental asylum model, which predominated in Brazil for many years, people with mental disorders were isolated and institutionalized, undergoing many types of violence. In the 1970 decade, with the Psychiatric Reform, there were many changes in care, management, and health practice models. Based on the principle of deinstitutionalization and organization of a psychosocial care network, a new perspective was developed with regard to care as a tool of assistance. (1) The pioneer in the use of occupational therapies to treat mental disorders was the Brazilian psychiatrist Nise da Silveira. She brought into mental health a humane treatment in 1956, proposing art as a mean to social rehabilitation. Through her work, Nise created three principles to develop activities, which were: liberty, efficiency, and activity. As a result, this therapeutic model was used in group activities, for patients to show their experiences and affective relations in an embracing environment, providing conditions for them to restructure their social lives. (2) Since then, the hospital-focused model and the medicalization have been replaced with other integrative health practices, whose objective is to implement natural mechanisms for promotion, prevention, and health recovery. (3) In 2017, art therapy was included in this set of new practices by the Ministry of Health, via Decree No. 849. (4) Art therapy is a technique used for the prevention, promotion, and rehabilitation of the individual. (5) This methodology can be applied to patients from all age groups and aims to aid the patient during physical and mental rehabilitation processes, despite being more common in the field of mental health. Many institutions use art therapy as a tool for the treatment of patients with psychic disorders, aiming to improve their illness or mental condition. (6) Art therapy is considered to be a therapeutic resource capable of offering a more effective communication between professional and patient, allowing for the expression of feelings that would hardly be shared verbally. (7) In this context, this technique can be executed in many settings and circumstances, with individual or group application, and can be conducted by a professional from the multiprofessional team, which includes nurses, social workers, physical therapists, occupational therapists, physicians, and psychologists in many situations. (8)(9) Aiming to promote health and quality of life, artistic activities are used as health care tools, involving many expressive forms of art, such as painting, molding, sculpting, poetry, drawing, decoration, movies, theater, music, and dance. This tool can be applied by many professionals to different audiences, and its objective varies from the evaluation of the mental state to the rehabilitation, focusing on the health field. (10)(11) It stands out, therefore, that art is present in the daily life of society and can be an accessible resource for health promotion. The exercise of art therapy, in its many forms, makes social reinsertion possible, since, in pleasurable activities, the patient may feel embraced in the health network, which can lead to the resignification of their self-knowledge for the expression of ideas or feelings, encouraging their autonomy in a creative way, through art. (12) However, working with people with mental disorders requires professionals with special abilities, who can develop a therapeutic bond with the patient; as a result, the nurse is essential in this process. Regarding art therapy and the assistance to patients with psychosocial disorders, nursing can aid the patient through the application of manual or mechanical techniques that provide an environment for self-reflection. Consequently, this activity enables the recognition of one's mental state, thus leading to the improvement of the symptoms caused by mental disorders, providing the patients with a better quality of life during rehabilitation. (13) This study is justified by the importance of divulging a nursing intervention using art therapy. The experience report provides a better understanding about the technique used by nursing students under the supervision of the multiprofessional team of the day hospital (a hospital for partial hospitalization). The relevance of this study for the academic world is related to its contribution for future academic researches, since it can be replicated in other actions, contexts, and settings, in addition to offering support to the professional practice of nursing. Socially, it is an important source to raise the awareness of the population, and to make this article available is to disseminate scientific content about this approach.
Considering the above, the objective of this study is to report the experience of the use of art therapy as an instrument of mental health promotion.

METHODOLOGY
This is a descriptive experience-report study, created from the experience of students from the course of nursing from the Universidade da Integração Internacional da Lusofonia Afro-Brasileira, during their internship for the subject Processes of Caring in Mental Health. It was carried out in July 2019, in a hospital that is a reference for psychiatric treatment in Ceará.
The participants were 20 adult patients who were under partial hospitalization in a day-hospital for patients with mental disorders, which is part of the Single Health System. From the patients in the sample, eight were female and twelve male, and their age group was from 20 to 45 years old. The pathologies of the patients were bipolar disorder, schizophrenia, obsessive-compulsive disorder, depression, and anxiety.
An art therapy session was carried out which lasted for one hour and a half, and its execution was carried out following the stages of planning, implementation, and discussion of the group activity. During planning, the researchers decided to use directive art therapy, with instructions and the naming of the main subject: (14) "What makes you happy?". The place for the action was chosen, as well as the materials to construct a panel with the work of the patients. The panel was created with fabric by the Nursing students and included the sentence: "If it makes you smile, it's good for you". The techniques chosen for the implementation were collage and drawing. The implementation stage followed the routine protocol of the health service, receiving the patients and starting with stretching exercises directed by the day hospital nurse. After this moment, the patients were brought into the occupational therapy room for the activity and were accommodated in chairs and tables that were available in that environment. The workshop was directed by the Nursing students, who started by explaining the activity to be carried out and that the objective would be to demonstrate, through drawings and collages, an event/motive/person who makes them happy. The activity was supervised by health professionals of the service (occupational therapist, nurse, psychiatry residents) and by the professor who was responsible by the internship group.
In the discussion stage of the group activity, researchers addressed the perception of patients about the art built, and, by asking participants to sit in a circle, the interns encouraged them to share their production, emphasizing the reason why the art made brought them the feeling of happiness.
Since this is an experience report that describes only the vision of nursing students in the performance of an activity, carried out according to the ethical directives recommended by the National Council of Health through Resolution No. 466/2012, from December 2012, about the preservation of human dignity, human rights, and protection of the participants, (15) an approval from the Research Ethics Committee was not necessary.

RESULTS
Performing the activity made it possible to get to know the reasons or motives that led patients to moments of happiness. Its focus was encouraging expression through feelings, emotions, and reports, about the experience of the mental disorders and its relations with the self, the colleagues, and the health service.
The occupational therapy room of the hospital has resources for many activities, such as painting, games, music, dance, and plastic arts. These are mapped according to the routine of the service, and, from this point on, places are selected for carrying out interventions. Usually, the occupational therapists and/or nurse conducts the workshop, and patients are monitored by the multidisciplinary team, which comprises: occupational therapist, nursing team, psychiatrists, and psychiatry residents.
Regarding the activity carried out, nursing students, under the supervision of their preceptor and the other professionals in the multidisciplinary heath team, acted as mediators and observers of the group activity, presenting themselves as facilitators of the process, encouraging creativity, teamwork, productivity, self-esteem, self-confidence, and the potentials of the participants.
The collage and drawing techniques used in the proposal were chosen due to being easy to operationalize. Sixty minutes were defined for the development of the artistic productions through collage and drawing. The participants were offered newspapers, magazines, scissors with round tips, glue, white and colored sheets, colored pencils, and markers.
During the implementation stage, the challenges found were: dispute for painting materials and competitiveness regarding the best drawing between some patients. When these events were observed, the distribution of the mediators among participants was reorganized, and there were dialogs about individuality, in an attempt to diminish the feeling of competitiveness between them, since the way each one expresses themselves is singular. Therefore, it was possible to take more advantage from the participation and increase the concentration in the activity to be performed.
There was an attempt to let patients at will, so they could express themselves as comfortably as possible. The drawings represented relatives, favorite foods, cartoons, super-hero movies, electronic devices, football, solar system components, gardens, and trips. Eight patients, from a total of twenty, requested another A4 sheet to make another drawing/collage, stating that they wished to bring their art to their homes.
After the pieces were finished, people were asked to sit in a circle, for a conversation which started the discussion stage of the group activity. The patients were offered thirty minutes to present their art. At first, the group conversation was difficult, with some patients shying from public speaking. However, the colleagues that were present encouraged them to continue their presentation. The researchers find that this attitude stemmed from the dialog about respect, individuality, and non-competitiveness between the participants, which took place during the implementation stage.
After the results were shared, the arts were collected in a panel made out of fabric, which was fixed to one of the day hospital walls. At this time, happy faces were seen, and positive statements were made about the moment experienced with the art therapy, not to mention expressions of happiness about the activity. As the action was concluded, many patients reported feeling happy due to how different the activity they had carried out during hospitalization was. Furthermore, the playful nature of the action enabled it to develop naturally, pacifically, and harmoniously, making it easier to overcome any challenges.
This experience showed that the involvement of the patient in artistic activities has the potential to improve their interaction in the health services they are in. As a result, art therapy was found to be an effective therapeutic device for the improvement of the health conditions of the patient with mental disorders, as well as to promote their wellbeing. Furthermore, it is a preventive form of care, related to the diminution of health problems. (16) It should also be mentioned that art therapy is an activity that can be carried out in a short period of time, with little financial investment, as it uses simple low-cost and easily available materials, as this report shows. Carrying out this activity gave an opportunity for nursing students to develop abilities to lead therapeutic groups, notice conflicts, and solve them. In addition, the students could observe the practical functioning of a mental health hospital, the relationship between patients and professionals, and the use of non-pharmacological therapeutic technologies, making them more sensible to the situation of people with mental disorders.
Furthermore, the sharing of opinions with no prejudice or presuppositions, in this experience, allowed them to identify expressions, statements, and actions, making it easier to understand peculiarities of this field of action that could hardly be shown in theoretical classes. (17)

DISCUSSION
The first step to provide a humane attention to patients with mental disorders is to recognize the uniqueness of each individual, associated with the conditions related to their pathologies. It is essential to understand that the process involving health and mental disorders is the result of a complex and inseparable set of biological, social, and psychological conditions. Changing one's point of view about human experience due to mental disorders make it possible to better confront the problems inherent to therapy. (18) In this context, developing therapeutic workshops aims to rehabilitate individuals through their interests and needs, enabling the expression of subjectivities, the development of productive activities, dialog, and embracement. (13) During the activities, the individual can recognize better their internal problems, and, from that, attempt to solve them, which represents a form of care in mental health for the resignification of new experiences. (19) The feeling of impotence, the diminution of autonomy, and the loss of freedom are common in cases of hospitalization, as the results of a revision study from 2018 show. (20) Considering this, the implementation of art therapy in hospitalized patients is extremely relevant, since its practice enables these patients to develop their personality process, to observe, intrinsically, their own consciousness, and pacify possible conflicts that exist in parallel between the exterior and the interior world of each human being. (21) The act of drawing offers the individual the capability of expressing their own story with transparency, allowing for the development of their visual-motor and space coordination, training and conditioning their attention and concentration to the activity that is being carried out. (22) In its turn, the process of collage allows for symbolic expression and the synthesis of feelings, in addition to the signification of productions, also allowing the development of feelings of integration, structure, and space, by concentrating the art in a limited space. (20) A study carried out in São Paulo, Brazil, about the use of art therapy, found that asking the patient about the creation of their work is part of the therapeutic process, allowing the professional to analyze the content expressed. After all, it is known that objects that are considered universal may have another meaning from the perspective of the patient. Furthermore, in artistic works, the individual tens to include their personal experiences and cultural traits. (22) Studies suggest that therapeutic workshops are important resources that enable the rehabilitation and reinsertion of people with mental disorders in society, in addition to increasing the autonomy of the patient, while encouraging social interaction and the remission of the symptoms that cause psychic suffering. (1,12) Furthermore, studies carried out in 2018 show that these activities can be responsible for improving humor, stimulating practical and cognitive abilities, and soften behavioral disorders, since mental disorders such as these can provoke situations that tend to push the individual away from their social settings. (11,23) This study is limited with regard to the short time that the students stayed in the institution. This made it more difficult for them to establish a bond with the patients and made it impossible to turn this work into a deeper evaluation of the therapy used.
The study could contribute by encouraging other health professionals to promote similar activities, since it provokes reflection about new inclusive practices that aim to increase the autonomy of patients with psychic suffering. Furthermore, since 2017, art therapy integrates the set of complementary and integrative practices. As such, it is important for the nurse to acquire knowledge about said technique and about its benefits for the recovery and improvement of the quality of life of patients with mental disorders.

CONCLUSION
It can be concluded that the experience shown here allowed the students to develop a different, more humane and holistic perspective, with regard to the uniqueness of each patient and their mental disorders. One can also understand the complexity of mental disorders and that the hospital-focused model is a backwards form of treatment, considering that there are many more humane possibilities that provide good results, such as the Complementary and Integrative Practices, among which, art therapy.
Art therapy provided a direct interaction between a therapeutic group and its professionals, since the study could identify emotions, feelings, and the perception of the patients about their own reality. Furthermore, the approach provided clarifications to the participants, diminished distress, helped them with self-reflection, and with their autonomy regarding their mental conditions. Solidary spaces for dialog were also created, with qualified listening and increasing the proximity between the participants.