Wellness at Universities

University counseling centers (UCCs) nationwide report increasing utilization rates and see higher numbers of students with diagnosable psychological problems than in previous years (Gallagher & Taylor, 2015). With more college students seeking treatment, UCCs must adapt services to accommodate increasing demand. The purpose of this article is to propose the benefits of implementing art therapy groups at UCCs as a means to address increasing utilization and to expand effective treatment options available for students. This article discusses common clinical presentations of students who seek counseling services, presents the benefits of group art therapy for the college population, and provides recommendations for art therapists and other mental health professionals to consider when developing art therapy groups in UCCs.

Using Group Art Therapy to Address College Students’ Needs

College students face various developmental tasks, often for the first time, as they transition from adolescence to young adulthood. Navigating dependence, interdependence, and independence; developing communication and relationship skills; and building an evolving self‐concept and worldview are among the challenges young adults encounter in college (Chickering & Reisser, 1993). Academic pressure, separation from family, and work responsibilities are just a few of the life stressors that precipitate or exacerbate mental health issues experienced by college students (Pedrelli, Nyer, Yeung, Zulauf, & Wilens, 2015).

According to the American College Health Association's (2017) annual report, which assesses the health of college students across the United States, students reported experiencing the following within 12 months: feeling “overwhelmed by all you had to do” (87.0%), “very lonely” (62.2%), “very sad” (67.7%), and “overwhelming anxiety” (60.8%; pp. 13–14). In the same report, students also indicated that within the past 12 months (2016–2017) they perceived the following as “traumatic or very difficult to handle” (American College Health Association, 2017, p. 15): intimate relationships (30.9%), other social relationships (27.2%), family problems (27.2%), and academics (47.5%).

UCCs use various services to address college students’ mental health needs, including individual counseling, couples counseling, group therapy, art therapy, biofeedback, peer education, outreach, and online self‐help services (Brunner, Wallace, Reymann, Sellers, & McCabe, 2014). Group therapy, a standard treatment modality used by UCCs nationwide, provides effective treatment and addresses the problem of increasing utilization by allowing counselors to see higher numbers of students per hour than would be the case using individual therapy alone (Daltry, 2015). Group therapy addresses the multifaceted issues that underlie the concerns people bring to therapy (Yalom, 2005) and is a natural fit for UCCs and the issues young adults may face (Daltry, 2015). College students who are away from family and friends for the first time often feel anxious or unsure about initiating friendships and building social support. Group therapy offers students a space to confront feelings of isolation and anxiety, connect with peers, manage depression, address interpersonal relationship concerns, and improve self‐esteem (Damer, Latimer, & Porter, 2010; Parcover, Dunton, Gehlert, & Mitchell, 2006; Yalom, 2005).

Group art therapy, an alternative approach to group talk therapy, improves college students’ well‐being by combining the benefits of traditional process groups with the strengths of art therapy (Boldt & Paul, 2010). Art therapy is unique because it grants individuals the opportunity to externalize internal processes through the creation of permanent, concrete, and tangible art products (Wadeson, 2010). The use of imagery leads to the uncovering of unexpected material and promotes the development of insight and self‐awareness (Wadeson, 2010). These aspects make art therapy particularly useful for individuals who struggle with expressing themselves verbally. We also found that overly verbal students, or those who tend to overintellectualize, benefit from this treatment modality because they are encouraged to conceptualize and express themselves through less familiar (i.e., less verbal) means.

Group art therapy is especially beneficial for socially withdrawn individuals who would otherwise struggle to connect with others in a traditional talk therapy group. Wadeson (2010) indicated that the sharing of images is one of the most beneficial aspects of art therapy groups in that it allows individuals to receive attention from other group members and integrate into the group. It is through this process that group members can know each other on a different level as they come to learn recurring themes and motifs in each other's imagery (Wadeson, 2010). Art therapy serves as a bridge for social connection, helping students explore and assert their feelings and concerns with peers in a space that feels more safe, contained, and validating than traditional forms of group talk therapy (Lenz, Holman, & Dominguez, 2010). According to Potash and Ho (2011), art therapy is effective for exploring interpersonal concerns and engaging students in developing empathy and connecting with others. Potash and Ho also postulated that making and viewing art serve as essential formats for human social connection and communication and that art therapists facilitate relationship building through specific art directives and discussions.

Counselors underuse arts‐based interventions with the college population despite the inherent qualities that make art therapy and group art therapy viable and effective treatment modalities (Aaron, Rinehart, & Ceballos, 2011). The literature on the use of art therapy with college students is limited, and there is no research examining the efficacy of group art therapy for college students. However, several studies exploring the relationship between art making and anxiety in undergraduates suggest that briefly engaging in art making has a positive influence on college students’ anxiety (Curry & Kasser, 2005; Sandmire, Gorham, Rankin, & Grimm, 2012; Walsh, Chang, Schmidt, & Yoepp, 2005). Other researchers have demonstrated art therapy as an appropriate intervention for addressing a wide variety of mental health concerns, including depression (Chandraiah, Anand, & Avent, 2012), posttraumatic stress disorder (Ugurlu, Akca, & Acarturk, 2016), sexual abuse (Pretorius & Pfeifer, 2010), and eating disorders (Rehavia‐Hanauer, 2003), that are commonly expressed by students seeking counseling at UCCs (Blanco et al., 2008).

Developing an Art Therapy Group at a UCC

As art therapists employed at a UCC, we developed an art therapy group for undergraduate students. Counselors are encouraged to consider the institution and counseling center in which this group runs, which we describe in some detail to provide context for the development of this group. We work at a public university in the southeastern United States with a population of about 40,000 students, mostly undergraduate. The geographical area is primarily suburban and rural, and about 80% of the students live off campus. Approximately 60% of the student population identifies as Caucasian, 18% as Hispanic, and the remaining 22% as various other ethnicities. A majority of the students (55%) identify as female (Florida State University Office of Institutional Research, 2018).

Our center has 34 licensed staff (five of whom are art therapists), two postdoctoral clinicians, four doctoral interns, and two master's‐level interns. Approximately 4,117 students visited the UCC in the 2017–2018 academic year, and the demographics of those utilizing services generally reflect the overall student population, with approximately 67% of students being female, 75% undergraduate, 57% Caucasian, and 23% multiracial. The top presenting concerns of students at the UCC include anxiety or stress symptoms, depressive symptoms, and family relationship concerns (C. Gomez, personal communication, February 14, 2018).

It is essential to have the support of the center's clinical staff and administration when considering the development of art therapy groups at a UCC. Our UCC has an extensive group therapy program with more than 25 structured and unstructured process groups running weekly. Staff also have the opportunity to attend a weekly Group Administration meeting to discuss current and developing groups. Gaining administrative support with such a substantial group program is not as challenging as in other settings, such as smaller institutions or UCCs in which groups are used to a lesser extent. Consultation and in‐service presentations in such instances are ways to educate colleagues on the use of group art therapy and gain support for developing an art therapy group at a UCC.

We developed the art therapy group in part out of the growing need to provide undergraduate students with additional treatment options to both support and, at times, replace individual therapy. Group therapy often becomes the primary or even sole treatment, depending on students’ unique needs, which results in students requiring less individual therapy. This reduced need for students to see their primary clinicians addresses the aforementioned increasing utilization rates of UCCs and alleviates the burden on individual clinicians.

The need to serve students who struggle to connect with others in traditional talk therapy groups also contributed to the development of this group. Some students feel intimidated and overwhelmed by the notion of having to speak about personal topics within a group setting. The nonverbal aspect of art therapy provides a less threatening means for them to do so. Thus, the goals of this group were twofold: to provide an alternative and effective treatment for students who are unable to benefit fully from current services offered and to reduce the frequency of students’ utilization of individual therapy sessions.

Group space. We encourage art therapists to consider the group space when planning for a group. For art therapy groups, in particular, this goes beyond the typical considerations of simply locating an available space. Our UCC has several rooms for group therapy, but these rooms were designed for talk therapy and are large enough for about 12 chairs and a small cabinet for books, art materials, or other items that counselors may need for groups. With art materials, drawing boards, and students, the room can feel full and cluttered at times. A space created for group art therapy would be ideal. It should include a tiled floor for easy clean‐up; a sink for washing hands and paintbrushes; water for painting, clay work, or other needs; a large table for students to work at; and enough room to walk around and spread out as needed for art directives.

Of course, as is our experience, many centers’ rooms are not constructed for group art therapy, and most UCCs cannot afford to construct new spaces specifically for art making. The minimal requirements for a group include a large room that fits 10 to 12 chairs, art materials, and drawing boards, and space on the floor or tables to make artwork. Sinks in a nearby restroom or kitchen area will work if there are none in the art therapy group room. Meeting the minimal requirements is usually sufficient because students are flexible and find creative ways to make space work. We encourage art therapists to do the best they can with what they have and to advocate for more space, materials, or other needs to provide art therapy groups at their center.

Group member selection. We emphasize careful consideration when selecting group members. Yalom (2005) is an excellent resource for considering group member selection in talk therapy groups, and many of his recommendations work well for art therapy groups. With that said, art therapy groups have unique aspects that differ from talk therapy and are essential to consider in the construction of an art therapy group. As previously mentioned, art therapy is beneficial for students who struggle to express themselves and connect with others verbally. Our experience is congruent with this in that students display the ability to connect with others through their artwork, both in addition to and instead of verbal communication.

It is common for talk therapists to consider artists or art‐loving students as good referrals for an art therapy group. We caution art therapists to be thoughtful and thoroughly assess whether this is the case. Art students may have trouble engaging in the expressive aspects of art therapy and focus more on creating an aesthetically pleasing or beautiful piece. Art therapy is about the process of creation, and some art students have trouble with this concept. Because not all art students are inappropriate for art therapy groups, it is important to screen them with just as much thought and intention as any other referral. It helps if students are open to the idea of art therapy, because some students are opposed to or even anxious about the notion of art making within therapy.

A wide range of presenting concerns are suitable to address in an art therapy group. It is our experience that students present to the group with myriad concerns, including, but not limited to, disordered eating, generalized anxiety, social anxiety, identity development, substance use, problems with the family of origin, adjustment to college, depression, self‐esteem, interpersonal relationships, and academic stress. The most salient issues we observe are depression, social anxiety, self‐esteem concerns, and interpersonal issues.

We use a group referral process in which students’ primary therapists refer potential group members. The primary clinicians first offer a description of the group to assess students’ interest, motivation, and availability for the group time. If students are available, interested, and appropriate candidates for group therapy, the primary clinician sends us the referral. The group referral form includes students’ age, major, observations and recommendations for the group, and any other clinically relevant information.

We rely on referrals primarily from UCC clinicians for several reasons, the first being that students are required to be established with a primary clinician before they are referred to the group. We can closely work and consult with referring clinicians regarding shared students when students have a primary clinician at the UCC. With the number of group referrals generated from within the UCC, groups typically fill quickly and do not require external referral sources. There are other resources to explore when it is not feasible to rely solely on UCC staff for referrals. Creating relationships with other departments on campus is a great way to advertise the group and increase student awareness and interest. Having connections with local clinicians who are in private practice is another avenue for receiving referrals for students who may be receiving individual therapy off campus. This option may be particularly useful on smaller campuses in which the number of internal referrals is not sufficient to fill groups.

We schedule a screening appointment for students we determine are good candidates for the group to assess appropriateness. The purpose of the group screen is to introduce students to the group structure, the art therapy process, and us as group leaders. We also discuss group guidelines, review expectations, and develop students’ goals for the group during the group screen. We take the culture of the group into consideration when screening group referrals—for instance, determining whether this is a fast‐paced, high‐functioning group of individuals or a mellower, gentler group of students. As with any therapy group, creating a culture and sense of community in which students feel connected, safe, and accepted is key to fostering successful outcomes (Yalom, 2005).

We also explore any ambivalence, concerns, or questions students may have about joining a group. Ideally, we screen for potential complications, such as multiple students from the same major or student organization joining the group. This approach is not always possible, mainly if the group targets a specific population (i.e., LGBTQ+, graduate students, etc.) or if groups are running in a smaller institution. In such cases, we recommend that group leaders adequately assess any instances in which students may know one another outside of the group to ensure confidentiality, comfort, and appropriateness. Sometimes we cannot do this until the group begins, at which time we process these circumstances with the group. We inform students whom we deem appropriate for the group of when they may start.

Although infrequent, there are occurrences in which we deem students unfit for joining the group. This usually happens when we learn that a student's needs or goals are incompatible with the goals of the group. Students are also determined to be unfit for the group if they exhibit symptoms that could significantly disrupt group dynamics, such as antisocial characteristics, psychosis, or paranoia. It is also possible for us to determine that students are a poor match for the group if they experience severe anxiety about group participation or if they are unwilling to adhere to group guidelines. Logistical reasons, such as a schedule conflict, also prevent students from joining the group. We debrief with students who are a poor match for the group and review why this group may not be the best option for them. We provide these students with other group options and encourage them to discuss alternatives with their primary clinicians.

Group membership roughly reflects the general student population at the university in terms of ethnicity. Nearly all group members identify as cisgender women, whereas only 55% of enrolled students at the university identify as women (Florida State University Office of Institutional Research, 2018). That said, UCCs do tend to see a higher percentage of women seeking services than men seeking services (American College Health Association, 2017), which may account for higher female attendance in this particular group. We created this group in particular for undergraduate students because of the UCC's need for more undergraduate groups. This type of group, however, has the potential to work equally well for graduate‐level students and even nontraditional students. Ideally, we encourage group leaders to maintain a balance of group demographics (age, sexual orientation, academic status, gender, ethnicity, etc.) to reduce the possibility of group members feeling isolated.

Group structure. As with group member selection, we also give careful consideration to developing the structure of the group. We run this group once weekly for 90 minutes throughout each semester. Members have the option of remaining in the group semester to semester; however, because of scheduling conflicts, this does not always occur. For the first group meeting, and when a new member joins the group, we begin with a review of the group guidelines and introduce new members. The review of guidelines and the introductions help solidify group norms and culture. They also encourage students to agree to group guidelines, such as confidentiality, prompt arrival, consistent attendance, respect, participation, and transparency in relationships and interactions with members outside of group meeting times. Establishing group norms and guidelines when new members join the group promotes a culture of safety and consistency.

We begin meetings with a brief check‐in, during which members can voice topics they want to address during the group session. Following check‐in, we use several approaches to incorporating art therapy directives into the group sessions. One approach is to open the first half of the group for discussion and then check in with members halfway through the group about transitioning to the preplanned art directive. A benefit to this approach is that it provides time for us to prompt group discussion related to the theme of the planned art directive. One disadvantage of this approach is that the art directive has the potential of being unrelated to the group discussion. This approach also allows limited time to process artwork at the end of the session.

The other method we use is to transition into the art directive immediately following a brief check‐in with group members. This structure allows ample time for the directive and processing of the artwork. One potential problem with this approach is that the art directive is capable of influencing and directing subsequent group discussion and does not always allow enough time for members to discuss what they initially planned at the start of the group. This issue is often resolved by asking members at the end of the group if they have any topics or issues they have not yet discussed and, if so, agreeing to discuss them at the start of the next group meeting.

We preplan the art directives week to week to align with the presenting needs of the group. It is important to note that although we are art therapists and use art directives at most meetings, art is not a part of every group session. Group leaders must remain open and flexible to group needs in any group setting and maintain awareness of group member cues (Yalom, 2005). This applies similarly to art therapy groups, in which group leaders may need to revamp their original plans if the group has differing needs at that moment. Art directives foster space and dynamics for group members to achieve their therapeutic goals, but there are also times when it is appropriate to defer the originally planned directive to another session and focus all of the time on group discussion. This is a nuanced decision that is unique to each situation, and it is important for art therapists to consider when a change in the planned directive is appropriate and therapeutic.

Benefits of Group Art Therapy at a UCC

Changes in both individual processes and overall group dynamics demonstrate the various benefits for students attending the art therapy group. The following themes emerged through our experience of leading this group over multiple semesters.

Self‐expression and self‐disclosure. Each student's artwork is an extension of himself or herself, and the art‐making process allows students to disclose personal information in ways that feel less threatening than a verbal conversation. The visual nature of art therapy allows individuals to disclose information without having to say anything, which for students is often intimidating. We find that further self‐disclosure, cohesion, and increased confidence develop when group members’ moments of vulnerability are well received by the rest of the group. Creating artwork and feeling validated by other group members help students to see the group as a safe place where they can experience vulnerability and express themselves.

This notion is highlighted by the experience of one student, in particular, a 19‐year‐old White woman, who used one of the directives to come out to the group as gay. We gave the directive for group members to create an inside/outside box to depict emotions or aspects of themselves that they display to others on the outside, as well as the inside—what they keep hidden from others. The student described the outside of her box as representing how she often reveals a lot about herself to others, which she depicted by gluing dozens of buttons to the top of her box. She created a rainbow of colors out of tissue paper on the inside of her box, and she secured the lid with a string wrapped around it. She explained that the inside of her box represents her sexual orientation and that she does not often reveal that part of her identity to others. Creating artwork helped the student explore her identity and feel validated by others’ supportive responses, which in turn helped her build confidence and momentum in other social situations outside of the group.

Social connection. Group cohesion and social connectedness fostered by art directives and group discussion help members experience a sense of belonging, which in turn allows them to feel connected with their peers. During one meeting, when the group was nearing termination for the end of the semester, we created a directive to promote cohesion and connectedness among group members. The group was given the directive to work together to paint a large, 6‐foot (approximately 1.8‐meter), shared group mandala that reflected their thoughts and emotions about group ending. Group members worked together to design their mandala and talked freely with one another as they painted. Their ability to work together to create a single, cohesive image, as well as their observed comfort engaging in conversation with one another, was a testament to their increased connection.

Reduced anxiety in a social setting. We find that increased connection with peers alleviates some of the anxiety that students feel in a group setting. Creating a judgment‐free atmosphere is a crucial component to cultivating the sense of safety required for members to experience less anxiety in this setting.

For example, our group typically struggles with silence, with members often expressing discomfort in social situations and feeling pressured to maintain a conversation in an attempt to avoid seeming “socially awkward.” Group members usually work on their artwork silently and independently during the early stages of the group. After several sessions, the group slowly experiences fewer periods of silence and members become increasingly able to engage in surface‐level conversation with each other. Members also express increased comfort within the group space as they connect on various topics. The group requires less prompting over time as members talk more candidly with one another during the art‐making process and discussions. The topics of discussion typically become increasingly personal.

One group member, a 20‐year‐old White woman who presented to the group to address social anxiety and family‐of‐origin issues, depicts this progression of group dynamics. She was mostly nonverbal initially; however, she slowly increased her participation in the group throughout the semester. She reflected at the end of the semester on how getting to know others in the group allowed her to “open up” to others on a deeper level, which positively influenced her relationships outside of the group. She also noted that, through the art‐making process, she had less concern about the judgment that typically triggered her social anxiety in other settings.

Insight. The art‐making process and subsequent reflection on the artwork created allows for the development of new insight. Students are required to think about aspects of themselves, their emotions, and behaviors through visual means, which often is a novel experience. This, in turn, provides students with new avenues for self‐reflection and increased insight.

Amy (a pseudonym), one of the group's returning members, exemplifies the ability for art therapy to set the stage for the development of insight. She was a 19‐year‐old White woman with a long‐standing history of anxiety, body image and eating concerns, low self‐esteem, depression, and attention‐deficit/hyperactivity disorder. Amy initially presented to the group with a limited understanding of herself and social anxiety symptoms that stemmed from bullying about her weight as a child. She also regularly experienced a depressed mood and ruminative thoughts. During her time in the art therapy group, she frequently directed the conversation, rarely spoke of her concerns, and openly admitted that she typically tried to avoid distressing topics by focusing on others or discussing less upsetting experiences in the group. Despite her tendency to limit emotional openness, others remained curious, open, and patient with Amy and often asked her questions about her artwork or concerns.

One of the directives that facilitated the development of insight for Amy was an adaptation of Hays and Lyons's (1981) bridge drawing. We directed members to depict an image of where they felt they were now in their lives on one side of the paper, an image of where they wanted to be on the opposite side of the paper, and a bridge connecting the two. After completing the directive, Amy freely discussed her artwork, which depicted an image of her looking “fat” on the left side of the drawing, and on the right side a number of “thin people” who had “imperfections of their own.” A bridge with many holes and missing boards that covered a “deep hole” connected her present and future images. Amy stated that she must “overcome the deep hole just to get to the bridge.”

Through this directive, Amy was able to openly address the issues she had with her self‐image and her desire to “be thin.” She was able to acknowledge her depressive feelings and begin to visualize them (the deep hole). Amy allowed herself to experience vulnerability within the group setting and express to members the struggles she experienced as she tried to achieve her goals. In response to her vulnerability, members were supportive and validating, providing Amy with a positive social experience that profoundly differed from her previous experiences with peers bullying her in middle school.

The decreased burden on individual clinicians. We find that more times than not, students who attend this group ultimately see their primary clinicians less often than do students who do not attend this group. Anecdotal evidence from our observations, as well as feedback from other UCC staff, indicates that these weekly meetings also allow students the opportunity to meet their treatment goals faster than those receiving individual therapy on a biweekly or even less frequent basis.

Limitations and Recommendations for Future Practice

Research on the use and efficacy of group art therapy, particularly for the college population, is much needed. One of the limitations of this article is that recommendations are based on observations and impressions from running art therapy groups and not on quantitative or qualitative data collected from the group members. We recommend that art therapists use systematic methods, such as pre‐ and postmeasures, when running art therapy groups to accurately measure effectiveness. Comparative studies on group art therapy and group talk therapy would be valuable contributions to better define the benefits unique to group art therapy, because this is also lacking in the literature.

We recognize that although one of the goals for this group is to reduce or eliminate the need for students to see individual clinicians, this does not always occur. Some students require individual therapy regularly in conjunction with the group. Our experience is that typically, students who attend this group meet with their clinicians less frequently than do nonattending students. As we base this claim on anecdotal experience, it warrants future research on the ability of an art therapy group to reduce students’ utilization of individual therapy.

Although we find that group art therapy works well within a UCC setting and for the undergraduate population, research is needed to determine the efficacy of group art therapy within other settings and with other populations. Another limitation of this article is that it may not be generalizable to other settings or populations.

We wish to stress the importance of clinicians operating within their scope of practice when considering the development of an art therapy group. With the use of art therapy, as with any other form of psychotherapy, comes the risk of potential harm to clients. Art therapists receive specialized, clinical training in human development, psychological theories, and the therapeutic use of art materials. They are also trained to assess the possible impact such use may have on individuals, and how the use of specific media and art directives brings about therapeutic change. Therefore, it is imperative for a trained art therapist to run or colead any group using art therapy. Counseling centers that do not have art therapists or art therapy interns on staff are encouraged to reach out to art therapists in the community for collaboration and to allow opportunities for art therapists when hiring new staff and interns. Art therapists working at UCCs are encouraged to consider not only ways in which art therapy groups can be developed to meet students’ and the counseling centers’ needs but also ways to incorporate systematic research to develop the field further.

Conclusion

It is essential to provide students with a variety of effective treatment options as UCCs across the United States experience increased utilization. Group art therapy is an underused yet highly viable option for counseling centers to offer their students, particularly those students who may not benefit fully from traditional talk therapy groups. In these groups, students can safely and openly discuss their vulnerable experiences and feelings through art media that provide containment, structure, and an avenue for connection with others.