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Wednesday, 15 May 2024 14:13

Self-compassion Focused Art Therapy Model for Suicidal Persons

Abstract

This study offers a theoretical intervention model that shows how increasing self-compassion can be beneficial in the treatment of persons with suicidal behavior and which art therapy therapeutic factors help to do so. The study was directly focused on the target group of clients with suicidal behavior. However, the purpose of the study is not to generalize the target group, but to find the therapeutic factors of intervention for cultivating self-compassion and overcoming suicidality.

The intervention proposed in this article uses a three-step art therapy model for cultivating self-compassion and overcoming suicidality. The study was conducted with five suicidal people and consisted of eight individual 60-minute sessions once a week. Qualitative methods (semi-structured individual interviews) were used to identify therapeutic factors behind the art-therapy process.

 

Participants of the study reported no suicidal thoughts after the therapy was over, and three years after the study they still remembered several activities and the underlying philosophy, which continued to support them. Therapeutic factors of intervention were categorized according to components of self-compassion. Fostering mindfulness was supported by self-discovery, increased awareness and feeling in control; fostering self-kindness was supported by widening self-perception and supporting and helping oneself; common humanity was supported by sharing experiences and feeling connected to others. In conclusion, our findings give initial support for the role of self-compassion in treating depression and suicidality.

Keywords: art therapy, self-compassion, suicidality, depression, mindfulness, common humanity

 

 

Introduction

Suicide is an important cause of death across the lifespan. According to WHO (2019) it is the fourth leading cause of death in 15-29-year-olds in the world. For each adult who died of suicide there may have been more than 20 others attempting suicide (Saxena et al., 2014). Despite the major risk to people’s health and well-being, there are not many non-medicated therapy programs available which are specially developed for overcoming suicidality, ASSIP (Attempted Suicide Short Intervention Program, Michel et al., 2017) and CAMS (Collaborative Assessment and Management of Suicidality, Jobes, 2012) being two of the few examples. The focus of both programs is on acquiring strategies for dealing with suicidal episode: knowing the triggers of suicidal thoughts, assessing one's risk, managing behavior, etc. CAMS uses a variety of assessment tools to evaluate patent suicidality when working with a patient.

The clinical model of suicide conceptualizes suicidal behavior as a solution to an unbearable state of mind, experienced as psychological pain (Birtchnell & Alarcon, 2011; Schnyder et al., 1999). Cultivating self-compassion has given promising effects on depression related suffering (Kirby et al., 2017; MacBeth & Cumley, 2012) and therefore may particularly benefit individuals with suicidal behavior (Kelliher, Sirois, & Hirsch, 2017). There are currently two main compassion focused therapies used in psychotherapy. Compassion-Focused Therapy (CFT) (Gilbert, 2010), designed for use with clinical patients, showed significant outcomes in decreasing self-attacking, shame, feelings of inferiority and depression. Mindful Self-Compassion Therapy (Neff & Germer, 2013) is focused on resilience and self-compassion related skill building and is used outside clinical settings. 

What is self-compassion?

Although most of the compassion-based interventions used in modern psychotherapy are secular, their roots originate in the Tibetan Buddhist tradition (Gilbert, 2010; Neff & Germer, 2013).

By Neff’s definition, self-compassion consists of three primary parts. Self-kindness – extending kindness and understanding to oneself in instances of perceived inadequacy or suffering rather than harsh judgment and self-criticism. Mindfulness – holding one’s painful thoughts and feelings in balanced awareness rather than over-identifying with them. Common humanity – seeing one’s experience as part of the broader experience of being human, rather than as isolated and separate from others (Neff, 2003). Gilbert (2010) adds to the concept of compassion emotion regulation systems and distinguishes them into three categories: 1) threat protection system, which provides responses to the threat; 2) drive system, which activates motivation in seeking awards and resources; 3) soothing system, which provides individuals with ability to sooth themselves and originates in mammals caring process of their infants and is seen as main source of compassion. Gilbert (2010) stresses that people with childhood maltreatments have poor access to the soothing system and therefore have troubles in reassuring and soothing themselves.

This study builds on the positive effects of self-compassion on depression that have emerged in previous studies and aims to elucidate the integration of self-compassion elements into art therapy in individuals with suicidal behaviour.

Self-kindness against psychological pain

Psychological pain is at the centre of many theories that attempt to explain suicidal behaviour: Baumeister’s “escape theory” (Baumeister, 1990), Shneidman’s "psychache theory" (Shneidman, 1993); Linehan’s “emotional regulation theory“ (Linehan, 1993). The motivation for suicide is to escape from intolerable psychological pain (Baumeister, 1990; Li et al., 2014; Shneidman, 1993). Psychological pain is an aggregate of intense negative states and ideation: desperation, hopelessness, loneliness, shame and self-stigmatization, the sense of being a burden on others, self-hate etc. (Baumeister, 1990; Shneidman, 1993). Negative thinking and hopelessness are main cognitive characteristics associated with suicidality, which prevents the person from seeing other solutions to the situation besides suicide (Aish et al., 2001). According to Gilbert (2010), the activation of soothing affect regulation systems helps to encounter psychological pain. Self-kindness as a part of self-compassion teaches individuals to approach difficulties from the angle of self-help, benevolence and empathy, not through shame, self-criticism and self-hate (Neff, 2003; Neff & Germer, 2013).

Mindfulness against cognitive avoidance

Studies show that a tendency to escape or avoid unwanted psychological experiences is one pathway to suicidality (Hayes et al., 2006; Li et al., 2014; Luoma & Villatte, 2012; Pettit et al., 2009). Avoidance of specific details in memories is used as affect regulation strategy in difficult situations (Sumner, 2012). Over time this may develop into an over-generalised retrieval style and develop into a state called overgeneralized autobiographical memory (Williams et al., 2000; (Sumner, 2012). Overgeneralized autobiographical memory manifests in difficulties in recalling specific episodes and details in life, even problems remembering one’s reasons for living (Arie et al., 2008; Williams et al., 2000). An extreme state of cognitive avoidance arises during acute suicidal behaviour, also called suicidal mode. As the result of psychological pain, dissociative symptoms arise, such as disconnection from physical body and insusceptibility to physical pain (Michel et al., 2017; Orbach, 1994). ASSIP founders (Michel et al., 2017) teach people to “not trust one’s own brain” during suicidal mode and to rely on rational knowledge regarding this condition. Thus raising awareness about suicidal condition is of great importance in coping with suicidality. Self-compassion helps to replace avoidance based stress reduction strategies with soothing affect regulation systems, which activates feelings of self-care (Gilbert, 2009). Self-compassion component mindfulness teaches non-judgmental observation of one’s psychological and bodily experiences without identifying oneself with them to an excessive degree. Relief comes from the knowledge that one’s self and one’s feelings are not one and the same (Neff & Germer, 2013).

Common humanity against isolation and self-stigmatization

The founder of interpersonal psychological theory, Joiner, and colleagues (Joiner, Brown, & Wingate, 2005) have demonstrated that suicidality stems from a combination of thwarted belongingness and perceived burdensomeness. The strong stigmatization (both social stigma associated with discrimination and self-stigma) that arises from mental disorders (including suicidality) is also directly responsible for isolation (Schomerus et al., 2012). Self-stigma arises when a person internalizes the stereotypes surrounding their disease and develops a view of oneself as abnormal, different (Corrigan et al., 2009).

Research offers significant evidence that improving social relationships, especially in perceived connectedness is a promising strategy in reducing suicide risk (Chang et al., 2017). Experience of the authors of this study shows that the concept of common humanity can be a great boon to reducing the feeling of stigma and isolation encountered in suicidal people. Common humanity lies in understanding the universality of human suffering, which helps to normalize the human condition of mental suffering (Neff, 2003).

Three-step art therapy for cultivating self-compassion and overcoming suicidality

Art therapy is based on therapist-client-art relationship. The combination of the verbal and nonverbal in therapeutic activity expands possibilities for communication. Artworks expand the information obtained about the client and the possibilities for taking note of resources that are not revealed in verbal communication.

There are also some examples of integrating art therapy with the concept of compassion. Recently published study (Haeyen & Heijman, 2020) combined Compassion Focused Therapy (Gilbert 2010) with art therapy for clients diagnosed with personality disorder. The main goal of the intervention was to strengthen compassion skills like inner warmth, safeness and soothing and achieve more adaptive emotion regulation. Williams (2018) explored the interference between art therapy, mindfulness and self-compassion and argued that creative process is suitable for deepening the skills and resources associated with self-compassion. Creative processes suitable for deepening compassion related skills were: facilitation of emotional regulation, making explicit that which is implicit, integration of affective and imaginal experiences and nonverbal communication.

In the current research the art therapy was used in the intervention involving three steps for cultivating self-compassion and overcoming suicidality.

Step I: Learning to observe and regulate emotions (mindfulness based observation of ones conditions)

Aim: Ability to observe and regulate emotions.

To target these aspects of suicidal psychology: Avoiding strategies in coping with difficulties.

Self-discovery and rising awareness is one of the fundamental benefits of art therapy (Blomdahl et al., 2013; Gabel & Robb, 2017; Haeyen et al., 2015; Van Lith et al., 2013). Depicting emotions with art can be used as a counterweight against the suppression or avoidance of one’s emotions. Through self-discovery, art therapy can teach the regulation and structuring of chaotic emotions (Kalmanowitz & Ho, 2016; Nan & Ho, 2017). Art therapy also underlines the reflection of the process of creating an artwork. Clients are taught to pay attention to their experiences, sensations and thoughts during the creation of artwork (Knill et al., 2005).

In mindfulness-based art therapy, the clients explore their emotional reactions and are instructed to observe their reactions without judgment and fear, but with acknowledgement and acceptance (Kalmanowitz & Ho, 2016). Guided art-making enables the experience of sensory stimulation, which occupies brain activity (Blomdahl et al., 2018). This gives suicidal people a valuable experience, an understanding of being in the moment without negativity. Honest expression of one's thoughts and feelings through art offers relief and creates the basis for acceptance. Therefore, art therapy enables to study client’s emotional and cognitive reactions and test possibilities of coping with them (Blomdahl et al., 2013).

Step II: Adding supportive perspectives about the self

Aim: Ability to be supportive and kind toward self.

To target these aspects of suicidal psychology: hopelessness, negative thinking, difficulties in recalling specific life events, self-attacking behavior, self-hate and self-criticism, perceived burdensomeness.

Since people with suicidal tendencies tend to think in negative way and are facing hopelessness, adding more perspectives is important. Second step of the intervention involves adding kind inner talk and compassionate attitude towards self (self-kindness), also adding more perspectives about self.

Compassion involves focusing attention on self-supportive features (Gilbert, 2009) and treating oneself as friend in cases of difficulties. As discussed before suicidal people have difficulties in remembering reasons for living and recalling specific life events. Art Therapy enables the imagining of good feelings and focusing on personal skills, potentials and depicting them through art. Depicting mental images in pictures allows access to material not otherwise easily accessible (McNiff, 2004). Mental images evoke the same brain activities as real images and are therefore good tools for focusing on better feelings (Gilbert, 2009). Once art work is examined and then merged back into its own experience it can change internal experiences and ways of acting (Jones, 2020).

Art therapy also enables people to face difficulties, maintaining self-encouraging and friendly inner talk. Art therapy helps people to become aware of the patterns of inner talk and practice alternative ways of thinking, acting and feeling through self-observation during art making process and with the help of art therapist (Haeyen & Heijman, 2020).

Step III: Overcoming stigma and isolation

Aim: Ability to feel connected to others.

To target these aspects of suicidal psychology: isolation, self-stigmatization.

The final step is focused on overcoming stigma and isolation by seeing similarities between one's own and other's experiences (common humanity) (Neff, 2003). It has been highlighted that art therapy elicits a sense of overcoming stigma and discriminatory beliefs, by making ones conditions visible and sharing them with the friendly therapist (Papagiannaki & Shinebourne, 2016). A systematical review (Van Lith et al., 2013) summing up the findings of art therapy studies highlighted that self-expression and ensuring communication lead to self-validation and overcoming feeling of isolation.

Franklin (2010) suggests that, creating art helps to modulate emotions that arise within the attachment relationship. Therapist attunement to patients inner state, while exploring patients artwork, is similar to the affective synchronicity that occurs between infants and their caregivers. Franklin (2010) points out that art therapists can develop empathic resonance that will help clients develop empathy for themselves and compassion for others. Treating oneself as a friend and receiving compassion from the therapist activates a soothing emotional regulation system, which is the main source of compassion (Gilbert, 2010).

 

Method

This is an intervention-based (Carolan, 2001; Kapitan, 2015) pre-pilot study which explores the experiences of a small sample of suicidal people during and after the application of the three steps self-compassion focused art therapy to make the initial decision about the feasibility of the intervention and to find the therapeutic factors of intervention for cultivating self-compassion and overcoming suicidality. Therapeutic factors are defined by Blomdahl et al. (2013) as healing mechanisms behind the art therapy process.

Recruitment and participants

In order to obtain practice-based information of the benefits of self-compassion focused art therapy, psychiatrists of the public North Estonia Medical Centre’s (PERH) Psychiatric Clinic and private Nõmme Health Clinic (both in Tallinn, Estonia) were asked to suggest patients with suicide ideation to participate in the study. Inclusion criteria: participants were outpatients, their psychopathology was restricted to Mood disorders (F30-F39 Class V of ICD-10) trigged by negative life event(s) and there was no acute suicide risk.

Recruitment lasted one month and five persons, two male and three female, expressed their wish to participate. Participants’ ages were 19, 20, 25, 30 and 36, three were unemployed, one was employed, and one was on maternity leave. Participation in art therapy was voluntary, patients themselves contacted the researcher by e-mail and gave their informed consent. Intervention as well as the follow-ups were conducted in the Nõmme Health Clinic. Participants were asked about their previous psychiatric treatment and in accordance with that information all participants had some contacts with psychiatrists in outpatient setting and the use of antidepressants was irregular. Pharmacological treatment had lasted from two months to one year before the study started, depending on the participant.

Study design and measurements

Duration of the study included an intervention after two months and a follow-up after three years. Intervention consisted of eight individual 60-minute, weekly, self-compassion-focused art therapy sessions held in the private outpatient Nõmme Health Clinic. Short descriptions of the art therapy exercises used are given in Appendix 1.

In order to evaluate the outcome of the intervention qualitative data collection method were applied. The qualitative data were collected by individual in-depth interviews carried out immediately after the end of the intervention (duration about 20 minutes) and three years after intervention (duration about 20 minutes) with the purpose of studying participants' well-being and the possible benefits attributed to intervention.

The topics of the interviews were:

  1. Participants’ thoughts related to suicide and what had changed during therapy.
  2. How participants are coping with difficult emotions and did they notice any changes during therapy.
  3. Which art therapy exercises were / were not helpful for the participants?

Interviews were analysed according to thematic analysis, which is a method for identifying, analysing, and reporting patterns (themes) within data (Braun & Clarke, 2006). Steps were taken to ensure the validity of the analysis. Initial thematic analyses were carried out by the first author (K.T.). Coding procedures were discussed with another author (E.R.); this allowed the reassessment of the themes and interpretations until consensus.

Ethical considerations

The study was conducted in accordance with the code of ethics of the Estonian Association of Creative Arts Therapies (Eesti Loovteraapiate Ühing – ELTÜ, 2015), which stems from the Declaration of Helsinki, and the protocol was approved by Tallinn University, Estonia, in 2015.

The intervention was carried out as supporting therapy. If necessary, participants could receive psychiatric care at the time the study was conducted.

 

Results

Therapeutic factors of self-compassion focused art therapy

Based on the qualitative thematic analysis of interviews, a number of categories were identified that, in their essence, describe the therapeutic factors of intervention. Therapeutic factors were linked with the aspects of suicidal tendencies, steps taken and components of self-compassion (Table 1).

 Table1

 

Step I

Therapeutic factors supporting the first step – Observe and regulate emotions – were: self-discovery, raising awareness about thoughts and feelings, and feeling in control.

 

Art provided a nice and safe means for self-discovery. For instance, participant J2 describes: "I was able to put my negative sides on paper and meet them face to face. If you don't know what causes you that fear and alarm, then you don't know where it comes from and what it is. You're just frightened and alarmed, but art therapy helped me to visualize these fears in a creative way and put my feelings on paper, to give them form and study them." Participants raised awareness about the nature and dynamics of their feelings and thoughts. They learned the passing nature of feelings and started to acknowledge better moments besides the "endless horror". Participant A1 describes: “I often remember the very first picture, where we drew my suicidal thoughts. We talked that just as lightning passes, so do feelings, they are not permanent. I immediately remember this whenever I get really depressed. Knowing that it'll pass helps me to come through. It gives me the sense of security." Raising awareness, in turn, helped participants to feel in control. For example, participant J2 describes: "I'm no longer afraid of them (negative thoughts), but it's as if you're in the same room with some sort of beasts. You know that, okay, it'll pass, just two more days, three more days. I'm not afraid of them."

Step II

Therapeutic factors supporting the second step – Adding supportive perspectives about the self – were: widening self-perception and supporting and helping oneself.

Participants said that art therapy helped them to see their strengths and resources, thereby widening their self-perception. Widening of self-perception in a positive direction was also considered to be important in giving up suicidal thoughts, as it brought back joyful memories. J2 reminisces: "My suicidal thoughts were taken away by the new feelings I was unable to feel earlier, but that were opened by art therapy. Hope, some kind of joy and memories of once being happy and glad. Before that I had already dug a grave for myself. I felt useless and it didn´t matter, whether I exist or not"

Art was used also to stimulate a benevolent and helping attitude towards self. Implementing helping attitude in the case of suffering presumes taking positive attitude towards oneself. Participant K2 describes: "I used to be really mad, why am I incompetent and can't manage, I was mean to myself. Now I'm friendly, I may make mistakes and fall, but I will eventually get up and go on. I did something for myself in art therapy, pictures." Another quotation demonstrates how understanding the dynamics of feelings was added to friendly attitude to cope with suffering. K2: "I look for ways to comfort myself, to understand that I'm sad right now, instead of fighting back and trying to be oh-so-happy. I know that this feeling will pass. It used to be difficult to understand this."

Step III

Therapeutic factors supporting the third step – Overcoming stigma and isolation – were: sharing experiences with therapist and being connected to others.

Art therapy gave an opportunity for sharing experiences (both verbally and non-verbally). It was considered important to visualize one's situation to the therapist in its honest and blunt form. Participant J2 describes: "How I started drawing helped me. I didn't speak as much, I was just expressing my feelings on paper. I didn't even know how much relief it could bring. Every meeting, every picture was something where I took a part of my burden and left it on paper." Sharing one's concerns during communication between therapist and participant turned out to be just as important. A1 adds: "Here I was able to spill all my anguish without guilt and stress. Family and friends can't listen to you and they start to panic themselves. What helped me was that you listened and understood."

Seeing connections between the suffering of oneself and others helped to reduce the feeling of isolation, normalize one's own reactions and gave courage to act. Participant KM2 describes: "I was hidden deep inside my shell and didn't want to see anyone. I thought everybody was having fun but me. That only I was feeling down. /.../ Then I realized there was no such thing as a perfectly carefree life, that everyone had their problems and it was just a normal part of life."

All the participants brought out during interviews that their social relationships had started improving after therapy. Above all, they mentioned more courage to communicate and reconnecting with friends and family. The experience of positive interaction may have encouraged people to communicate in real life as well.

Subjective changes over three years in people participating in therapy

Immediately after the intervention participants stated that they do not have suicidal ideations anymore. A follow-up interview carried out three years after intervention revealed that three participants had not experienced any new severe depression episodes. One of the participants had experienced a single six-month depression episode from which he recovered. One of the participants still experiences disturbances of mood, but is no longer suicidal. The main reasons for giving up suicidal thoughts was said to be understanding the final nature of death and valuing oneself and their loved ones.

Challenges and difficulties

There were also some challenges in carrying out the intervention. Gilbert (2009) has pointed out that self-critical people have difficulty being compassionate about themselves because they believe they do not deserve compassion or friendliness. This proved to be one of the challenges in carrying out this intervention. The breakthrough came from the common humanity exercises, during which the participants began to realize that they too deserved care like any other being in the world.

Experiencing friendliness towards themselves proved to be a very moving experience for most participants. At the same time, it can cause feelings of deprivation, even grief, in people who have not experienced much care and love before in their lifetime (Neff & Gremer, 2013). Therefore, as a therapist, this possibility must be considered and the intensity of the exercises must be chosen accordingly.

The pictures describing thoughts of suicide provided relief for the participants and were important in helping them learn about themselves. Situations where the client considered suicide as a solution turned out to be a challenge. The breakthrough was in stimulating better emotions and reminding them of good memories with the help of art. Also raising awareness of the finality of death and discussing what alternative “solutions" the person’s compassionate friend or close relative would offer. Therapists working with suicidal ideation have also pointed out that dealing directly with suicidal thoughts is a necessary part of the healing process. People with suicidal thoughts want to share these thoughts with someone honestly and without euphemisms (Henden, 2008).

Discussion

In this paper, we have described a theoretical model of intervention that uses a three-step art therapy for cultivating self-compassion and overcoming suicidality. The study was directly focused on the target group of clients with suicidal behavior and psychopathology and was restricted to mood disorders (F30-F39 Class V of ICD-10) trigged by negative life event(s). We performed a pre-pilot study based on five case studies. This article does not provide precise instructions for carrying out intervention, because the selection of exercises and emphasis vary according to the client's needs. However, this article provides qualitative material about therapeutic factors behind the compassion-focused art therapy process carried out during the intervention. The therapeutic factors revealed during the interviews are not novel to art therapy, but this article places them in the context of self-compassion and shows which psychological aspects of suicidality can be better coped with as a result of developing self-compassion.

Therefore, the strength of this research was the integration of therapeutic factors of art therapy with self-compassion components and with psychological aspects of suicidality, which were combined into a three-step intervention model (Table 1).

The aim of the first step of the intervention was to overcome avoidance and suppression of difficult emotions in order to start observing and regulating them. Developers of the suicidal treatment program ASSIP (Michel et al., 2017) highlight the need to learn about the difficult feelings associated with suicide, in order to know the triggers of one's suicidal thoughts, to learn the dynamics of emotions and to learn strategies for coping. Therefore, the ability to observe and regulate emotions is one of the key skills in overcoming suicidality (Linehan, 1993; Luoma & Villatte 2012). Art therapy offers unique opportunities to explore emotions through art. Depicting emotions through art and exploring them mindfully was used in the intervention as a counterweight against the suppression or avoidance of emotions. Interviews carried out after the intervention revealed three therapeutic factors of art therapy that support observation and regulation of emotions: self-discovery through art, increased awareness about feelings and thoughts and a feeling of being in control of difficult emotions by better understanding their dynamics and triggers. These factors are considered the main therapeutic factors in several art therapy studies (Blomdahl et al., 2013; Van Lith et al., 2013; Haeyen et al, 2015) but in this study the process of art therapy was additionally combined with mindfulness. Participants where taught to observe their difficult emotions without trying to change or avoid them, which gave them information about the nature of their emotions. The aim of the second step, which was focused on developing self-kindness, was to overcome self-hate, self-criticism and perceived burdensomeness, which are the causes of severe emotional psychological pain in suicidal people (Baumeister, 1990; Shneidman, 1993). The motivation for suicide is usually to escape intolerable psychological pain (Baumeister, 1990; Li et al., 2014; Shneidman, 1993). Self-kindness teaches individuals to approach difficulties from the angle of self-help and empathy, not through shame, self-criticism and self-hate (Neff, 2003; Neff & Germer, 2013). Interviews revealed two therapeutic factors that support the aim of second step. Firstly, self-perception was increased by the exploration of new perspectives through art work and by gaining access to material not otherwise easily accessible for people with depression (art exercises brought back good memories, skills and resources). Secondly, participants gained a supportive and helping attitude towards themselves by becoming aware of their patterns of inner talk and practising self-kindness during the art process. Exploration and testing of new feelings and things through art is also considered an important therapy process factor in art therapy studies (Haeyen et al, 2015).

The aim of the third step, which emphasized common humanity, was to overcome stigma and isolation. Research offers significant evidence that overcoming the feeling of isolation is a promising strategy in reducing suicide risk (Chang et al., 2017). Interviews revealed two art-therapy therapeutic factors that can help with overcoming isolation and stigma: sharing experiences and feeling connected to others. Increasing feelings of connection is also mentioned as an important therapeutic factor in art therapy (Papagiannaki & Shinebourne 2016; Van Lith et al., 2013). It can be explained by the idea that the art therapy process is similar to emotional states that arise within an attachment relationship (Franklin, 2010). Also soothing the emotional regulation system, which is the main source of compassion, creates a sense of peace and a feeling of connection (Gilbert, 2010). Since suicidal people have poor access to the feeling of connection (Chang et al. 2017) the activation of soothing systems and being heard by a therapist can provide great relief. Art therapy exercises that introduce the philosophy of common humanity also have the potential to help participants to overcome the feeling of isolation. The healing mechanism in common humanity lies in the understanding of the universality of human suffering, which can help to normalize the human condition of mental suffering and reduce a view of oneself as abnormal or different (Neff, 2003).

Interviews with the participants showed that learning to observe and regulate emotions, learning to use self-supportive features and creating a sense of connection during the art process may have reduced suicidality among the participants of the study.

A number of limitations can also be put forward regarding this study. Firstly, the small sample of the intervention is the main limitation of the study, but the beneficial results of the therapy applied encourage the use of the intervention with a larger group as well as with patients with less dramatic diagnoses.

Secondly, the entire assessment was based on self-reported material, but given the small number of subjects, it was not justified to add quantitative measurement tools. Also, the study focused on the substantive aspects of the intervention model, including the identification of therapeutic factors, and less on specific measurable changes in self-compassion and suicidal behavior. This would need to be done in further studies with a larger number of subjects.

Also, medical documents could not be used in the study because of data protection requirements, which is why the impact of self-compassion art therapy cannot be assessed separately from medical treatment. In accordance with the participants’ subjective feelings from session to session and the self-reported improvements during the intervention and during follow-up interviews in all cases, we can assume the effectiveness of compassion-focused art therapy.

 

Acknowledgements

The authors are grateful to the participants for participating in the intervention and sharing their experiences.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Appendix 1

Three-step model sample exercises


Step I Learning to observe and regulate emotions

a) Please depict a feeling that makes you think about suicide.

This exercise gives an opportunity to take a closer look at suicide. How it arises and how it disappears. Also exploring things related to death, without pretending or pseudo-reality. Making visible and sharing of painful thoughts and feelings with therapist gives relief and feeling of being seen and heard.

b)Please depict a feeling or a memory that makes you think about suicide less (good mood).

Highlighting various positive situations injects optimism into suicidal people and reveals resources, strengths, skills and capabilities and paves the way for seeing new solutions (Henden, 2008).
Comparing body experiences during the art process of first and second picture also raises a patient’s awareness of his or her ability to experience different feeling. Also study the nature of the emotions.

c) Move your hand and arm freely to find a movement you like to make, now take a brush, choose the colours you like and paint something on paper with the same movements. / Use the colours to create images on paper that you like to look at.

This exercise gives to suicidal people a break from being worried and tests the possibility of well-being. It also gives an experience of being in the moment. Monitoring body experiences, changes of emotions and inner talk during working with art is also applied during these exercise.

 

STEP II Adding supportive perspectives about the self

d) Please make a picture about “My strengths” – the skills and values in my life that support me, my earlier successes, the things I like, or used to like.

This exercise injects more optimism into suicidal people, by adding resources, strengths, skills and capabilities to the self.

e) Please look at your suffering (suicidal feelings) and mindfully accept that the moment is painful. Pay attention on your body experiences and inner talk. Then remember that imperfection is part of human experience and embrace yourself with kindness and care in response and focus on what you need most at the moment (Neff & Germer, 2013). Make something that makes you feel loved using art supplies.

This exercise teaches you to be friendly and compassionate towards self in cases of suffering.

f) Please depict your self-criticism and then self-friendliness. What colours or symbols would you use? What kind of voice tone comes to your mind and what messages are they carrying? Feel the difference between being critical versus being friendly. Please note that being mean to the self only makes you feel bad. You can motivate yourself more by being friendly and supportive in cases of difficulties.

This exercise raises awareness of the inner talk and gives the opportunity to test friendly attitude towards self.

STEP III Overcoming stigma and isolation

g) Please draw a card of wishes to the millions of people all over the world who are experiencing similar or even more difficult things at the same time as you. After drawing the card and working with it, the client is asked to wish the same things for themselves.

h) Please visualize your compassionate friend and think what that friend would say and give you as a reminder of his/her endless love and compassion towards you. Then remember that this friend is part of you. Please make a gift from your compassionate friend to remember his presence, using art materials.

Neff (2022) describes a compassionate friend as powerful and wise, with endless love and acceptance towards you, he knows exactly how you feel and cares deeply of you. If a client has deep suicidal thoughts, he can examine suicide through the eyes of the compassionate friend and discuss with a therapist what other solutions would this friend recommend.

 

Appendix 2

Case examples

Case example 1 – Mark

A young man Mark (name is changed) started suffering from depression after breaking up with his girlfriend. He dropped out of university, didn’t work. Mark decided to seek therapy after he started having suicidal thoughts.

Step I focused on express and regulate emotions.

Picture1sml
First Mark got to depict a feeling that makes him think about suicide. Mark depicted and described his pain to therapist (K.T.) as a serrated disc (Picture 1), which has extremely sharp corners and when this disc starts spinning, it cuts everything to shreds as a serrated disc inside you. The faster it spins, the worse the pain gets. He named this feeling ‘the cutter’. Mark said the cutter started spinning when he was thinking that he was not doing anything with his life and that he was afraid of everything. Mark described how all he did was lie in bed and that disc was spinning inside him. At the same time, his body was gripped by strong urges to kill himself. Depicting his psychological pain made Mark realize that he and his pain are not one and the same and he can study it as an onlooker. The all-encompassing pain had acquired a form and a shape, which made it easier to manage. As the cutting disc does not support Mark, the therapist asked him to imagine that the cutter inside him had stopped for a minute, sent to rest. Although it was difficult for Mark to imagine, he drew yellow waves on the paper. He called them ‘good mood’ waves, which oscillate slightly, happily go along with everything, make the inside light and warm. Comparing the pictures of the different feelings showed Mark that states of mind are not fixed, but changing all the time.

Step II focused on adding new perspectives about self, also stimulating a caring and warm attitude towards oneself in the case of difficulties.

In order to add new perspectives about the self, Mark got to name and depict his strengths and skills that support him or things he used to like. He depicted his skills on little stickers and put them around the good mood waves. Remembering and focusing on skills encouraged Mark to be more active, for example he started visiting the gym again. Mark studied himself in a new light that supported him, and the verbal self-image he had created was supported by the visual image.


Picture2
Art therapy with Mark also focused on the development of inner talk that is friendly towards oneself and the experience of being in the moment. Simple art therapy exercises were used to achieve this condition (Picture 2). Mark had to reflect on the entire process of creating art. Mark describes how his discomfort gradually disappeared and the paints grabbed all of his attention, making his fear of the end result disappear. As quitting had been the main method of coping for Mark, the finished art work gave him an experience of ‘completing something’. Mark learned to appreciate his efforts and concentrating on supportive inner-speech.

Step III focused on seeing the similarities between one’s own suffering and the suffering of others. Thus overcoming stigma and isolation.

Picture3
Mark made a collage card of wishes from one suicidal person to another (Picture 3). This step helped Mark transfer the compassion he felt for others to himself and see himself as a friend who needs help. It also helped him understand that he is one of the people who deserves compassion. As Mark had previously tended to isolate himself with his feelings and considered himself a person who is worse than others, then understanding the similarity of his and other people’s experiences was liberating and encouraging to him. Mark was afraid of going on work interviews and talking to people. Understanding the philosophy of common humanity helped him reduce fear. His message to the others was: things will get better, don’t lose hope, don’t blame yourself, don’t dwell on things, just relax! He was asked to wish the same good things to himself. Therefore Mark observed his emotions and learned to be more friendly toward himself and it gave him great relief. Step by step he practiced how to be friendly towards himself. He started to feel more in control of his life and see his values and strengths. Art therapy gave him a push to be more active and led him out of the deadlock.

 

Case example 2 - Mary

A young woman, Mary, started suffering from depression after a complicated relationship. Mary started cutting herself to ease the pain.

Picture4
Step I
focused on getting to know about oneself. In art therapy, she learned to confront her pain. Mary depicted her suicidal thoughts as four black tulips (Picture 4). Two of the tulips are strong with green leaves and sharp teeth. They are poisonous tulips that rip your flesh and their roots are deep in the ground. Mary said that there used to be lots of colourful tulips, but the tulips with teeth ate them all. The two tulips on the left are the only two that have remained from a blossoming meadow, but they will also die soon. Mary was given the opportunity to study the picture with the therapist and think about the sources from which these tulips get their power? She understood that the tulips with teeth were a symbol of the pain she was feeling because of the man. This pain had destroyed the blossoming field of tulips and taken away her joy. In order to give her hope and stimulate good memories, the therapist asked her to recall what had been different when a field of tulips had been blossoming instead. Mary wanted to draw a picture of a beautiful landscape where she is walking with her sister. This gave her hope that the good times may come back and a change is possible.

Picture5
Step II
After studying her feelings, attempts were made to bring friendliness towards oneself to daily life. The therapy moved on with exercises that helped cultivate friendliness towards oneself. Mary could play with colours and decorate pebbles to experience sensory stimulation. As she was a very creative woman, she started drawing at home as well in order to reduce tension. Mary had been feeling anger towards herself for a long time and felt that she did not deserve to live. Mary was also given the opportunity to draw a card of wishes for people in the same situation as her (Picture 5). On the right side of her card, Mary depicted a dark and bleak city, which has no colours. On the left side is beautiful nature, colours, birdsong. There is a path in the middle. A girl is standing at a crossroads and Mary really hoped that she would go left, where the sign “Future” was pointing. Mary wished that the people in the same situation as her would choose the right path. Instead of that Mary admitted that she did not deserve anything good.

Step III Focused on seeing the similarities between one’s own suffering and the suffering of others. Thus overcoming stigma and isolation. When the therapist asked her to describe the girl on the picture (Picture 5), Mary realized that it was her and that she does deserve some kindness. Starting to feel compassion for herself was an extremely important turning point for Mary. The realization of common experiences of humankind was also important for her, to become more accepting towards herself and seeing oneself as normal person in pain.

Picture6
Step by step Mary learned to be more friendly towards herself and learned to pay attention on her body experiences and inner talk during art making process. She focused more and more on her needs and made pictures she liked. After some sessions Mary wanted to draw five colourful tulips with the sun shining above them. Mary dedicated these tulips to her values: the love she wanted to share, beauty and positivity, helpfulness (Picture 6). She dedicated a rose to her weakness (bad mood and difficulties), which shows that she had also integrated difficult feelings into her self-image in an acceptable manner. She said that she was able to cope with the feelings and they did not scare her anymore. She had a purple rose for this: security.

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