Notes in Tune: Arts-based Therapy (ABT) at Schizophrenia
Awareness Association in Pune, India
World Centre for Creative Learning (WCCL) Foundation
Chabukswar A. (2016)
Notes in Tune: Arts-based Therapy (ABT) at Schizophrenia Awareness
Association in Pune, India International Journal of Psychosocial Rehabilitation. Vol 20 (1) 62-77
Aanand Chabukswar, Project Head (Courses),
World Centre for Creative Learning (WCCL) Foundation
F 1001, Felicita, Baner-Pashan Link Road,
Pune 411045. Maharashtra. India.
use of the arts as therapy is a paradox in India. Despite a long
tradition of healing rituals and practices, there is barely any
arts-based model consistent used for contemporary mental health needs
and settings. With the aim of introducing and investigating use of ABT
(Arts-based Therapy), regular sessions were conducted at Schizophrenia
Awareness Association’s day-care centre in Pune, India over a period of
eighteen months. The group was heterogeneous, with varied severity of
symptoms of schizophrenia. With therapeutic goals of present moment
attention and interpersonal engagement, participant responses were
recorded through PANSS (Positive and Negative Syndrome Scale), a Rating
Scale, a Checklist and qualitative observations. All data sources show
definite though variable response to ABT. PANSS scores noted a decline
in negative symptoms and general psychopathology, especially the
sub-items marked ‘severe’ show a clear trend of reduction. The
correlations between PANSS, Rating Scale and Checklist are notable
though not statistically significant. The qualitative data uncovers the
nuances of the process. Despite a small sample size, the study points
in the direction of use of ABT in mental health settings, especially
within the Indian context.
Keywords: ABT, Arts-based Therapy, Schizophrenia in India, arts in mental health, PANSS
Arts-based Therapy (ABT) sessions were conducted at
the day-care centre of Schizophrenia Awareness Association (SAA) in
Pune between September 2013 and April 2015 for a group of 14
participants. Of that, data was collated for 7 persons in the age range
of 23 to 60 years, all diagnosed with Schizophrenia. The aim of these
sessions was to reduce symptom severity, with the therapeutic goals of
building present moment attention and interpersonal engagement.
is evidence-based use of art forms to accomplish individualized goals
within a therapeutic relationship. ABT derives theoretical base from a
systematic training in Subtle Energy Guide (Pillai-Balsara 2013) drawn
from the Indian Mind Traditions, notably Buddhist Psychology and Ethics
further interfaced with information from neuroscience and developmental
psychology (Balsara et al 2013). The practice of ABT is based on use of
multi-arts modality to address the therapeutic goals. Within this
framework interventions are designed as per the specific needs of each
Schizophrenia causes a number of fundamental
disturbances and distortions in cognition, perception and behavior of a
person. There are an estimated four million people diagnosed with
schizophrenia in India, with different degrees of impact on some 25
million family members (WHO 2010). Within India, for those who reach
out for help, the first line of treatment is mostly psychotropic
medication and institutionalization. Even after medication clients
experience persisting symptoms, side effects and need for care and
capacity building. Additionally, Long term disabling consequences of
lost opportunities, stigma, residual symptoms, and medication side
effects are also well documented (Spearing 1999, WHO 2001). The SAA
day-care centre is thus a host to a growing number of persons seeking
relief and care.
Historically within India, like in other
native cultures, spirituality, rituals, shamanic rites were used in
conjunction with traditional healing and medical systems (Davar and
Lohokare 2009, Evers 2008, Simoes 2002). In post-independence in India
period ‘the need to develop services beyond mental health institutions’
(Kumar 2004, p. 174) was recognized, which called for a distinctive
approach. However, insights were not followed up with systematic
actions and the ground reality thus has been the degeneration of
traditional understanding and treatment modalities on the one hand and
inadequacy of mental health care institutions and trained personnel in
face of high need (Thirunavukarasu and Thirunavukarasu 2010) on the
other. A middle way that combines the strengths of traditional healing
with contemporary specifics has been mostly unexplored. Interestingly,
in what is termed as the ‘outcomes paradox’, markedly better outcome
for schizophrenia patients in India has been reported in WHO’s
long-term studies (Jablensky and Sartorius 2008, Padma 2014). The
better results are attributed to socio-cultural factors, like family,
community and local conditions. WHO’s recent programmes in India also
clearly report that in the Indian context it is important to have
‘innovative programmes’ that are ‘strongly anchored in the community’
and are ‘family-based and family-oriented’ (WHO 2010, p. 3). Approaches
that recognize the differences and nuances of social, cultural and
economic variations are extremely important.
In this context
ABT strives to make way. In ABT, the difference between the person
labeled with mental illness and the one without is considered one of
degree and intensity of suffering, and its consequent impact on
functioning in life. Multiple realities and their coexistence are
acknowledged, and the ability of a person to navigate skillfully and
meaningfully between different levels of experiences and existence is
The arts are uniquely situated as they
experientially create alternative realities, yet the boundaries between
them are held in awareness. ABT offers a range of artistic tools — a
rich language of music, rhythm, songs, stories, drama, visual art
methods — and their numerous combinations. The artistic activities
bring the attention onto colours, images, stories, rhythms, musical
phrases. Metaphors make things manageable, and possible to understand.
Sharing, giving-receiving in a co-creative spirit happens seamlessly in
a group. Here, the emphasis is on the process, the artistic outcomes
are secondary and playfulness ensures that there is no stress, no
pressure. The focus is on the ‘capability’ of the person no matter how
small or insignificant the contribution may seem (Chabukswar and Daniel
The artistic process also presents a complementary
counterpoint to mere verbal engagement in therapy – that experience can
transcend conceptual barriers to ‘reach’ a person. The creative
interactions record nuances of the therapeutic process that otherwise
cannot be documented. ABT thus navigates towards symptom relief,
supplementing the vital institutional agenda in the rehabilitative
ABT projects in adult mental health from 2006 to 2013
from WCCL Foundation’s archives were reviewed (Chabukswar 2013) to note
case studies of 129 participants in the age range of 15 to 79 years,
all diagnosed with mental health disturbances (depression,
schizophrenia, emotional distress, trauma) all engaged with ABT for a
minimum period of 6 months. Client-specific individualized therapeutic
goals were worked on and overall positive therapeutic outcomes are
noted (Table 1). These projects used varied assessment tools, including
standardized assessments tools, checklists and observation formats.
However, qualitative data (interviews, structured and unstructured
feedback, observations) yield more meaningful data. Many projects note
the limitations of time, tools and methods and lack of availability or
reliability of standardized assessment tools given the specific
conditions of work in India.
Table 1: ABT projects in adult mental health (2006 - 2013):
| Therapeutic outcomes|
• Better mood and affect than before
• Better comprehension of tasks
• Clients opening up: showing interest and initiative
• Higher confidence and self-efficacy
• Improved communication in the group
• Improved speech through storytelling and singing
• Improvement in perception and cognition
• Increase in attention span
• Increase in expression of emotions
• More effective symptom management
• Overall improvement in somatic memory
• Sensory integration
paper explores the trajectory of a particular ABT intervention at SAA
in Pune, India. How engagement with ABT challenged the symptoms that
resulted in a significant decrease in severity, and reflected a decline
in negative symptoms and general psychopathology measured on PANSS
(Positive and Negative Syndrome Scale). The observations from PANSS
further demonstrate a positive correlation with ABT Practitioner’s
Rating Scale as well as the Checklist on attention and interpersonal
engagement. This is further corroborated by qualitative observations
made by an independent third person and the ABT Practitioner. The
outcomes are significant enough to make a case for ABT as a friendly
and accessible therapy that complements the tools for symptom relief
and rehabilitation in Schizophrenia.
MATERIALS AND METHODS
The setting and the group
Awareness Association’s (SAA) Swanand Punarvasan Kendra is a day-care
centre for people with mental illness. At the centre, such a person
comes to an environment that is meant to provide a structure and tools
for day-to-day functioning that can support the process of recovery.
Activities like yoga, dance, cooking, computer training and vocational
activities like making lamps, paper bags etc. are done at the centre.
Therapeutic activities include counseling, self-help tools, parents’
support group and the newly introduced, ABT.
attended the ABT sessions, of which data was collated for 7
participants who were part of the group for the entire 18 months.
Individualized therapeutic goals for each participant were set (Table
2) and common therapeutic goals were identified as ‘keeping attention
here and now’ for reality contact and increasing ‘interpersonal
engagement’ for reduction in isolation.
Table 2: ABT Group
background, symptoms and therapeutic goals
(age in 2013)
Symptoms in 2013
Disorganized schizophrenia. Onset
1985. ECTs and medication. Tobacco addiction and diabetes.
No hygiene, auditory and visual
hallucinations. Sudden outburst of laughing and muttering. No participation,
Make reality contact by keeping attention in the ‘here
Being active/participative in ABT.
Schizophrenia. Onset 1995. Given ECTs and medication.
of concentration, confidence. Irritation and suicidal thoughts. Mood swings,
irrelevant talk, poor self-care and hygiene. Persecutory delusions, OCD about
food and touching.
Make present reality
contact by being active in ABT
strength to feel worthy of living
Schizophrenia. Sudden onset in 2010. Obsessive,
irritation, poor social interaction. Borderline IQ.
Self-talk, auditory and visual
hallucinations, sometimes violent. Guilt about past violent behaviour. Sometimes
laughing uncontrollably and intense anger at times.
Control and express emotions
appropriately Building interpersonal skills and interactions
disability and Psychosis. Onset 1998.
features i.e. stiff muscles, long reaction time, poor fine-motor skills. Poor
social interaction, barely audible. Delusions and OCD about eating, touching,
poor hygiene as a result. Flat affect.
Improvement in gross and
fine motor coordination
Being attentive and
audible thereby expressing himself clearly in the ABT sessions
Paranoid Schizophrenia, onset 2002.
Tactile hallucinations, persecutory delusions. Poor
hygiene (no bathing). No interaction at all.
Attention to the here and now
Improvement in speech (volume and audibility)
Meaningful interaction with others
Schizophrenia, onset 1991. ECT (once) & medication.
and auditory hallucinations, severe persecutory delusion. Not much
interaction with others, anxious about her future. Has insight.
Reduction in tension and
to be at ease
Ease in interactions
Male, age 33
since age of 6 years, calcium deficiency and low IQ. Onset of schizophrenia
uncontrolled laughing, crying, swearing. Heavy (91 kg), very sleepy all the
time. Repeating same thing over and over. Very little attention span.
To pay attention, to be present
Increase span of attention on the
here and now
some ability to interact with others in a specific, meaningful way
All except one participant showed direct signs of visual,
tactile hallucinations. Four of them had severe symptoms of social
withdrawal, were almost non-verbal, showing no interest in any activity
or interaction. To varying extent, all were locked or engaged in
alternative reality, lacking external reality contact. Three
participants were verbal—one of them apprehensive of interactions due
to persecutory delusions and another hyper-interactive, demanding but
with limited verbal range. The group was diverse in severity of
symptoms and the duration since onset of schizophrenia varied between 4
to 23 years when the study commenced.
Design and data sources
premise for the study was to use ABT as an adjunct to reduce symptom
severity. A total of 51 weeks of ABT sessions were spread out from
September 2013 to April 2015, equally divided between the Pilot phase
(12 weeks) followed by 3 phases of intervention (13 weeks each).
is a medical scale used to measure symptom severity; a 30-item, 7-point
rating instrument that gives representation of positive and negative
symptoms at increasing levels of psychopathology, where 1 = absent, and
7 = extreme (PANSS Institute, Kay et al 1987). The PANSS is widely used
for ‘strong psychometric properties in terms of reliability, validity
and sensitivity’ (Leucht et al 2005) and was selected for its
accessibility and familiarity. SAA clinicians rated PANSS for
participants once at the beginning of the ABT pilot project in
September 2013 (AS1) and 4 more times during the next phases (AS2 –
AS5), at an interval of 3 to 6 months.
Studies confirm that
‘most PANSS items are either very good or good at assessing the overall
severity, particularly items within the Negative Symptom subscale’
(Santor et al. 2007). The criterion of ‘schizophrenia remission’, where
a score of mild or less (less than 3) in case of the 8 selected
criteria in PANSS for a minimum period of 6 months indicates remission
(Andreasen et al. 2005, p. 447) have been recently in discussion.
‘Remission is a new research outcome indicating wellness’ (Yeomans et
al. 2010, p. 86), and thus these sub-items have been analyzed
separately. The clinicians also rated a Checklist of 8 items on
‘Attention: here and now’ and ‘Interpersonal Engagement’. Higher scores
under Checklist reflect better attention and interpersonal engagement.
5-point Rating Scale was modified from WCCL Foundation’s earlier study
(Daniel et al 2013b) and was rated 4 times during the intervention
period by the ABT Practitioner. It is a holistic scale that records
responses and behaviours in the sub-domains of Body, Attention, Group
Interaction, Cognitive, Narrative Capability, Expressive Capability.
The rating statements are positive indicators of well-being and, higher
scores reflect better response. Qualitative Observations of responses
and interactions within every ABT session were also recorded by the ABT
Practitioner and by neutral observers.
Table 3: ABT Techniques for Attention
Singing or prayers
at the beginning and closure; memorizing them
Name ritual: acknowledging
and greeting self and others in a particular pattern
of attention through observations of objects e.g. bell (auditory), incense
(visual, olfactory); of people e.g. clothes, colours, styles; of weather and
sections of concentration on an object: e.g. focus on trees, on breath
Ritual to be
light: letting go and mentally/physically throwing away unwanted materials,
thoughts and distractions
ritual for ‘coming back’ here and now: reminders accepted from group and
facilitator for this
stories: listening to stories, recalling stories, narrating stories
(participants and facilitator)
crayons: free drawing and colouring, theme based drawings, occasion specific
Table 4: ABT Techniques for Attention &
and ball juggle with partners, triads and the entire group
warm-ups and voice exercises
warm-up and movement with music
group-work e.g. working with partners on embodiment activities, games
structured around movement, attention and interaction
improvisations: Making interactive theme based scenarios and developing them,
e.g. at the seashore, waking up and the beginning of the day, guests at
school, visiting a restaurant etc.
and Images: Verbal / physical work with images – identifying images,
expressing them. Joining images into narratives or stories, using toys, clay,
puppets to create narratives
from a story enacted, playing with roles and dialogue
Recalling series of songs on a particular theme and singing them together in
group, e.g. season, journey, morning, nationalism, fearlessness, picnic songs,
A. R. Rahman songs, light, lightness etc.
variety of percussions, playing them with songs
and visualising: Listing activities planned for an ideal day, articulating
personal intent for the year
conversations: Discussions about picnics and travels, about pets and animals,
about friends and friendships
in focus: Exploring metaohors for each group member’s special qualities,
observations from the group about ‘what can each one improve’ – done with extensive
process and permission from each member
Apart from client-specific therapeutic goals, ‘key
concepts’—non-measurable positive aspiration for the participant
group—are an important aspect of ABT intervention. At SAA, the quality
of ‘generosity’ was the key concept, where the idea of ‘giving’ and
‘sharing’ was woven as a subtext for all sessions. This key concept is
a vital step in mind training; it is also a logical progression towards
harmonious, compassionate and successful social interaction. This key
intent was integrated in all phases of intervention, and regular
specific exercises were designed for it (table 5).
Table 5: Exercises based on ‘Key Concept’
Thanking every time someone does something for us; acknowledging others for
their presence. Thanking everyone with eye contact at the closure of each
List of who gives us what? what in oneself troubles others? what gives joy to
others? Discussing significance of small acts
(Giving): If we have the means or imagination for it - what will you give to
those in need? Imagination of how much of food water shelter and goodies can
one give and keep on giving, to whom all? What and how much can I give to the
group members here? Articulating creatively (even through songs) what it means
to ‘want good for others’
Making an intent for oneself, making greeting cards
for loved ones and giving it to them, making action plan for days or week and
following that plan
Overall, there is remarkable
difference between the scores on ‘negative’ and ‘general pathology’
sub-scales when comparing September 2013 and March 2015 scores in
PANSS. The correlations between PANSS, the Checklist and Rating Scale
are notable, however the changes in the scores in the Rating Scale and
Checklist would not be considered statistically significant. The
statistical findings should be interpreted in conjunction with the
qualitative observations and limitations, discussed later.
were conducted to check if participants did indeed show significant
changes in symptom severity and wellbeing after having participated in
different phases of ABT from September 2013 to April 2015. The changes
on the ABT Rating Scale and the Checklist scores cannot be considered
statistically significant, but there was a substantial difference seen
on the scores for the PANSS. While the mean score in September 2013 was
90.428 (SD = 6.7), the mean score in March 2015 was 65.428 (SD =
18.78). In spite of unequal variance, this difference was found to be
statistically significant in favour of improved health [t (7.504) =
3.316; p < 0.05].
This difference was further explored to
reveal not all aspects of PANSS showed the same amount of change. While
overall scores showed a distinct move towards better mental health, it
was only the scores for negative symptoms and general pathology that
showed a statistically significant improvement. While the group
experienced a mean score of 28.57 (SD = 4.649) on negative symptoms in
September 2013, this mean score had come to 18.143 (SD = 8.63) by March
2015. Again, this difference achieved statistical significance in spite
of unequal variance [t (9.213) = 2.815; p<0.05]. Similarly, while
the group showed an average score of 44.285 (SD = 3.98) on general
pathology in September 2013, the mean score on March 2015 was 33 (SD =
10.01). This reduction in score was statistically significant although
the variance was very different [t (7.856) = 2.77; p<0.05]. Both,
the scores for positive symptoms and the composite score show a
distinct improvement across the group; but these differences did not
reach accepted levels of statistical significance.
There is a
serious increase in the variance in scores between the initial and
final testing. This suggests wide variation in the performance of the
participants on different scales and test items towards the end of the
testing period. Since there was far lesser variability in scores at the
beginning of the data collection process, it could indicate that some
participants benefitted from ABT more than others.
were computed across different instruments used to collect data. It was
seen that all the sub-scores on the four subscales of ABT Rating Scale
significantly correlate to each other; suggesting there are some common
factors that govern the extent to which participants demonstrate bodily
awareness, interaction with the group, cognitive ability and narrative
and expressive capacity.
All the sub-scores on the Rating
Scale significantly correlate to the Attention sub-score on the
Checklist. Logically this makes sense, since attention to the here and
now is an important factor associated with—awareness of one’s own body,
the ability to interact with each other, and with expressing thoughts
and ideas, and explaining them to others. On the other hand, only the
group interaction score in the Rating Scale seems to share a
significant relationship with Interpersonal Engagement sub-score from
the Checklist - which is the only sub-score that it shares a meaning
with. It is rather intuitive that better interpersonal interaction
would be associated with enhanced engagement within the group.
among the ABT Rating Scale sub-scores, PANSS as a whole reflects
negative correlation with bodily awareness and narrative capacity. The
relationship with group interaction and cognitive ability
sub-scales—while strong and in the expected direction—fell just short
of statistical significance. As participants do better on Rating Scale
items, they report fewer and lower intensity of clinical symptoms in
PANSS. This finding is reassuring, since it suggests as participants
start having fewer issues, they also start experiencing improved
Although, as expected, while the values of the
correlations are strong and negative, PANSS did not share statistically
significant relationships with either of the Checklist sub-scale. This
suggests that better performance on the Checklist is associated with
somewhat fewer clinical symptoms; and the relationship may need to be
explored with a larger group to make sense of it.
these trends heartening is they represent an interesting shift from the
type of relationships seen among scores at the beginning of the testing
period. Before ABT was introduced, all sub-scores on the Rating Scale
and on the Checklist shared significant positive relationships; but
none of these scores shared either a significant or a strong
relationship with PANSS. But as some of the participants started
showing improvements, these relationships started to become evident.
Self-awareness and expression in particular, seem to improve as
symptoms go down. To a lesser degree, attention, aspects of social
interaction and cognitive process also seem to improve when clinical
symptoms are lower.
PANSS Remission Items
the scores on the eight remission items are looked at specifically, out
of the 7 participants 5 show reduction in symptom intensity, while 2
did not benefit across the testing sessions. For some participants in
particular sub-items the initial scores were low and continue to stay
low. For others, there is reduction in scores for some items, but not
Table 6: PANSS scores on 8 Remission Items
AS1: Sep 2013
AS2: Mar 2014
AS4: Nov 2014
AS5: Apr 2015
Graph 1: PANSS Remission Items
The chart for the same data
PANSS Severe Items
impact of ABT becomes a little clearer when we identify items in the
PANSS that had severe rating in September 2013, and isolate them from
the others. For some participants, there were many such items, while
others had a severe score on only a handful of items. The scores for
all these items were tracked separately across different data
For ease in comparison, the scores across
all tracked items were aggregated for every participant during each
data collection session. This was done so that the number of items
being tracked would not confound the trends being explored. As observed
from Table 7, there is a distinct trend towards severity reduction as
time progresses for most participants.
Table 7: Average Scores on PANSS Severe Items
AS1: Sep 2013
AS2: April 2014
AS3: July 2014
AS4: Dec 2014
AS5: Apr 2015
This trend is better understood through the following graph.
Graph 2: PANSS Severe Items
observations by neutral observers and ABT Practitioner correlate with
the statistical data. They reflect reduced symptomatic behaviours and
an increase in the instances of attentive engagement with the ‘here and
now’ and others. Qualitative notes for two participants are included
Notes for Avinash
disorganized schizophrenia in 1985, and living with it the longest from
within the group. Avinash was of 50 years of age when ABT started. He
is married and has a daughter. In the initial period, Avinash never
established eye contact or participated in any activity, and never
responded verbally to any suggestions or instructions. He did not
maintain hygiene, was lost in talking and laughing, engaged with
auditory and visual hallucinations. His past treatment included ECTs at
some point. Therapeutic goals for Avinash were set as ‘bringing
attention to here and now’ and ‘being participative in ABT sessions’.
during the sessions, Avinash would be ‘pacing about, mumbling, abruptly
leaving the room’. These observations recur through the entire first
phase. It took 6 months to make the first eye contact, first physical
participation and first coherent response within the session. Another 6
months later ‘leaving or pacing’ was observed only once during the
entire third cycle. ABT invited his attention and Avinash began to
interact, sample this: ‘Sitting in his typical ‘head bowed down’
position and mumbling, nodding, hallucinating. The facilitator called
him out to join-in. He shook his head and said ‘no’. The facilitator
persuaded, he looked-up, said yes. The facilitator sat in front of him
and threw a ball at him, he reached out for the ball. A game of
catch-throw ensued’. Another ball was added, two balls simultaneously,
‘Avinash smiled as he juggled the balls’ notes the observer. Subsequent
sessions build on this further ‘Avinash played ball juggle with
Pratiksha - he was alert, catching all the time, without dropping ball.
He then invited the facilitator (who was on the side) to join-in. They
played ball juggle, 3 persons, 3 balls simultaneously’. Eventually this
moves on to spontaneous interaction in another session, ‘played a long
rally of balloon pass with the facilitator. Avinash, smiling gave a
hi-five to the facilitator, then played in a triad with Nikash too’.
started participating in the ritual of greeting each person by name and
making eye contact without being prompted to do so. It is also noted
that he reminded Nikash or Pratiksha to ‘fold hands and greet’! His
reluctance continued, like a habitual response, but it gave way with a
bit of insistence. There was some newfound inquisitiveness. Once as the
facilitator arrived Avinash ‘waved and smiled’ and started a
conversation of his own accord, asking the facilitator questions. In
the session during a concentration exercise, he added his own
observations to the group’s, ‘I see bluish colour in the smoke of
incense, the incense stick is brown’. He was coherent in speech and
neater than before. Observations recur to note that he ‘participated in
prayer without prompt and did voice exercises on prompt’ or that he
‘smiled in response to a joke, not hallucinatory smile’. In one of the
activities making drawings and intent for the year, Avinash declared ‘I
will participate in activities here!’
These notes coincide
with PANSS scores—the sub-scale of 8 remission items show a notable
decline in symptom severity (Table 5, Graph 1). While the symptom
severity lessens, the Attention and Interpersonal Engagement Checklist
indicates marginal increase in average scores. The Rating Scale also
shows a gradual positive incline in the overall scores, indicating a
tilt towards wellness. Consistent bettering in all scores coincides
with period when Avinash did not miss a single ABT session (AR1 and
AR2). There is a marginal fall in the last phase (AR3), during this
period he had missed almost 40% of the sessions. The effect of this
absence was noted in observations as well, ‘Avinash came today after 4
weeks. Said hello, smiled, but seemed inside his own world again’. This
suggests a connection between regularity in ABT sessions and response
level, and thereby the therapeutic effect.
During one exercise
in which each person named their own or others’ ‘extraordinary
quality’, the facilitator turned to Avinash and teasingly asked ‘as you
will not speak, may be we should assign you something - a high quality
stubbornness….shall we say?' He promptly replied ‘no’ and pointed to
his ears, tapped on them and said, ‘listening, listening’. Everyone in
the group saw and heard this, and laughed and agreed. In another
session he explained a drawing meaningfully ‘this is a lotus, and it
grows out of the mud’. In these instances, his worlds, his tune and
ours came close together.
Notes for Madhu
age 32, experienced a sudden onset of obsessive thoughts and
hallucinations 4 years earlier. She is the most recently diagnosed
within the group. Her IQ was recorded as ‘borderline’. Her parents are
supportive, but she felt tremendous guilt for past violent outbursts
towards them. She sometimes laughed uncontrollably and experienced
sharp intense anger. She would mumble to herself, give
instructions to herself, and suddenly retreat into her shell.
therapeutic goals for Madhu were set as ‘appropriate emotional
expression’ and ‘building interpersonal skills’. She was enthusiastic
in the ABT sessions right from the outset and enjoyed movement
exercises, singing songs, drawing, and other artistic exercises. Early
on, the observer notes that she was ‘attentive herself, and urging
others to pay attention as well’. Yet suddenly she would be adrift,
‘mumbling, lost. Took time to orient herself’. During one of the ABT
sessions, she said ‘am feeling very angry, like hitting someone’. This
turned into an activity of ‘imaginary boxing’ game, moved on to body
movements with music. The ABT sessions opened opportunities to express
what was difficult otherwise. During an improvisation exercise around
the theme of ‘guests’, Madhu said, ‘there's a presence…. she competes
with me all the time. Whenever I want to do anything, the other one
comes and takes space. She does all that I would like to do; I am upset
because of this’. She spoke ‘haltingly, grappling for words’, records
the observer. A conversation about being alert, and about handling
wanted and unwanted guests ensued. In another session, with a drawing,
she managed to define things that she wanted to throw away forever in a
black hole: she explained them as her ‘moods, negative thoughts, anger’
and the surrounding chaotic lines as ‘fear and difficulty around me’.
In ABT, the art-loving Madhu seemed to find a way to clarify and
express her experience.
Madhu was sincere and she took
to heart the various artistic rituals created to keep alert, to say
‘stop’ to obsessions and telling the hallucinatory presence to ‘go’.
She reported ‘I have been using the stop and go, especially when I get
very angry, and it was useful.’ She was always enthusiastic to narrate
stories or enact them. Once, as she started telling one story of Birbal
and his khichdi, mix of rice and pulses, she mixed the narrative with
another story, and continued, and further mixed it up with yet another
story. Everyone just listened. At the end of her narrative she quipped,
‘I made khichdi (mix-up) of 3 different stories together!’
time the group was working with a Marathi folktale. Apparently it is a
children’s tale, with rhyme and chants, about an old woman who is
accosted by predators on her journey to her daughter’s place. She is
going there to rest and recover her health. On her way back, she gives
a slip to the predators by hiding inside a pumpkin. Madhu was the first
one in the group to identify it as ‘a children’s tale heard in
childhood!’. Others caught on and memories of the tale were discussed.
Madhu added her reflections ‘I think it’s a story about protection,
when we are not well, to take care.’ This was appreciated by the group
and the facilitator. She spontaneously substituted the story’s rhyme
with a ditty of her own ‘chal re mana aplya gava’ (O mind, let's go to
our true home). This was applauded by all. As the discussion went round
from person to person, Madhu came back with another understanding, ‘I
think there is no pumpkin. When the old woman recovers from illness,
she is a changed person. She is well-fed and her health is restored, so
she has become large, like the pumpkin.’ On this, much laughter ensued,
but the myriad meanings were not lost.
Here was someone, riding
on the back of traditional tale, uncovering an insight. The PANSS
scores corroborate these shifts—in the sub-scale of 8 remission items,
all items except one show stable low or consistent decline to below
severity scores. PANSS sub-items that were severe for Madhu in
September 2013, all without exception, declined, showing remission
sustained for period of 6 months in subsequent assessments (Table 6).
The Checklist and Rating Scale correlate, where the latter shows a
positive jump in expressive capability and attention.
recurring observations note how enthusiastically Madhu sang songs and
how they changed from sharp, shaky notes to more measured and accurate
expression. ‘She expressed happiness in dance movement, was alert in
ball throw and made meanings in the stories’ the observations note.
Commenting on the African folktale of the Greedy Hyena and the Great
Tree, she had the last word in the group ‘the thoughts that trouble,
like the hyena in the story, must be deleted forever’.
techniques were employed in a bid to analyze the objective trends seen
among participant scores. Although the findings suggest changes, it is
necessary to interpret them in context. The sample size was
extremely limited (n = 7); and the data collection for PANSS in
different stages was done by 2 different clinicians - a factor that may
have confounded the more subjective scores. It is important to remember
that the group was heterogeneous to begin with, many participants were
also on medication, and that this data does not reflect any special
circumstances that could have confounded the scores at any of the
testing sessions. The researchers accept that these factors reduce the
value of the statistical findings; but nevertheless we have chosen to
explore said findings as one part of a larger analysis. The study is
also constrained by limitations of time and resources, and lack of
availability of a matching control group.
project has been one of its kind long-term interventions within India.
It has explored the capacity of the artistic within the Indian paradigm
to be helpful to those with mental health issues in an institutional
setting. ABT is uniquely situated; addressing personalized therapeutic
needs, within the context of local patterns and possibilities of
healing and rehabilitation. It works in complementation (not
confrontation) with other therapeutic work that may be going on.
that ABT engages the participant in artistic and expressive modes, it
is almost intuitive that it has had a remarkable change in negative
symptoms and general psychopathology as measured on PANSS. Yet,
studying carefully each participant’s scores and notes, it is clear
that actually for this particular group at SAA, the maximum ‘severe’
items were on the negative scale followed by general psychopathology in
PANSS, and those are being addressed through ABT. ABT systematically
focused on, and therefore dovetailed with the therapeutic needs of the
participants. We can therefore safely assert that ABT positively
impacts the ‘therapeutic needs’ of a participant. This is supported by
initial observations of a second ongoing group of participants at SAA
for a period of 6 months in 2015 that reported reduction in severity
despite dissimilar symptoms than the earlier group.
methods and approach of ABT create an artistic atmosphere. The sessions
are fun, there is ease and laughter, and it relaxes the participants.
ABT works with what one ‘can’ do, what is intact. A reassuring contact
with artistic rituals, the known and unknown music, movements and
paintings is possible. Participants can choose to relate or retreat as
much as they want. The individual’s safeguard’s are protected, but
prodded playfully. It was not burdensome to be persistent and make
contact with Avinash because of this underlying understanding, and also
because it was essentially a playful, ‘arts-based’ persistence.
is recognized that the participants are unceasingly coping with the
situation they find themselves in, and their coping is to be aided with
appropriate modes and tools. In the sessions each one would make and
shape experiences with voice, images, narratives, rhythms or tunes.
This world there was manageable, even malleable. Getting a ‘hold’ over
an experience can give a sense of charge over it. Madhu mixed-up
narratives while telling her story, but navigated herself in that
mix-up (others and she, herself, listened), and she did playfully quip
that she made a mix-up! The process created opportunities to express,
examine and evolve the coping energy into practical and useful
explorations. The flexibility and rich variety of tools and techniques
of multiple art forms enabled an eclectic, fittingly personalized
ABT worked with a person rather than his/her
diagnosis in the true sense. No matter how severe the symptoms or how
difficult a person might seem, we strove to open a dialogue with the
experience of the person. After 23 years of being increasingly
locked-up inside his world, Avinash seemed to eventually trust, not the
words or the show of respect, but the actual experience of an
alternative space. His smiles and contact with us indicated a
refreshing change. Madhu could listen or tell stories and eventually
arrive at insights on her own despite the label of ‘borderline’
intelligence. Such potential is there in every session and each
participant, all through.
Each small step took us to common,
shared ground. Madhu enjoyed working with colourful clay, and then she
told narratives about it, attention and appreciation from others
encouraged her. Avinash was amused with ball-juggle and balloon-pass,
and that got him to interact. His drawing of a lotus in mud said
something. In successive sessions, attention rested—for one moment,
briefly, or longer, as per person—in the here and now, leading to
acknowledgement of self and others, and interaction.
be emphasized enough that trained ABT Practitioners don’t approach
mental health with merely a bag of artistic tools and techniques, but
are informed with study of mind and training in compassion as a the
preliminary mode of relating. ABT is not mere ‘art activity’; it works
with a decided and dedicated therapeutic framework. As a complementary
therapy, it doesn’t deny the role of other therapies and approaches. It
works extremely well in suitable organizational and institutional
This particular study is just a beginning of a
journey. A plea for more trained ABT Practitioners is a plea for a
systematic approach in the arts, informed with appropriate theoretical
framework and culture-specific models of intervention. Considering
holistic support, care and therapeutic work for those experiencing
mental illness is an urgent and forcefully growing need. There is also
need for more systematic long-term studies with larger sample size and
in-depth qualitative and quantitative measures to underline and extend
the mere notes of this present study into well-formed score of
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Many visible-invisible hands shape WCCL Foundation’s ABT action research and training and we owe deep gratitude to all of them.
for the project ‘Notes in Tune’ at SAA, we sincerely thank the funding
support that came forth from many sources – the Praj Foundation,
Terragni Consultancy, Mr. Srikrishna Bharambe, Mr. Sunil Chavan, Ms.
Sulabha Mahajan, Ms. Shaheen Colombowala for the trust they posited in
The entire SAA team – Mr. Amrit Bakshy, Mr. Gurudutt Kundpurkar
for their support, Ms. Neelima Bapat and staff, the clinical
psychologists – Sarika, Kadambari, Tushar for the support in data
collection and assessments.
Ms. Gauri Sarda helped with her time and
effort without any qualms, analyzing, encouraging and helping with the
statistical data. Without her help, the writing wouldn’t have been
Thanks to Amruta and Kumud for painstakingly reading the
draft and for the suggestions. Dr. Bhargavi Davar contributed with her
critical and timely comments.
My family and team at WCCL – Zubin
because of him the systematic path of action research is diligently
followed, Asha who as the leader constantly eggs us on into huge vision
and refined action, Deborah, whose support and insights are always
valued, and Anisha for her invisible work. To them, I cannot thank ever
Last but not the least, to those members of SAA who have
participated in and have continued with ABT sessions. May the highest
possible benefit of healing and wellness come to them.
Bhavatau sarva mangalam