Which of These Elements of Art Is a Mental Concept?

• Journal List
• Front end Psychol
• PMC7546898

Front Psychol. 2020; 11: 572700.

Formal Elements of Fine art Products Indicate Aspects of Mental Health

Ingrid Pénzes

¹Department of Arts Therapies, Faculty of Health Intendance, Zuyd University of Practical Sciences, Heerlen, Netherlands

ⁱⁱKenVaK Research Eye for the Arts Therapies and Psychomotricity, Heerlen, Netherlands

Susan van Hooren

¹Department of Arts Therapies, Faculty of Wellness Care, Zuyd University of Practical Sciences, Heerlen, Netherlands

²KenVaK Research Eye for the Arts Therapies and Psychomotricity, Heerlen, Netherlands

³Kinesthesia of Psychology, Open Academy of kingdom of the netherlands, Heerlen, Netherlands

Ditty Dokter

⁴MA Music Therapy and Drama Therapy, Cambridge School of Creative Industries, Anglia Ruskin University, Cambridge, United Kingdom

⁵Master Dance Therapy, Codarts University, Rotterdam, Netherlands

Giel Hutschemaekers

^{half dozen}Kinesthesia of Social Sciences, Radboud University, Nijmegen, Netherlands

^viiPro Persona Mental Wellness Care, Nijmegen, Netherlands

Received 2020 Jun 15; Accepted 2020 Aug 31.

Data Availability Statement

The raw data supporting the conclusions of this article volition be made bachelor past the authors, without undue reservation.

Abstruse

Formal elements are often used in art therapy assessment. The assumption is that formal elements are observable aspects of the fine art product that allow reliable and valid assessment of clients' mental wellness. Most of the existing fine art therapy assessment instruments are based on clinical expertise. Therefore, information technology is not clear to what degree these instruments are restricted to formal elements. Other aspects might also exist included, such as clinical expertise of the therapist. This raises the question of whether and how formal elements as observable aspects of the art product are related to clients' mental health. To respond this question, four studies are presented that look at: (1) a meta-theoretical description of formal elements; (2) operationalization of these formal elements so they can exist analyzed reliably in clients' art products; (3) establishment of reliable and clinically relevant formal elements; (4) the relationship between formal elements and adult clients' mental health. Results evidence that the combination of the formal elements "movement," "dynamic," and "contour" are significantly interrelated and related to clients' mental wellness, i.eastward., psychopathology, psychological flexibility, experiential avoidance, and adaptability. These findings give insight in the diagnostic value of art products and how they may add together to clients' verbal expression and signal their potential to benefit from therapy.

Keywords: art therapy observation, cess, formal elements, art product, adult mental health

Introduction

Art therapy is an experiential handling in which the fine art form is therapeutically applied to initiate experiences that allow processes of change, development, stabilization or acceptance that support emotional, behavioral, cognitive, social, neurological or physical aspect of functioning (American Fine art Therapy Association [AATA], 2020; British Association of Art Therapists [BAAT], 2020). The art form – the use of fine art materials in an art-making process resulting in an fine art product– is specific and unique for art therapy handling and for art therapy observation and assessment. Fine art therapy approaches fundamentally presume that a clients' mental health is expressed in the art grade (Hinz, 2009, 2015, 2020; Haeyen, 2018; Abbing et al., 2019).

Art therapy observation and assessment is considered to be a key to estimate what the customer's trouble is, to determine whether a client may do good from art therapy, to formulate treatment goals and to utilise the appropriate art interventions (Hinz, 2009, 2020; Gilroy et al., 2012; Malchiodi, 2012). Several art therapy perspectives that depict from diverse approaches such equally psychodynamic, humanistic, behavioral, developmental and integrative approaches (Rubin, 2001,2005; Jones, 2005; Van Lith, 2016), have different views and theories on how exactly the art course relates to mental wellness. Nearly art therapists adhere clinical value to the art products of their clients. They recognize in art products signs of their clients' mental health, as well equally cues on how to treat, i.e., what therapeutic goals and interventions should be chosen (indication).

Testimonies of the clinical value of the fine art product tin can be traced back to the beginning of the 20th century (Prinzhorn, 1919; Plokker, 1963). Already before WW 2 all kind of projective drawing tests were developed pretending to provide insight in unconscious psychological conflicts (Murray, 1943; Cadet, 1948; Naumburg, 2001; Simon, 2001; Ulman and Bernard, 2001). From a psychometric perspective, these tests lacked reliability and validity; it appeared impossible to unequivocally score an art production in terms of content (McNiff, 1998; Betts, 2006). The focus subsequently shifted from symbolic content to the formal elements of art products, such as "line," "color," and "movement" as these were considered to be more objective (Gantt, 2001, 2004; Thomas and Cody, 2012). The underlying supposition is that formal elements in an art product represent the way clients collaborate with fine art materials in order to express themselves and that they are related to clients' mental health (Gantt and Tabone, 1998; Gantt, 2001, 2004; Hinz, 2009, 2015; Gilroy et al., 2012; Nan and Hinz, 2012; Pénzes et al., 2014, 2015). Several fine art therapy assessment instruments have been adult to mensurate these formal elements and relate them to clients' mental health problems (e.g., Cohen,1986/1994; Cohen et al., 1986; Hacking, 1999; Elbing and Hacking, 2001; Stuhler-Bauer and Elbing, 2003). However, these instruments have been field of study to serious psychometric critique regarding their reliability and validity. It has been argued that the existing instruments apply poor rating methods (Nan and Hinz, 2012) and inappropriate statistical procedures for measuring inter-rater reliability (Hacking, 1999; Eitel et al., 2008; cited in Betts, 2006; Schoch et al., 2017).

The existing instruments as well permit, and fifty-fifty demand, subjective estimation based on fine art therapists' own clinical experiences with different customer groups and different training orientations (Betts, 2006; Eitel et al., 2008; Schoch et al., 2017). This introduces all manner of interpretations, which tin can negatively affect the reliability. We still do not know to what caste formal elements equally the unambiguous observable aspects of an art production stand for the mental health problems of clients or how the clients cope with these bug. Critics of existing instruments also refer to the wide range of opinions regarding how formal elements should be interpreted in terms of mental health (Pénzes et al., 2018). Due to these shortcomings we all the same do not know whether or non art products tin can be used for diagnostic and indicative purposes. We know that the content of the art production cannot exist measured in a reliable and valid manner, but it is still possible that formal elements as the unambiguous observable aspects of an art product stand for the mental health problems of clients. The aims of this written report are to define formal elements that can be operationalized and analyzed reliably and are clinically relevant so their relationship with mental wellness tin be tested.

In this article, we report 4 studies that look at: (i) a taxonomy of formal elements; (2) an operationalization of these formal elements to clarify them reliably in clients' art products; (3) establishment of reliable and clinically relevant formal elements; (iv) the human relationship between formal elements and developed clients' mental health (run across Effigy one). We will make use of qualitative as well every bit quantitative enquiry designs.

Cursory descriptions of the four studies presented.

Study 1: Toward a Taxonomy of Formal Elements

In art therapy literature and clinical exercise, a large number and diverse formal elements were described equally clinically relevant. Fifty-fifty if considered equally sign of the richness embedded in the clinical do of fine art therapy, this huge number did non aid the growth of audio empirical studies on formal elements. Aim of this starting time report was to clarify this complication by returning to art theories on formal elements. Formal analysis of art refers to the appreciable pictorial qualities of art and is considered to be the nearly objective way of analyzing art products (Acton, 2009; De Visser, 2010).

Method

To describe the formal elements, art theory literature was reviewed and experts in the field consulted to gain meta-theoretical descriptions of formal elements. Art theories that presented a complete systematic "form analysis" of visual art were included, whereas theories that concerned only one category of course, such as "line," art history, art criticism, art philosophy, neurology and art perception, and/or aesthetics were excluded. As fine art theories cannot be found in scientific databases, three other sources were used. First, existing textbooks on art theory as found on the Internet and the university's library. Additionally, six experts in the field of art theory, specifically art assay, were consulted past email for communication regarding which boosted art theories to include. These experts consisted of teachers/researchers from the Netherlands, Germany, Israel, and Finland. These experts were chosen based on their expertise in the field of art theory, specifically form analysis, and/or in using formal elements in art therapy. Likewise, bibliographies of art therapy literature regarding formal elements in assessment were searched.

All included art theories were incorporated into a comparative content assay to see which formal elements were included and how they were described. We restricted our search to those formal elements that could be appropriately be described in two-dimensional art because this is mainly used in art therapy assessment (e.g., Moon, 2010; Pénzes et al., 2014). We began with four theories that incorporated a consummate systematic "grade analysis" of visual art: Acton (2009), the KPC model (Gerrits, 2018), the ILO UvA model (Van der Kamp et al., 2012); and Tate Modern (Gale, 2016; Wilson and Lack, 2016). Additionally, the consultation of the experts led u.s.a. to the theories of De Visser (2010), Taylor (2014), Huntsman (2016), and Boermans and van der Borght (2017). Viii theories were included in further comparative content analysis: the ILO UvA model (Van der Kamp et al., 2012), Acton (2009), the KPC model (Gerrits, 2018), Tate Modernistic (Gale, 2016; Wilson and Lack, 2016), De Visser (2010), Taylor (2014), Huntsman (2016), and Boermans and van der Borght (2017). We extracted the formal elements included in all theories and their descriptions were compared for similarities.

Results

The comparative content assay showed that all incorporated art theories divided the formal elements into categories. We recognized 6 principal categories: shape, limerick, color, space, surface quality and low-cal. Based on the comparative content analysis we found agreement on 17 formal elements across these categories: (ane) "shape," including "geometry" and "profile"; (2) "composition," including "symmetry," "rhythm," "line quality," "linearity," "movement," and "dynamic"; (3) "color," including "number of colors," "colour saturation," "color brightness," "hue," and "mixture of colour"; (4) "space," including "filled area," "used space," and "proposition of space," (v) "surface quality," including "texture" (encounter Table ane), and (6) "light," including "floodlight," "lite source," and "clair-obscure." Formal elements of category 6 mainly concern photography or fine art products with realistic styles as in "bizarre" and "romanticism." Because these are rarely seen in fine art therapy, nosotros did not include this category in our model.

TABLE 1

The five categories and the seventeen formal elements.

i. Shape
Geometry
Geometry refers to geometric shapes, such equally rectangles, circles, and triangles. The opposite of geometric is organic.
Contour
Contour refers to the sharp edges, outlines, and borders of and between split up parts of the art product. Contour is formed by the utilize of sharp lines or distinct borders. Shapes are completely accentuated past lines and/or have singled-out borders as if they were "cut out." The contrary of contour is pictorial, lengthened artwork.
2. Composition
Symmetry
Symmetry is formed past an optical vertical axis of the centre of the artwork. The left and correct half of the art product are mirrored and are equal with regard to color and/or shape, line, or figure. The reverse of a symmetric composition is a chaotic overall composition.
Rhythm
Rhythm refers to the regular return of lines, shapes, or colors. It is a repeated design that tin be predicted once information technology is recognized.
Line quality
The quality of a line is strong when it is serried, straight, sharp, and fluent. The opposite is a line that is broken, sketchy, wavered, crumbled, and cautious. To judge line quality, the quality of the lines present is observed rather than the number of lines.
Linearity
Linearity refers to the extent to which an artwork consists of lines. A line is a stripe not broader than the tip of the used tool (graphic art material) or the brush. Lines tin can class shapes. The opposite is a pictorial artwork that lacks lines.
Motility
Movement consists of a combination of elements, such every bit diagonals and overlap. Movement varies in corporeality.
Dynamic Dynamic refers to the tension within the artwork. Tension is created when the artwork seems to deny the frame. This is called "a-tectonic." The opposite is an artwork that shows no tension with the frame.
3. Colour
Number of colors
The number of singled-out, used colors. An artwork can be very colorful and have many colors. The opposite is an artwork that consists of a express number of colors.
Color saturation
The extent to which a color is saturated. The more saturated the color is, the less newspaper/sheet, etc., is apparent.
Color effulgence
Bright colors sparkle and are pure and fresh, such every bit the dark-green of grass, the yellow of the lord's day, and the blueish of the heaven. The color brightness of an artwork increases with the number of bright colors used. Colors that are mixed with water, white, or black (dark or pastel colors) are not bright.
Hue
Hue refers to gradience from light to dark tones of 1 color or grays (not different "families of color" such equally greens, blues, cold or warm colors).
Mixture of color
The amount of which colors are visibly mixed. The opposite is an art product in which the colors are not mixed and applied separately.
iv. Infinite
Filled area
Filled area refers to the "worked" space on the paper or sheet and the ratio between used and unused space.
Used infinite
Used space refers to the space on the paper/canvass, etc., that is used.
Proposition of space
Space tin can be suggested by several techniques, such as overlap, shadow, line perspective, atmospheric perspective, and foreground and background. The proffer of depth is created. The opposite refers to a "flat" artwork without any proposition of space.
v. Surface quality
Texture
Texture refers to the tactile surface of the artwork. This does not depend on the used paper or canvass only can depend on the art material used and the way it is practical.

All art theories conceptualized formal elements every bit continua with dominant presence of absence in the art product every bit polarities. Too, all the theories mentioned that formal elements can reinforce or weaken each other.

In conclusion, among a large number of elements we found agreement nigh seventeen formal elements described in terms of continua. The next step was to analyze whether it was possible to describe and observe them reliably in art products of adult clients. Therefore, a 2d report was conducted.

Study 2: Operationalization and Inter-Rater Reliability

In this study, we investigated whether it was possible to construct reliable formal elements in the fine art products of adult clients in art therapy. The formal elements that emerged from study i were operationalized and tested for inter-rater reliability.

Method

The formal elements that emerged in study 1 were operationalized in three test rounds (see Figure 2). This was peer debriefed by two art therapy teachers. Each round was evaluated with the raters and researcher. In the first round, two trained raters independently analyzed 31 art products made by 9 adult clients in i mental wellness setting. The operationalization of the formal elements was adjusted based on the evaluations and tested in a 2nd round where two new trained raters independently rated 60 art products from 25 clients in six mental health settings. Their ratings were tested for inter-rater reliability and evaluated. The operationalization of some of the formal elements was adapted based on the evaluation. Two new trained raters and then independently rated 46 art products from 46 clients in nine mental wellness settings.

Chart of the procedure followed in study 2.

In full, 137 art products from 80 clients were included in this study: 31 art products from nine clients in the first round, 60 fine art products from 25 clients in the following round, and 46 art products from 46 clients in the last round. Customer inclusion criteria included being aged between 18 and 65 years, being able to read and speak Dutch, and having no or minimal experience in making art and fine art therapy. Clients with psychotic disorders or in manic episodes were excluded. In line with the Declaration of Helsinki, informed consent was obtained from all clients. The art products in the offset two rounds were fabricated as function of regular art therapy assessment, pregnant they were of diverse sizes and styles and used diverse two-dimensional art materials like pastel, pencil, or ink. Some of the clients were instructed while making the products, while other art products were fabricated based on the clients' ain choices. The art products in the concluding round were made with standardized semi-structured didactics that consisted of painting a landscape with acrylic pigment on paper of l × xl cm in a 45-min session. All clients received the same color palette, the aforementioned brushes and pencils, and the same instructions from their therapists. The therapists were given paper and video instructions and took part in a telephone meeting to confirm that all their clients would receive the same instructions.

The sampled clients (52 female, 28 male person) started art therapy in 16 different settings for adult mental wellness care ranging in historic period from 19 to 60 (M = 39). They all just started art therapy, but after a psychologist gave a preliminary DSM-diagnosis. The sample was very heterogenic with regard to the preliminary diagnoses. Most clients (39%) were diagnosed with two or three diagnoses. Personality disorder (72%) and mood disorder (56%) were diagnosed nigh frequently.

In the first circular, the formal elements were operationalized categorically and analyzed for percentage of understanding. Finally, the formal elements were operationalized on a five-point Likert scale and tested for inter-rater reliability using Cohen'south kappa analysis. All analyses were conducted using SPSS version 25.

Results

Operationalization

Initially, the formal elements were operationalized by categories. Some of the formal elements consisted of two categories, while others consisted of three (encounter Effigy 3 for examples).

Examples of chiselled operationalization.

The overall inter-rater agreement was >88%, but despite this high agreement, the raters constitute it hard to rank the formal elements with different numbers of categories. They as well plant it hard to rate the art products based on the written definitions of the formal elements and suggested adding visual illustrations. The operationalization was adapted and all the formal elements were operationalized into five-point Likert scales (see Figure 4), with i representing no or minimal presence of the element and v representing a very high presence of the chemical element. For each formal element, example images of art products were provided for both ends of the scale.

Example of operationalization of the formal element "profile," (The appropriate permissions have been obtained from the copyright holders of this piece of work).

Inter-Rater Reliability

In round 2, the inter-rater reliability for "rhythm" and "movement" was fair (κ = 0.34 and κ = 0.29, respectively), while the reliability for "contour" (κ = 0.57), "color saturation" (κ = 0.43), and "mixture of colors" (κ = 0.47) was moderate. Reliability for "proposition of infinite" (κ = 0.65), "number of colors" (κ = 0.65), "color brightness" (κ = 0.64), "symmetry" (κ = 0.68), "linearity" (κ = 0.74), "line quality" (κ = 0.64), "dynamic" (κ = 0.71), and "texture" (κ = 0.65) was substantial, while reliability for "filled area" (κ = 0.82), "used infinite" (κ = 0.86), "geometry" (κ = 0.83), and "hue" (κ = 0.83) was almost perfect (Viera and Garrett, 2005).

The evaluation of round two highlighted three drawbacks of rating. Start, the definitions of scores 3, 4, and 5 for "number of colors" overlapped. Second, raters found the definition of the item "rhythm" as well complex and the definition of "motility" was plant to be unclear and incomplete. This could explain the relatively low reliability for these items. All other definitions were clear and the art production examples were found to be illustrative. Third, it was questioned whether the art materials might influence the ratings of the formal elements.

Based on these drawbacks, the definitions of "number of colors," "rhythm," and "move" were adjusted and tested for inter-rater reliability in a third and final round. The inter-rater reliability varied between moderate and substantial for all items except "texture" which had poor inter-rater reliability (run into Table ii). The inter-rater reliability for the adjusted formal elements "number of colors," "rhythm," and "motion" increased in the third round. The inter-rater reliability of all other formal elements remained like. But the inter-rater reliability for "texture" decreased significantly, therefore this item was not included in the subsequent studies. In conclusion, sixteen formal elements could be operationalized reliably. The next step was to examine which of these 16 formal elements were also clinically relevant. Therefore, a third written report was conducted.

TABLE ii

Terminal inter-rater reliability scores for each formal chemical element.

Formal elements	κ
Filled area	0.64**
Used space	0.79**
Suggestion of space	0.75**
Geometry	0.86**
Profile	0.56**
Number of colors	0.83**
Colour saturation	0.76**
Color brightness	0.80**
Hue	0.71**
Mixture of color	0.68**
Symmetry	0.61**
Rhythm	0.41**
Linearity	0.56**
Line quality	0.63**
Move	0.50**
Dynamic	0.65**
Texture	−0.012

Report 3: Clinically Relevant Formal Elements

We were able to operationalize most formal elements reliably, however, information technology was withal unknown which of these formal elements were clinically relevant. Especially as the fine art therapy literature was inconsistent in presenting tools or suggestions directed toward the clinical use of formal elements in art therapy observation and assessment (Schoch et al., 2017; Pénzes et al., 2018). In a previous written report (Pénzes et al., 2018), using Constructivist Grounded Theory, eight art therapists with diverse clinical backgrounds, training orientations, and nationalities were interviewed in-depth to identify which formal elements they observed in their clinical practice, how they described mental health and how they associated formal elements with mental health. Findings of this report revealed that seven formal elements appeared to be clinically relevant. Moreover, the art therapists in this study too observed a combination of the formal elements "motion," "dynamic," "contour," and "repetition" which they used to construct the overall structure and variation of the fine art product (i.due east., primary formal elements). And in addition "mixture of colour," "figuration," and "color saturation" as weakening or enhancing cues for this structure (i.eastward., secondary formal elements).

In this study nosotros tried to relate these vii formal elements to the reliably operationalized formal elements in study 2 above. Therefore, in this study, we compared the formal elements that were operationalized reliably in report 2 with the formal elements art therapists establish to be clinically relevant from the above mentioned previous study (Pénzes et al., 2018).

Method

A panel consisting of 3 art therapy teachers compared the formal elements identified past art therapists in the prior study of Pénzes et al. (2018) to the formal elements that were operationalized reliably in study ii. These formal elements, including their descriptions from fine art theories and art therapists, were incorporated into a table. "Figuration" was excluded, every bit fine art theories stated that this element could not be analyzed according to the level of its presence in an fine art product. Instead information technology is a categorical item that refers to the style of the art product as realistic, figurative, or abstract.

First, the comparison concerned which formal elements were identified past fine art therapist and art theory. Second, the descriptions of these formal elements were compared for similarities. Each proficient independently compared the formal elements on a calibration ranging from "0 = no similarities," "1 = some resemblance," and "two = similar or almost similar."

Results

The panel agreed that the formal elements "contour," "movement," "dynamic," and "mixture of color" were similarly described (see Tabular array 3). "Color saturation" was described differently because the art therapists had merged "color saturation" and "texture." The fashion the art therapists described "repetition" showed overlap with the formal elements "symmetry" and "rhythm" in art theory.

Table 3

Comparing of clinically relevant, objective and reliable formal elements.

	Clinically relevant formal elements according to art therapists	Formal elements operationalized in art theories	Agreement of experts
Principal	Motion Movement refers to the amount, character, and direction of the move. Movement becomes visible past the brush marks.	Move Motion consists of a combination of elements, such as diagonals and overlap. Movement varies in amount.	All experts gave a rating of "2"
	Dynamic Dynamic refers to tension (tectonic) inside the art product. Dynamic varies from static, restrained, and calm to fast, turbulent, energetic, and forceful. It refers to the vitality of the movement made.	Dynamic Dynamic refers to the tension within the artwork. This tension is created when the artwork seems to deny the boundaries of the frame. This is called "a-tectonic." The reverse is an artwork that shows no tension with the frame.	All experts gave a rating of "two"
	Contour Contour refers to the delimitation that emerges when shapes are outlined or are placed directly next to each other. This leads to rigid and sharp distinctions.	Contour Contour refers to the precipitous edges, outlines, and borders of and between split up parts of the art product. Contour is formed by the use of sharp lines or distinct borders. Shapes are completely accentuated past lines and/or have distinct borders as if they were "cut out." The opposite of contour is pictorial, lengthened artwork.	All experts gave a rating of "two"
	Repetition Repetition refers to the render of i or more formal elements in a pattern. A lot of repetition leads to symmetry. Rhythm refers to the repetition of motion.	Symmetry Symmetry is formed by an optical vertical axis of the middle of the artwork. The left and right half of the art product are mirrored and are equal regarding color and/or shape, line, or figure. The opposite of a symmetric limerick is a chaotic overall composition. Rhythm Rhythm refers to the regular return of lines, shapes, or colors. Information technology is a repeated design that can be predicted once it is recognized.	All experts gave a rating of "1"
Secondary	Mixture of color Mixture of color refers to the extent to which the colors are mixed inside the fine art product.	Mixture of color The amount of which colors are visibly mixed. The opposite is an art product in which the colors are not mixed and applied separately.	All experts gave a rating of "ii"
	Color saturation Colour saturation refers to the density of color within the art production varying betwixt transparent and impasto.	Color saturation The extent to which a color is saturated. The more saturated the color is, the less paper/sheet, etc., is apparent. Texture Texture refers to the tactile surface of the artwork. This does not depend on the paper/canvas, etc., used, just can depend on the art material used and the way information technology is applied.	All experts gave a rating of "1"

In summary, it was found that "motility," "dynamic," "contour," and "mixture of color" were similar. These formal elements could exist operationalized reliably and appeared to also be clinically relevant. See Figure five for examples of these formal elements in fine art products. A 4th study was then conducted to come across whether these formal elements are related to mental wellness.

Examples of motion, dynamic, and contour of art products.

Study 4: Relationship Between Formal Elements and Adult Mental Wellness

Art therapy literature demonstrates a wide range of opinions apropos the relationship between formal elements and mental health. In most studies, formal elements are related to disorders of the Diagnostic and Statistic Transmission of Mental Disorders (DSM) or the International Statistical Nomenclature of Diseases and Related Health Problems (ICD) (Gantt and Tabone, 1998; Hacking, 1999; Kim et al., 2012). Whereas in more than recent studies formal elements are related to clients' strengths (Hinz, 2009, 2015; Pénzes et al., 2014, 2015) in line with perspectives on positive mental wellness (Huber et al., 2016). Thus, literature has been inconsistent in interpreting formal elements of art product in terms of mental health.

According to our previous written report, art therapists considered mental health in terms of residual and adjustability. Residue existed when allowing, experiencing and expressing emotions and cognitive control were in proportion to each other. Adaptability consisted of self-management, flexibility, openness, and inventiveness. Art therapists associated residue, specifically existence out of rest, with the severity of clients' problem and adaptability with clients' strengths and resources. The power to assess the level of balance and adaptability may support art therapists to codify treatment goals to adapt the individual needs and potential and to cull art interventions that raise or develop the client's mental health (Pénzes et al., 2018). Likewise, in our previous study nosotros showed that art therapists did not related individual formal elements to mental health; they related specific combinations of formal elements, specifically the principal formal elements of "dynamic," "movement," and "profile" to mental health.

In this study we tested the combination of formal elements and the relation to mental health.

Method

Xl-six adult clients in 9 unlike mental health settings participated in this study. These were the same clients and art products examined in the concluding round of study 2. Client inclusion criteria included being anile betwixt 18 and 65 years, beingness able to read and speak Dutch, and having no or minimal experience in making fine art and art therapy. Clients with psychotic disorders or in manic episodes were excluded. Art products were made with standardized instructions (see the final round in report ii). The two raters in the final round in study 2 independently rated the formal elements. Written informed consent was obtained from all participants in accordance with the Declaration of Helsinki.

The sampled clients (34 female person, 12 male) started art therapy in nine different settings for developed mental health care ranging in age from 19 to 60 (M = 37). They all just started fine art therapy (<iii weeks), merely after a psychologist gave a preliminary DSM-diagnosis. The sample was heterogenic regarding clinical diagnoses, eighteen clients had a dual-diagnosis, nine clients had triple-diagnoses, and three clients iv or more diagnoses. Most ofttimes diagnosed DSM categories were personality disorder (31 clients, 67%) and mood disorder (27 clients, 62%).

During the same week that the client made their art product, they filled in the Dutch version of the Brief Symptom Inventory (BSI) (de Beurs and Zitman, 2006), the Resilience Scale (RS-nl) (Portzky et al., 2010), and the Acceptance and Action Questionnaire – Two (AAQ-Two) (Jacobs et al., 2008). The BSI was used to assess the level of the clients' mental illness/psychopathology, while the RS-nl and the AAQ-II were used to assess the clients' mental health.

The BSI was a self-rating instrument consisting of 53 items derived from the SCL-90 and is used for the screening and assessment of psychopathology. The BSI was considered appropriate for patients without severe psychiatric disorders. Psychometric qualities were in line with the SCL-xc (alpha > 0.71) with good correlations with other instruments (Buwalda et al., 2012). The respondents scored the extent to which they experienced various psychological symptoms during the concluding week on a five-betoken Likert scale ranging from "a lot" to "non at all." The BSI consists of three scales and nine subscales, including a general measure of psychopathology (total score). In this study, merely the total score of the BSI was used considering the art therapists described mental illness in general terms instead of specific disorders or symptoms.

The RS-nl was a self-rating musical instrument for screening resiliency. The respondents scored the extent to which they hold with 25 items on a four-betoken Likert scale ranging from "totally agree" to "totally disagree." The RS-nl consists of two subscales: "personal competency" and "acceptance of self and live." A high total score suggests adjustability, balance, and flexibility. Psychometric qualities are "good" for content and construct validity and for internal consistency (Windle et al., 2011).

The AAQ-Ii measured the corporeality of experiential acceptance, experiential abstention, and psychological (in)flexibility. Information technology consisted of x items that respondents scored using a seven-indicate Likert calibration ranging from "never truthful" to "always true" (Bond et al., 2011). A high total score indicated college experiential acceptance or psychological flexibility and less experiential avoidance. Persons that scored high on experiential abstention generally used avoidance strategies that were related to repression of negative emotions and college psychopathology. Psychometric qualities showed good internal consistency (Cronbach Alpha = 0.89) and construct validity of −0.67 to −0.79 on repression and psychological complaints (Jacobs et al., 2008; Fledderus et al., 2012; Bernaerts et al., 2014).

As fine art therapists related the combination of formal elements to mental health, Spearman correlation analysis was used to test whether the formal elements of "motility," "dynamic," and "profile" were related to each other. Linear regression assay was used to test whether the combination of the formal elements "movement," "dynamic," and "contour" was related to clients' scores on the BSI, RS-nl, and AAQ-II. All analyses were conducted in SPSS version 25.

Results

Table 4 presented an overview of the hateful scores, standard deviations, and variances for the formal elements "movement," "dynamic" and "profile" and for the BSI, RS-nl, and AAQ-2 scores.

Tabular array 4

Descriptive statistics for the formal elements dynamic, movement and contour, and the BSI, RS-nl, and AAQ-II scores.

	Mean	Std. Deviation	Min.	Max.
Dynamic	2.fifty	0.66	1	iv
Movement	3.00	0.82	2	iv
Contour	2.fifty	0.78	1	4
BSI	90.07	36.45	12	163
RS-nl	60.77	10.25	40	lxxx
AAQ-II	30.threescore	9.18	17	51

Inter-Relatedness of Formal Elements

Results of the Spearman correlation analysis indicated a positive significant relationship between "movement" and "dynamic:" r _south (46) = 0.76, p < 0.001. This suggests that an increase in "movement" is related to an increase in "dynamic" and vice versa. The results as well indicated a pregnant negative relationship between both "movement" and "profile:" r _s (46) = −0.41, p = 0.004 and "dynamic" r _s (46) = −0.34, p = 0.020 and "contour."

Relationship Betwixt Formal Elements and Mental Health

Results of the regression analysis (see Table 5) showed that fifty-fifty though "dynamic" and "move" significantly related to the BSI total score, the overall model was non pregnant (R ⁱⁱ = 0.16, p = 0.072). The overall model significantly related to the AAQ-Ii total score (R ⁱⁱ = 0.29, p = 0.003), however, with main effects found for "dynamic" (β = 0.60, p = 0.004) and "movement" (β = −0.76, p < 0.001). The overall model also significantly related to the RS-nl total score (R ² = 0.19, p = 0.034) with one main outcome institute for "dynamic" (β = 0.65, p = 0.004) and a trend for "movement" (β = −0.40, p = 0.070). The combination of "movement," "dynamic," and "contour" explained 19.iii% of variance in RS-nl scores and 29.1% of the variance in AAQ-II scores. The combination of these formal elements was thus significantly related to resiliency and to psychological flexibility/experiential acceptance but not to the level of complaints.

TABLE 5

Regression analysis results: relationships between the formal elements dynamic, movement and contour and the BSI, AAQ-II, and RS-nl total scores.

	BSI total score		AAQ-Ii		RS-nl
	B (SE)	B	B (SE)	β	B (SE)	β
Dynamic	−30,494 (34,777)	−0.556*	8,350 (2,741)	0.602**	9,977 (3.271)	0.647**
Motility	twenty,785 (9,834)	0.459*	−viii,647 (2,247)	−0.764***	−5,040 (2, 709)	−0.396
Contour	−7,109 (7,228)	−0.154	ane,246 (1,669)	0.107	1,712 (1,991)	0.132

Discussion

In study 1 seventeen formal elements emerged from the analysis of art theories. Findings of study two show that the majority of these seventeen formal elements can be observed reliably. Based on the results in Written report 3, the formal elements "dynamic," "motion," and "contour" are found to be primarily clinically relevant and tin be measured reliably. Results of Written report 4 show that the combination of the formal elements "dynamic," "movement," and "contour" explain nineteen% of the variance in RS-nl scores and 29% of the variance in AAQ-2 scores. These findings imply that the combination of the formal elements "dynamic," "movement," and "profile" are related to adult clients' resiliency and experiential acceptance. The same combination of elements shows only a slight non-significant statistical relation to the BSI; fifty-fifty though "dynamic" and "movement" related significantly tot the BSO total score, the overall model that also included "profile" is not significantly related. Looking at each formal element, "movement" and "dynamic" are significantly related to clients' mental health, whereas "profile" is not. The relationship is most pronounced for positive mental wellness concepts, such every bit experiential acceptance and resiliency. These results are in line with other art therapy studies that stress the importance of positive mental wellness in art therapy cess (Hinz, 2009; Betts, 2012; Pénzes et al., 2018). Rather than focusing on DSM diagnoses or symptoms, art therapists often emphasize clients' strengths and resources, embracing a perspective of mental health that is in line with the thought of positive health (Huber et al., 2016) and the recovery approach (Anthony, 1993; Jacob et al., 2017). These results are somewhat unexpected equally Haeyen et al. (2017) found the aforementioned consequence sizes for flexibility and mental illness (OQ-45 and SMI maladaptive scales) in their study on furnishings of art therapy for patients with a personality disorder. A variety of hypotheses tin be formulated to business relationship for these outcomes: perhaps the differences are related to differences in patient samples, the utilise of specific measures (BSI versus OQ-45 and SMI), of differences in study design (we did not study the furnishings of an fine art therapy intervention and did non calculate effect sizes). In addition, a recent scoping review of Lasiello et al. (2020) identified a considerable body of empirical research investigating the validity of the dual-continua model, and the overarching notion that positive mental wellness and mental illness correspond 2 distinct, yet related, constructs. They strongly advocate assessing positive mental health and mental illness together, rather than using simply one or the other. Our results are in line with their conclusions; a focus on either positive mental health or mental illness alone would not provide a complete image of the mental wellness condition of an individual or population. Undoubtedly, further enquiry is needed to dominion out the different hypotheses and to enlighten us in more detail about the nature of the relation between affliction and positive health.

The results of Written report four likewise indicate that the combination of formal elements is related to mental health and that the involved formal elements are strongly interrelated, east.m., an increased presence of "dynamic" and "movement" is related to a decreased presence of "contour." This is in line with existing studies that have argued that private elements mean zilch unless considered every bit a cluster (Gantt, 2001) or specific combinations of "primary" formal elements that construct the "structure" of the art product (Pénzes et al., 2018).

"Motion" and "dynamic" are strongly interrelated, indicating that an increase in "movement" is related to an increase in "dynamic." When relating these elements to mental health measures, nevertheless, "motion" is negatively associated with mental health and "dynamic" is positively related. A possible explanation for this tin can be plant in a previous report in which the concept of "variation" emerged (Pénzes et al., 2018). "Variation" refers to the diversity that can be recognized in one or more formal elements within the art production. Art products with depression "dynamic" and low "motility" or high "dynamic" and high "motility" have less "variation." In contrast, art products with low "dynamic" and high "movement" or vice versa have more "variation." Fine art therapists largely agree on the importance of observing this aspect of art products to assess client mental health. Hereafter research could address operationalizing "variation" to investigate its relationship with mental health.

In summary, the relationships betwixt formal elements, positive mental health, and mental illness show that art products are indeed associated with aspects of positive mental health and mental affliction. The classic assumption of art therapists is in line with this. This implies that the lack of reliability and validity of existing art therapy cess instruments is non due to the absenteeism of such a relationship or to wrong theoretical assumptions, simply to inconsistent operationalization or weak report design.

Implications for Clinical Practice of Art Therapy

Despite the ongoing discussion nigh how to translate the formal elements in art therapy assessment (e.g., Hinz, 2009; Gilroy et al., 2012), most studies seem to agree that formal elements are related to how clients brand art products (Gantt, 2001; Hinz, 2009; Conrad et al., 2011). In previous studies, this assumption has been specified using the concept of "cloth interaction," which refers to the art making procedure and the clients' interaction with the art materials (Pénzes et al., 2014, 2015). In these studies, it is conceptualized that material interaction is reflected past the formal elements of the fine art production and related to mental health. The significance of the combination of "movement" and "dynamic" might imply that these formal elements reflect the clients' fine art making, i.e., the amount and kind of movements that clients make when interacting with art materials to create an art production.

The "dynamic" and "motion" of the art products and "motion" of textile interaction can be linked to Stern's (2010) concept of "forms of vitality," which refers to the forces and sensations linked to the motility that creates forms. Stern states that peoples' health can be evaluated based on the vitality that is expressed in their almost abiding movements. This implies that formal elements might be considered equally manifest visual forms of vitality and that these formal elements in fine art products reverberate mental health and mental disease.

Further research is needed to investigate the possible relationship between "dynamic" and "movement" in clients' fine art products and clients' "material interaction" in art making. For the time being, these 2 formal elements are observable and visible aspects of the art product. This visibility allows the joint reflection of the fine art therapist and the customer, leading to insights and awareness that may help formulate handling objectives and fine art interventions. The human relationship between the formal elements and mental health is virtually pronounced for positive mental health aspects, such as experiential acceptance, adaptability, and resiliency. This may have implications for art therapy cess and treatment. The clients' adaptability, flexibility, and resiliency may indicate the potential for alter in therapy and art therapists in a previous study associated adaptability with clients' prognoses in therapy (Pénzes et al., 2018). Several studies have likewise shown the therapeutic potential of diverse art textile properties to create experiential interventions that allow change and ameliorate mental wellness (Hinz, 2009; Moon, 2010; Snir and Regev, 2013; Pénzes et al., 2014). This assumption requires farther longitudinal research.

Methodological Considerations

In this report, art products made with various materials and instructions are included. The analyses of studies 3 and iv are based on art products made with acrylic paint. This is a serious limitation of our study equally the art materials and instructions may have influenced the results. For example, the formal element "filled space" might have emerged when art products were fabricated on larger pieces of paper, with smaller brushes, and/or with more time allowed.

We excluded "mixture of color" from the assay in study 4 because theoretically, it was non conceptualized equally a "primary" formal chemical element. The primary formal element "repetition" was too excluded from analysis, equally information technology did not bear witness plenty resemblance to formal elements in art theories. Future research could include these formal elements to investigate if they influence the formal elements' relationship with mental health measures.

The relationship between the formal elements and mental health found in this piece of work is based on a cantankerous-sectional study design, which does not allow for insights into causality and effects over time. Longitudinal studies including a series of art products could investigate whether therapeutic experiential fine art interventions change the fine art making, i.e., material interaction, and whether these are reflected in the formal elements of "motion" and "dynamic" and in the enhancement of experiential acceptance, adjustability, and resiliency.

In report 3 we compared formal elements from art theory to formal elements that art therapists in a previous study found relevant in clinical practice. The majority of these art therapists practise in the netherlands. Although we did include a few art therapists from other countries such as Israel, Finland, Germany, the United states, and United Kingdom to dissimilarity findings, further generalizability of art therapists' perspectives may demand to be checked through further enquiry.

Conclusion

The combination of the formal elements "motility," "dynamic," and "contour" are significantly interrelated and related to clients' mental health, i.e., psychopathology, psychological flexibility, experiential abstention, and adaptability. Numerous questions remain unanswered and require further inquiry. Even though it is methodologically challenging to study fine art and the fine art-making process in relation to mental health, this report highlights the possibilities for future research. Art products seem to take diagnostic value and may add to clients' verbal expression and indicate their potential to benefit from therapy.

Information Availability Argument

The raw information supporting the conclusions of this article volition exist made available by the authors, without undue reservation.

Ethics Statement

Ethical review and approving was not required for the written report on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

IP developed the research blueprint, conducted the research, and outset authored this commodity. SH, DD, and GH supervised the development of the enquiry design and research procedure, and co-authored this article. All authors contributed to the article and approved the submitted version.

Conflict of Involvement

The authors declare that the enquiry was conducted in the absence of whatsoever commercial or fiscal relationships that could be construed equally a potential disharmonize of interest.

Acknowledgments

We give thanks all clients, therapists, students and experts that participated in this research. We are thankful for the research funds provided past Zuyd University of Applied Sciences.

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