Everyone, irrespective of age, gender or culture, can be creative through their occupations and leisure time (Reynolds 2009). Occupational therapy’s belief that something new can arise through ‘doing’, means that occupational therapists seek to nurture the creative potential assumed to be inherent in every individual. The performance of many activities is thus synonymous with being creative and, therefore, creativity is part of everyday life. Just as occupation is central to being human, so is creativity (Perrin 2001; Blanche 2007). To express oneself creatively can positively influence an individual’s health and wellbeing (Perruzza and Kinsella 2010) and, like engagement in meaningful activity, it can also be seen as a human right (Hammell 2008; Warren 2008).

One way in which occupational therapists can facilitate and encourage creative expression is through the use of creative activities, which have been used by occupational therapists throughout the history of the profession (Griffiths and Corr 2007).

Defining Parameters

What is Creativity?

The term ‘create’ comes from the Latin word creare meaning to make and the Greek krainein meaning to fulfil. To be creative is to have the ability to create or ‘to bring into existence’ (Merriam-Webster’s Dictionary 2011) and creativity is the process of creating something new or original that is of value to the creator or to others (Fasnacht 2003).

Activity, Occupation, Meaningfulness and Creative Media

In discussing creative activities, this chapter does not make a distinction between activity and occupation. Furthermore, it assumes that most activities which are meaningful for an individual can involve creativity. For example, the daily choice about what to wear involves both practical considerations (about appropriateness for the weather, for example) and creative considerations such as the expression of one’s sense of style and cultural identity.

Occupational therapists may engage with individuals’ creativity through the use of creative media such as creative writing, painting, drawing, desktop publishing, silk screen printing, scrapbooking, clay work, sculpture, web design, needlecraft, knitting, willow work, felting, marbling, tie dyeing, card-making, music, singing, dance, photography, cooking, woodwork, metalwork, video and film-making.

A HISTORICAL AND CULTURAL CONTEXT

Occupational therapists have used creative media or crafts since the profession began. Their use grew out of the moral treatment movement (McKay 2008) and was subsequently influenced by the arts and crafts movement in the late 19th century (Thompson and Blair 1998). Both these movements are explored more fully in Ch. 1. Since then, their use has been shaped by various paradigms of healthcare prevailing at different times. Between the 1950s and 1970s, the use of creative activity became understood in terms of psychodynamic and humanistic approaches to health and wellbeing (Thompson and Blair 1998). However, in the early 1980s, occupational therapy underwent a crisis of confidence (Perrin 2001). This was due to the dominance of a positivist bio-medical paradigm, which valued experimental and quantitative research evidence and the profession’s wish to adopt these values to maintain its scientific credibility (Perrin 2001; Creek 2009; Turner 2011).

A further influence on the use of crafts is gender. Creative activities have historically been seen as feminine and domestic. It has, arguably, been a challenge for a largely female profession to transcend this stereotype and use creative activities with pride and confidence (Pollard and Walsh 2000). However, an increase in recent research activity shows that there is a resurgence of interest in the therapeutic potential of creative activities (see Maratos et al. 2008; Clift 2011; Clift and Morrison 2011; Caddy et al. 2012; Crawford et al. 2012). It is proposed that there are three reasons for this revival: a growing recognition of the importance of building social and cultural capital, the technological advances of the digital age, and a cultural rebooting of creative activities that relocates them more gender-neutrally within our culture. Each of these will now be discussed in turn.

Social and Cultural Capital

A health service orientated exclusively to a narrow bio-medical paradigm will not have the resources to address the needs of a population that is living longer and with long-term conditions, because many of the challenges faced by people are about adaptation. Society has to find ways to engage with the enduring nature of conditions such as depression and schizophrenia and reduce the functional limitations they impose (Denton and Spencer 2010). Consequently, there has been increasing interest in building social and cultural capital within communities (Abel 2008), along with health promotion, and behaviour change management initiatives (Lancet 2012). (See Ch. 2 for further description of social capital.) Creative activities have a part to play in these processes hence the growth of the Arts in Health movement, which is explored later in this chapter.

The Digital Age

The digital age has increased the number of creative activities that can be explored by the lay person and many of them may be perceived as being comparatively gender-neutral. Desktop computers, laptops and mobile devices are powerful enough to manipulate text, graphics, sound, high-resolution images and video. People commonly capture images and video on their phones. You Tube, blogging and online social networking offer a readily available way of publishing this work to a global audience. Thus, we have the concept of ‘curating the self’ (Potter 2009), whereby each of us becomes a curator of our own online presence through our uploading, social networking, gaming and blogging activities.

Digital creative media can be utilized to motivate positive health choices and aid rehabilitation. For example ‘Tree Fu Tom’, an animated series made for children’s television (see Further reading/additional resources, below), was developed in consultation with occupational therapists and incorporates exercises designed to help children with obesity and dyspraxia/developmental coordination disorder (Payne 2012). Similarly, ‘Zombies, Run!’ (Moses 2012) is a mobile phone app which combines a running aid with a story and game. It encourages users to become part of the story, running missions fed via their earphones and collecting items within a zombie-related narrative. It is an entertaining way to incentivize physical activity, the benefits of which are explored more fully in Ch. 14.

The Cultural Re-Booting of Creative Activities

Creative activities are escaping the confines of the domestic domain and are being performed in new ways and for new purposes. Yarn bombing is a form of benign graffiti where street objects are covered in knitting (Wollan 2011). It has practitioners all over the world and is supported by a vibrant online community (see Yarn Corps 2011). Similarly, guerrilla gardening, the subversive act of planting on urban wasteland, neglected traffic islands and pavement verges, brings beauty to public spaces and, arguably, improves the quality of life for all (Reynolds 2011).

WHO ELSE USES CREATIVE ACTIVITIES AS THERAPY?

Occupational therapists are but one group who understand the potential of creative activity to influence health and wellbeing. It is important that occupational therapists are aware of the approaches of other professionals and organizations working with creative activities so partnerships can develop. A short description of three groups who work with creative activities is outlined below.

The Arts Therapies

Art Psychotherapist, Art Therapist, Drama Therapist and Music Therapist are all protected job titles in the UK and are professions regulated by the Health and Care Professions Council (HCPC 2012). In the USA, Goodill (2010) identified art therapy, music therapy, dance/movement therapy, poetry therapy, drama therapy and psychodrama as arts therapies, stating that their focus is to combine artistic expression with psychotherapy to promote healing, wellness and personal change. In addition to being experts in their chosen media, arts therapists will have undergone a graduate or masters programme of study involving psychology and psychotherapy, as well as practice placements and coursework.

Arts in Health and Arts on Prescription

There has been growing interest in the promotion of the arts within healthcare, with initiatives such as Arts in Health (Clift 2011) and Arts on Prescription (Bungay and Clift 2010), which act as adjuncts to conventional therapies. They involve activities facilitated by artists and musicians, for example, rather than occupational therapists or arts therapists and are frequently accessed by people living in the community with mild to moderate health problems (London Arts in Health Forum 2010).

This kind of social prescribing is seeking to build social capital and community engagement for the purpose of enhancing health and wellbeing. However, in their review of the field of arts and health, Brodzinski and Munt (2009) state that they became aware that there is ‘a lack of theoretical underpinning within the field’ (p. 280), indicating that this is a developing area.

The Medical Humanities Movement

Medical humanities is an academic discipline which initially arose out of medical student education. It explores a person’s subjective experiences of medical care and draws on areas such as philosophy, the history of medicine, anthropology, social sciences, history, literature, the arts and theology (Smith et al. 2006). It focuses on achieving authentic interdisciplinary collaboration, including collaboration with service users. The movement encourages anyone who has an interest to become involved and examines how new ways of thinking about health, ethics and wellbeing impact on the culture of healthcare provision. Creative activity such as literature, poetry and film are used as well as other creative media to support this exploration (Macnaughton 2011).

THEORETICAL UNDERPINNING FOR CREATIVE ACTIVITIES AS THERAPY

Researching Creativity

Creativity has been researched by many disciplines with differing emphases influenced by differing perspectives. For example, the business sector focuses on identifying and developing the characteristics, skills and attitudes of creative people so greater creative problem-solving and commercially original products may result.

From this perspective, cognitive science research has sought to identify the key features of ‘creative people’. Such individuals are commonly described as highly motivated and possessing skills of decision-making, problem-solving, convergent and divergent thinking, evaluation and complex learning (Wang 2009). Cognitive science associates creativity with higher cognitive processes that discover new, original and useful relations between concepts, phenomena and events (Wang 2009). Within the education sector, there is much interest in the influence of the environment on creativity and purposely designed ‘creative spaces’, for example. These are rooms with design features, such as whiteboard walls with in-built computer software that allows for the easy expression of ideas within groups, allowing students’ ideas to be easily recorded and with only minimal interruption to the flow of the group work. The aim is to encourage exploration, experimentation and experiential learning, which are essential features of creativity (Jankowska and Atlay 2008).

Also within education, Kleiman (2008) has offered a broad, research-based conceptualization of creativity as something process-orientated (that is, it may not be geared towards a tangible product) and as something product-orientated (creating something new, original and of value), which aims to bring about change internally or externally and to generate feelings of satisfaction and fulfilment.

Across these different perspectives, there is interdisciplinary agreement that creativity is influenced by the environment and can therefore be developed.

Creativity and Occupational Therapy

The existential view of human beings as constantly defining and redefining themselves through dialogue with the world is fundamental to the work of Carl Rogers, Abraham Maslow and Erich Fromm, and has been a huge influence on the development of occupational therapy. More recently, occupational scientists and occupational therapists have explored the relationship between creativity, health and wellbeing. For example, Blanche (2007) has identified that the meaningfulness and value of creativity relates to the goal of creating a product and/or to the pleasure gained from the process of creating. Pleasure may be gained from solving problems, asserting personal preferences, self-expression, or ‘losing oneself’ in the creative act and discovering something new about oneself. In this sense, Maslow (1974) and Zinker (1977) have suggested that the therapeutic impact of creativity is related to its capacity to foster transformation and change. Occupational therapists have also recognized that creativity can be a feature of the therapeutic process itself when, for example, a service user has entrenched problems for which there are no set solutions, and new solutions need to be co-created (Perrin 2001).

Research Evidence for Creative Activities as Therapy

Of the UK occupational therapists surveyed by Griffiths and Corr (2007), 82% reported using creative activities within their mental health practice, although, until recently, there has been little research-based evidence to support this work. However, two overviews of research in this field are noteworthy. Reynolds (2005) produced a comprehensive critical review of literature regarding the impact of the creative arts on health from the end of the last century until 2003 and Perruzza and Kinsella (2010) published a literature review on the use of creative arts occupations in therapeutic practice between 2000 and 2008. Both these reviews include evidence from a range of creative arts professions, as well as creative activities used in occupational therapy. Perruzza and Kinsella (2010) included 23 studies and identified six benefits of creative activities: enhanced perceived control, building a sense of self, self-expression, transforming the illness experience, gaining a sense of purpose, and building social support.

Other notable research regarding creative arts therapies includes the following:

■ A Cochrane systematic review (Maratos et al. 2008) which reviewed five randomized controlled trials of music therapy for people with depression. Four trials reported greater reduction in depressive symptoms among participants randomized to music therapy compared with those allocated to standard care

■ Clift and Morrison (2011) demonstrated that community group singing can have substantial benefits in aiding the recovery of people with a history of serious and enduring mental health problems

■ Crawford et al.’s (2012) multi-site randomized controlled trial of group art therapy for people diagnosed with schizophrenia – known as the MATISSE study (Multicentre Study of Art Therapy In Schizophrenia: Systematic Evaluation) – is thought to be the largest piece of research on an arts therapy in mental health practice to date. Although the findings were inconclusive, this rigorous study stimulated a lively debate in the British Medical Journal where Kendall (2012) commented, ‘arts therapies, because they rely on creative expression rather than verbal communication, … still have the greatest potential for success in the treatment of negative symptoms (of schizophrenia)’ (p. 1)

■ Caddy et al. (2012) found positive correlations between participating in a creative activity group and improved mental health outcomes in an Australian psychiatric hospital. The study examined hospital records between 2004 and 2009 and focused on 403 service users who had received at least six sessions of therapy in a creative activity group.

According to Clift (2011), there is now a vibrant research interest in arts and health, giving rise to the recent launch of three academic journals dedicated to arts/music and health research: Arts and Health: An international Journal for Research, Policy and Practice, the Journal of Applied Arts and Health and Music and Medicine, and the well-established Medical Humanities Journal (see Further reading/additional resources, below).

Theoretical Materials Relevant to Creative Activities

It is vital that occupational therapists are able to articulate and justify their rationale for using creative activities as therapy. The choice of theoretical underpinning is informed by the needs of the service user, the demands and opportunities of the environment, and the interests and skills of the therapist (Creek 2009; Iwama et al. 2009). The expert occupational therapy practitioner may incorporate many theoretical approaches, techniques and frames of reference, adapting swiftly to the needs of the service user through the practice of clinical or professional reasoning (Unsworth 2001; Creek 2010). The purpose of this section is to familiarize occupational therapists with some of the theories underpinning the use of creative activities. They are illustrated using case studies later in the chapter.

The Theory of Creative Ability

A South African occupational therapist, Vona du Toit, developed the Theory of Creative Ability during the 1960s and until her death in 1974. Since the 1990s, the theory has been presented as a model by de Witt (1992, 1997, 2005). Known for many years as the Model of Creative Ability, it was renamed the Vona du Toit Model of Creative Ability in 2010. The model is used in the UK and Japan, and widely used in South Africa.

Vona du Toit (1962) used Buber’s definition of creativity; that through one’s action, ‘something arises that was not there before’ (Buber 1947, p. 85). This is comparable with Carl Rogers’ (1959) view of creativity; that it involves the creation of an original product out of the person’s own uniqueness, their human and non-human environment, and the events and circumstances of their life. Therefore, creativity may result in something tangible (a product of some kind) or something intangible – such as new understanding, or an increase in self-esteem. Vona du Toit’s notion of creativity relates to the ability to create one’s world and oneself (tangible products) and also intangible products such as one’s sense of self and intrapersonal change. She proposed that this occurs progressively through levels of creative ability.

Levels of Creative Ability

There are nine levels of creative ability in the model. The first six levels (outlined in Table 17-1) are commonly seen by occupational therapists because they are levels at which people usually seek or need intervention. It is not the norm for people who are on the three final levels to be in need of intervention and therefore they are not usually encountered in occupational therapy practice. Rather, people may have been on a higher level before the onset of their mental health problems, but present on a lower level in health and social care services due to illness, injury or other issues. A detailed description of the levels is provided by de Witt (2005) and du Toit (2006).

TABLE 17-1

Six of Du Toit’s (1972) Nine Levels of Creative Ability

Level	Motivation	Action
6	ACTIVE PARTICIPATION: for egocentric reasons, to improve on activities or behaviour identified as a problem by the individual	ORIGINAL: able to analyse activities to identify aspects for improvement and can provide original solutions
5	IMITATIVE PARTICIPATION: to behave and perform tasks to standards/expectations; doing as well as others	IMITATIVE: demonstrates behaviours and task performance to socially accepted standards; evaluates; problem-solves
4	PASSIVE PARTICIPATION: to learn behaviours and skills for independent living; doing and being with others; learning socially acceptable behaviours and expectations of task performance	EXPERIMENTAL: experiments with behaviours and tasks in order to identify what is acceptable; experiments with activities to expand knowledge and skills; begins to evaluate performance
3	SELF-PRESENTATION: to develop a sense of self (likes/dislikes; what one can do); exploring the environment, people and situations; constructive doing; learning how to do; relating to others	EXPLORATIVE: willing to try ‘to do’ but lacking skills; shows interest in surroundings; needs supervision to do tasks and to complete them; tends to do a bit and then stop/feels unsure; communicates with familiar people
2	SELF-DIFFERENTIATION: to differentiate oneself from others and things; making contact with the environment	DESTRUCTIVE: engages with the environment; interacts with objects in a way that they are not meant to be used; limited awareness of/contact with people; brief periods of activity INCIDENTALLY CONSTRUCTIVE: through contact with objects, makes something happen by chance (unplanned)
1	TONE: establishing the will to live and maintaining biological tone as ‘the starting point from which all human systems needed in occupational performance develop’ (de Witt 2005, p. 21)	PRE-DESTRUCTIVE: little or no awareness of, or response to, the environment

du Toit posited that human beings are motivated to relate to the world around them and this occurs through acting on it; through doing. Gradual changes in human beings’ motivation and actions for doing are described in levels of creative ability. For example, motivation at the fifth level is termed imitative participation because there is motivation for occupational performance of a ‘good’ or socially acceptable standard which imitates, or conforms to, socially accepted behaviours and ways of doing things.

Progression, Regression and Recovery of Creative Ability

Influenced by the environment, progression through the levels of creative ability occurs sequentially, like progression through the stages of human development. However, illness, injury, trauma or difficulties associated with old age may cause a decline or regression in an individual’s creative ability to a lower level. In this case, restoration of creative ability is seen as the recovery of the self, albeit a changed self.

The Creative Process: Response, Participation, Product

The decision a person makes in response to each demand, opportunity or challenge of daily life, ultimately determines an outcome. Therefore making decisions is creative. In each decision, ‘Man’ is determining the quality of ‘Being’ – becoming Himself’ (du Toit 1962, p. 2). Making the decision to participate in life through mental and physical effort is known as a creative response, and is a precursor to participation. In mental health practice, service users’ responses to life may be affected by a number of factors including reduced motivation, reduced levels of activity, withdrawal or occupational deprivation. du Toit suggested that therapists are more likely to gain a creative response, elicit motivation and engage an individual if they offer an intervention that attends to the person’s level of creative ability which encompasses motivation. Through participation, there is the creation of tangible and intangible products and ultimately there is change – and the ‘becoming’ or creation of oneself.

Growth in Creative Ability

Participation requires mental and physical effort, but if this is felt (by the individual) to be beyond their abilities, it can result in stress, withdrawal or failure, which is not conducive to achieving growth in creative ability. Similarly, participation that is well within a person’s abilities and is felt to be easy or requiring very little effort has limited potential for bringing about growth. Rather, growth occurs through the mastery of ‘just right challenges’. That is, challenges which are at the limits of one’s ability and require effort. Mastery of challenges through effort results in a person’s growth towards, or into, a new level of creative ability (du Toit 1970). Identifying what constitutes the ‘just right challenge’ for mastery and growth is the therapist’s task. To assist with this task, the Theory of Creative Ability provides a guide to intervention for each level.

Intervention: The Creativity of the Occupational Therapist

du Toit (1962) suggested that within the therapeutic relationship ‘the patient and therapist very intimately share the problem of the patient’s recovery’ (du Toit 1962, p. 11). Coming alongside the service user, the therapist uses their own creativity to facilitate a therapeutic process for maintenance, growth, or recovery of creative ability through the use of carefully selected activities. This is informed by the therapist’s holistic view of the service user and of what is meaningful and purposeful for that individual. It involves understanding the occupational performance demands the service user faces and an appreciation of the therapeutic potential of the activity. Selected activities are then graded to enable the service user to respond with a decision to participate, to exert effort in the face of the ‘just right challenge’, to master occupational performance challenges and thus elicit motivation for further participation. In this way, the goals of therapy can be achieved for maintenance of creative ability (particularly for service users with progressive conditions), or the growth of it.

Grading occurs in relation to four principles: handling (therapeutic use of self); structuring (managing session time and environment); presentation (considering how the activity will be facilitated); and activity requirements (analysing activity characteristics to aid selection of the ‘right’ activity).

Flow Theory

The concept of flow has much to offer occupational therapists working with creative activities. It was developed by Hungarian psychologist Mihaly Csíkszentmihályi, and seeks to articulate the enjoyable, holistic sensation an individual experiences when totally engaged in an activity (Reid 2011). Flow, therefore, attempts to conceptualize optimal human experience (Csíkszentmihályi 1975).

Flow has been associated with happiness (Csíkszentmihályi 2002), creativity (Csíkszentmihályi 1997) and spirituality; particularly the faculty of mindfulness (Wright et al. 2007; Reid 2011). When in a state of flow, a person may feel deep enjoyment, or they may be unaware of any emotion, being completely focused on the task at hand. A person becomes so absorbed by the activity that ‘self consciousness is lost and worries or negative thoughts disappear’ (Wright et al. 2007, p. 136).

Csíkszentmihályi (2002) identifies five factors which are said to accompany a flow experience:

1. Clear goals and feedback

2. Concentration on the task in hand

3. A sense of control, or an absence of worry about losing control

4. A loss of self-consciousness

5. Changes in the way time is experienced.

According to Csíkszentmihályi (2002), engaging in flow activities leads to growth and discovery:

One cannot enjoy doing the same thing at the same level for long. We grow either bored or frustrated; and then the desire to enjoy ourselves again pushes us to stretch our skills, or to discover new opportunities for using them.

(Csíkszentmihályi 2002, p. 75)

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