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Evaluating Art Therapy to Heal the Effects of Trauma Among Refugee Youth: The Burma Art Therapy Program Evaluation

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Background. Art therapy uses the creative process to encourage personal growth and alleviate symptoms of mental illness. The Art Therapy Institute provides programs for refugee adolescents from Burma to decrease their trauma-related symptoms. This article describes and discusses the methods and findings from an evaluation of this program. The challenges of assessing art therapy with this population and assessment tool gaps are explored and suggestions for future evaluations discussed. Method. Four validated clinical assessment tools were administered to 30 participants at baseline and follow-up to measure symptoms of anxiety, depression, and behavioral problems. Focus group discussions with clinicians were used to assess the evaluation. Results. Nearly all participants had experienced one or more traumatic events. At baseline, results showed a higher prevalence of depression than national rates among adolescents. Follow-up results showed improvements in anxiety and self-concept. Qualitative findings suggest that specific benefits of art therapy were not adequately captured with the tools used. Discussion. This evaluation showed some effects of art therapy; however, symptom-focused assessment tools are not adequate to capture clients’ growth resulting from the traumatic experience and this unique intervention. Future evaluations will benefit by using an art-based assessment and measuring posttraumatic growth. Keywords: child/adolescent health; community intervention; community organization; mental health; minority health; evaluation methods; outcome evaluation
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Health Promotion Practice
Month XXXX Vol. XX , No. (X) 1 –8
DOI: 10.1177/1524839915626413
© 2016 Society for Public Health Education
1
Background. Art therapy uses the creative process to
encourage personal growth and alleviate symptoms of
mental illness. The Art Therapy Institute provides pro-
grams for refugee adolescents from Burma to decrease
their trauma-related symptoms. This article describes
and discusses the methods and findings from an evalu-
ation of this program. The challenges of assessing art
therapy with this population and assessment tool gaps
are explored and suggestions for future evaluations
discussed. Method. Four validated clinical assessment
tools were administered to 30 participants at baseline
and follow-up to measure symptoms of anxiety, depres-
sion, and behavioral problems. Focus group discus-
sions with clinicians were used to assess the evaluation.
Results. Nearly all participants had experienced one or
more traumatic events. At baseline, results showed a
higher prevalence of depression than national rates
among adolescents. Follow-up results showed improve-
ments in anxiety and self-concept. Qualitative findings
suggest that specific benefits of art therapy were not
adequately captured with the tools used. Discussion.
This evaluation showed some effects of art therapy;
however, symptom-focused assessment tools are not
adequate to capture clients’ growth resulting from the
traumatic experience and this unique intervention.
Future evaluations will benefit by using an art-based
assessment and measuring posttraumatic growth.
Keywords: child/adolescent health; community
intervention; community organization;
mental health; minority health; evalua-
tion methods; outcome evaluation
>
INTRODUCTION
Art therapy is an expressive psychotherapy that
uses the art-making process to improve social, mental,
and emotional functioning and increase feelings of
well-being. Art making allows for healing through non-
verbal communication, exploration of feelings, self-
discovery, and catharsis (Malchiodi, 2011). Art therapy
626413HPPXXX10.1177/1524839915626413Health Promotion PracticeTHE BURMA ART THERAPY PROGRAM EVALUATIONRowe et al.research-article2015
1North Carolina Coalition Against Domestic Violence, NC, USA
2Snow Camp, North Carolina, NC, USA
3University of North Carolina, Chapel Hill, NC, USA
4Art Therapy Institute, Carrboro, NC, USA
5Oak Ridge Institute for Science and Education, Atlanta, GA,
USA
6American Institutes for Research, Chapel Hill, NC, USA
Authors’ Note: Address correspondence to Cassandra Rowe,
Palladium Group, 1701 Englewood Avenue, Durham, NC 27705,
USA; e-mail:cassandrajrowe@gmail.com.
Evaluating Art Therapy to Heal the Effects of
Trauma Among Refugee Youth: The Burma Art
Therapy Program Evaluation
Cassandra Rowe, MPH1
Rose Watson-Ormond, MPH2
Lacey English, MPH3
Hillary Rubesin, MA, LPC4
Ashley Marshall, MPH5
Kristin Linton, MA, LPC, ATR4
Andrew Amolegbe, MPH6
Christine Agnew-Brune, MPH3
Eugenia Eng, DrPH3
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2 HEALTH PROMOTION PRACTICE / Month XXXX
as mental health treatment is used to relieve stress and
negative psychological symptoms and can also serve to
facilitate personal growth (S. Hussain, 2010)
The concept of posttraumatic growth (PTG) has been
defined as “positive psychological change experienced
as a result of the struggle with highly challenging life
circumstances” (Tedeschi & Calhoun, 2004, p. 1). There
are five domains of PTG: greater appreciation of life
and changed sense of priorities; warmer, more intimate
relationships with others; greater sense of personal
strength; recognition of new possibilities or life paths;
and spiritual development (Borwick, Schweitzer,
Brough, Vromans, & Shakespeare-Finch, 2013; S.
Hussain, 2010; Taku, Cann, Calhoun, & Tedeschi, 2008).
Through individual and group therapy sessions, art
therapists facilitate PTG by helping clients improve
their feelings of self-worth, increase resilience, and
bond with others who have experienced trauma
(Stuckey & Nobel, 2010).
Shown to be effective with vulnerable populations,
art therapy can be particularly useful with children and
refugees who have experienced severe trauma
(Malchiodi, 2008; Wertheim-Cahen, 1998) due to its
ability to circumvent language barriers and its focus on
positivity and growth. Malchiodi (2008) asserts that art
therapy is especially appropriate for children and ado-
lescents because many prefer to express their experi-
ences nonverbally. Art allows children to explore
memories and emotions subtly and symbolically
(Malchiodi, 2008), providing a safe space to resolve
overwhelming traumatic symptoms (Appleton &
Spokane, 2001). Therefore, art therapy is appropriate
for refugees who have experienced the trauma of war
and relocation (Wertheim-Cahen, 1998).
Stressors faced in home countries and refugee
camps, as well as postmigration difficulties, result in
unique mental health needs for refugees (Kowitt et al.,
2013; Schweitzer, Brough, Vromans, & Asic-Kobe,
2011). Studies indicate that refugee children and ado-
lescents have high prevalence of mental health issues,
including depression, anxiety, hyperactivity, and diffi-
culties in peer relationships (Hodes, 2000). A system-
atic review of psychiatric disorders among refugees
found that 11% of refugee children were diagnosed
with posttraumatic stress disorder (PTSD), and refu-
gees in the United States were about 10 times more
likely than the general population to have PTSD (Fazel,
Wheeler, & Danesh, 2005). PTSD can be extremely life-
disruptive and even disabling, characterized by flash-
backs and hypervigilance, and may increase risk of
substance abuse and suicide (Fazel et al., 2005). Upon
arrival to the United States, the mental health needs of
refugees are often met with logistical, cultural, and
language barriers (Crosby, 2013; Morris, Popper,
Rodwell, Brodine, & Brouwer, 2009). Art therapy may
present fewer cultural and language barriers to clients’
therapeutic success because it relies on little spoken
communication and encourages free expression
(Malchiodi, 2008).
Though additional evaluations of art therapy in this
population are needed, there is some evidence to sug-
gest that expressive therapies can reduce emotional
and behavioral problems and increase self-esteem in
vulnerable children and adolescents (Rousseau,
Drapeau, Lacroix, Bagilishya, & Heusch, 2005). A liter-
ature review included 12 evaluations demonstrating art
therapy’s effectiveness in helping children cope with
trauma (Eaton, Doherty, & Widrick, 2007). Many of the
studies reported improvements related to mental
health, including reduced symptoms of PTSD and
anxiety and improved emotional stability. These stud-
ies demonstrate that art therapy offers a mechanism
through which refugee children can communicate their
experiences and process their thoughts and feelings
(Eaton et al., 2007).
Most tools used to evaluate art therapy programs
have been adopted from other disciplines and focus
on the alleviation of symptoms of anxiety, depression,
and maladaptive social behaviors. Two examples are
the State Trait Anxiety Inventory and the Profile of
Mood States (McNair, 1971; Speilberger, Gorsuch, &
Lushene, 1969). The State Trait Anxiety Inventory has
been used in art therapy evaluation to assess the par-
ticipants’ current state of anxiety (Rao et al., 2009).
The Profile of Mood State is also used to assess art
therapy and measures six dimensions of mood, cen-
tering on anxiety and depression (Puig, Lee, Goodwin,
& Sherrard, 2006). While these and other standardized
tools are useful in capturing some of the effects of art
therapy, they lack items that capture the growth-based
approach of art therapy. That is, art therapy encour-
ages personal growth; however, most evaluation tools
focus on symptoms or deficits and their improvement,
rather than the recognition and development of per-
sonal strengths.
Substantial knowledge gaps exist regarding the
appropriate tools and methods to evaluate art therapy.
This article presents an evaluation of the Art Therapy
Institute’s (ATI) work with refugee children and adoles-
cents from Burma living in North Carolina. With lim-
ited evidence on art therapy’s effectiveness with
refugees, there is a need for program evaluations to
examine the myriad effects and mechanisms of art
therapy. Evaluations that capture a more accurate,
holistic assessment of mental health interventions pro-
duce more meaningful data, which will serve to inform
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Rowe et al. / THE BURMA ART THERAPY PROGRAM EVALUATION 3
and improve programming. It is with this objective in
mind that this article offers recommendations for future
evaluations of art therapy and other interventions for
traumatized populations.
>
BACKGROUND
Since 1962, the country of Burma, or Myanmar, has
experienced civil war and ethnic tensions, causing hun-
dreds of thousands to flee to refugee camps due to pov-
erty, food scarcity, political violence, and severe human
rights violations (BBC News, 2013). The nation’s insta-
bility has made Burma a major source of refugees
(Crosby, 2013), who constituted 23% of refugee arrivals
in the United States in 2013 (Martin & Yankay, 2013).
Through the U.S. Refugee Resettlement program, over
14,000 refugees from Burma have resettled in North
Carolina over the past 10 years (Anderson & Bouloubasis,
2012).
ATI is a community-based organization that has
been providing art-based counseling services in the
Piedmont region of North Carolina since 2006. Among
their many programs, ATI serves refugees from Burma,
both children and adults, through the Burma Art
Therapy Program (BATP). Art therapy is an effective
psychotherapy for traumatized individuals based on
the theory that trauma is stored in the memory as
imagery, and art making is an effective tool for process-
ing these images (Appleton & Spokane, 2001). ATI’s
school-based art therapy program is uniquely suited to
serve its adolescent refugee clients, because a per-
ceived sense of safety at school and of school belonging
protects against PTSD, depression, and anxiety (Fazel,
Reed, Panter-Brick, & Stein, 2012).
BATP is a multifaceted program in which individual
and group art therapy sessions are conducted within
schools and community health clinics by master’s-level
clinicians. The program seeks to develop clients’
strengths as well as ameliorate negative symptoms
associated with the refugee experience, such as depres-
sion and anxiety. Art therapists worked with their cli-
ents to form therapeutic goals during initial sessions,
followed by both structured and unstructured weekly
art therapy sessions.
Therapeutic goals included, but were not limited to,
the following: feeling safe, personal identity, connection
to others, acculturation, resilience, hope, and goals for
the future. Over the course of 6 months throughout the
school year, 16 sessions of 50 minutes each were com-
pleted per client. Clients were pulled from their classes
once per week on a consistent schedule arranged with
their teachers, and art therapy sessions were conducted
in private spaces within the school. The art therapy
interventions delivered within the sessions were tai-
lored to the client’s specific needs and therapeutic goals,
as established by the client, the family, and the therapist.
The therapy was free to clients and funded through
myriad small grants, internal fund-raising, and third-
party insurance.
This evaluation was undertaken with the aim of
assessing ATI’s art therapy intervention on the mental
health outcomes of traumatized refugee adolescents
from Burma. The evaluation also uncovered critical
gaps in the way trauma and mental health outcomes are
assessed. The authors intend to demonstrate these gaps
in the existing tools and identify further areas of
trauma research. As children make up 39% of incom-
ing refugees to the United States (Martin & Yankay,
2013), it is our hope to encourage future evaluations to
capture a more holistic picture of the experiences of
trauma and effects of therapy.
>
METHOD
An outcome evaluation of BATP during the 2013-
2014 school year measured mental health outcomes,
behavioral issues, trauma exposure, and impact of art
therapy in a sample of 30 refugee adolescents from
Burma. In addition, focus group discussions (FGDs)
were conducted with ATI clinicians to improve future
iterations of this and other evaluations.
Participants
All BATP clients between the ages of 11 and 20
years were considered for participation. All individual
clients participated in the study, and group clients par-
ticipated if therapists could feasibly conduct the assess-
ments without compromising client confidentiality.
Participants (n = 30) were from the Karen, Burmese,
and Chin ethnic groups in Burma or Thailand. All par-
ticipants were middle and high school students,
between 11 and 20 years old. Out of 30 participants, 20
(67%) were male, 18 (60%) were in high school, and 25
(83%) were in English as a Second Language classes
(see Table 1). Participants had been in the United States
for an average of 5 years.
Study Design and Procedure
The outcome evaluation used a single group pre-
and posttest design. No control group was used due to
ethical concerns; the population receiving therapy
from ATI is relatively small and has access to few other
mental health resources. Consent was obtained from
participants who were 18 years and older and from
parents of minor participants, using translators in the
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4 HEALTH PROMOTION PRACTICE / Month XXXX
case of parents. Assent was obtained from minor par-
ticipants. This internal evaluation of an agency’s ser-
vices was reviewed and deemed exempt by the
Institutional Review Board of the University of North
Carolina at Chapel Hill.
Baseline data were collected in October 2013 and
follow-up data in March 2014, using four validated
clinical assessments to measure mental health out-
comes. The Piers-Harris Self-Concept Scale (PHSCS;
Piers & Herzberg, 2009), the Hopkins Symptoms
Checklist (HSC; Derogatis, Lipman, Rickels, Uhlenhuth,
& Covi, 1974), and the Harvard Trauma Questionnaire
(HTQ; Mollica et al., 1992) were administered to stu-
dents to measure self-concept, symptoms of anxiety
and depression, and previous experience of trauma at
baseline, respectively. The students’ teachers or social
workers completed the Strengths and Difficulties
Questionnaire (SDQ; Goodman, 2001), which measures
clients’ behavior and performance in school. Measures
of internal consistency among items for each of the
scales were strong, as reported by previous studies
using Cronbach’s alpha: .74 to .83 for PHSCS (Cooley,
1988), .75 to 84 for HSC (Derogatis et al., 1974), mean
of .65 for HTQ (Mollica et al., 1992), and mean of .62
for SDQ (Goodman, 2001).
Participants’ respective art therapists at school
incorporated survey administration into regularly
scheduled art therapy sessions. All assessments were
administered in English as most participants could
not read in their first languages. If participants had
difficulty understanding questions, clinicians read
them aloud and provided definitions. Interpreters
were not used during assessments so as to not com-
promise confidentiality and disrupt clinical rapport
between participants and therapists.
Before each session, participants were reminded
about therapeutic confidentiality, told that they could
stop the assessment at any time, and assured that
choosing to stop would never negatively affect their
therapy or relationship with their therapist. At the
end of each assessment, participants were given the
opportunity to verbally and artistically process the
thoughts and feelings that came up during the assess-
ments. Therapists conducted art-based grounding
activities with clients as needed to stabilize their
thoughts and emotions before sending them back to
class. For group clients, participants were pulled out
of class one by one from the group to complete the
HSC and the HTQ. The PHSCS was completed in a
group setting, based on the tool recommendations.
School staff were asked to return completed SDQs
within 2 weeks of receipt.
Student participants received approximately 16
weekly art therapy sessions from trained clinicians.
Students were placed in individual or group sessions
based on school staff recommendations. Sixty percent
of participants received individual therapy, and the
remaining received group therapy. Each session lasted
an average of 50 minutes. Four participants failed to
complete the follow-up assessments. One participant
moved out of the school district during the assessment
period. The other three participants did not complete
the follow-up assessments because they were being
provided emergency grief counseling immediately fol-
lowing the sudden death of their art therapist near the
end of the treatment period. None of the other partici-
pants were working with this therapist and therefore
were not affected.
One FGD and one group interview with ATI clinicians
(n = 5 and n = 2, respectively) were conducted by authors
who are not ATI clinicians to assess experiences with the
data collection process and identify any perceived gaps
in the assessments tools. The discussions were split
between two groups due to scheduling constraints. The
FGD guide was informed by Linnan and Steckler’s (2002)
process evaluation framework, whereby therapists were
prompted to describe the extent to which they were able
to (a) follow the planned protocol for administering each
assessment tool (fidelity) and (b) actually complete the
planned protocol as intended (dose delivered). FGD were
facilitated by one of the authors who is not an ATI clini-
cian and lasted 60 minutes each. The FGD guide con-
sisted of five questions and additional probes and covered
items such as the following: “How did administering the
TABLE 1
Participant Demographics at Baseline
Sex
Male 20 (67%)
Female 10 (33%)
Average age in years 15 (11-20)
School level
High school 18 (60%)
Middle school 12 (40%)
Insurance status
Insured 25 (83%)
Uninsured 5 (17%)
Average time in the United States in years 5 (1.25-12)
English as a Second Language classroom 25 (83%)
Art therapy received
Individual 18 (60%)
Group 12 (40%)
Average session length in minutes 50
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Rowe et al. / THE BURMA ART THERAPY PROGRAM EVALUATION 5
assessments go? (Prompt: What went well? What were
some challenges?)”; and “How could [challenges identi-
fied by clinicians] be improved?” Transcripts were not
produced; however, extensive notes were taken by two of
the authors.
Analysis
Clinical data were analyzed using SAS Version 9.3
statistical software. Baseline data were analyzed for
descriptive statistics, and pre–post comparisons were
made using Wilcoxon signed-rank test. For analysis of
process evaluation data from FGD with clinicians,
direct quotes were compiled and summarized.
Qualitative data software was not used for analysis of
FGD.
Outcome Evaluation Results
From baseline data analysis, we found that nearly
all participants had experienced, witnessed, or heard
about a traumatic event, with an average of 14 events
reported per participant. Eighty-three percent of par-
ticipants had directly experienced a traumatic event,
90% had witnessed a traumatic event, and 97% had
heard about a traumatic event. Commonly reported
experiences of trauma included the following: lacking
adequate food, witnessing rape, and hearing about
combat. On average, participants had directly experi-
enced two, witnessed four, and heard about eight trau-
matic events.
Data collected at baseline demonstrated participants’
mental health needs. Six participants (20%) reported
symptoms of anxiety, and 12 participants (40%)
reported symptoms of depression. Figure 1 shows that
of the BATP participants, 5 (16.7%) had definite or
severe emotional and behavioral difficulties and 9
(30%) had minor difficulties. Comparatively, on a
national survey of parents of U.S. adolescents, only
6.1% and 14.2% of 11- to 17-year-olds, respectively,
had definite or severe difficulties and minor difficulties
(Substance Abuse and Mental Health Services
Administration, 2012).
In addition, BATP participants had relatively low
scores on the self-concept assessment regarding their
intelligence, school standing, and physical appearance.
In other words, over 70% of participants felt poorly
about themselves in these areas. However, most BATP
participants reported positive feelings about their
behavior at school or home and happiness and satisfac-
tion with life.
Baseline findings informed individual art therapy
sessions during treatment period. Following 16 weeks
of art therapy, BATP participants reported fewer symp-
toms of anxiety. Changes in median scores for per-
ceived and actual symptoms of anxiety were statistically
significant (p = .051 and p < .0001, respectively). The
proportion of participants reporting symptoms of anxi-
ety decreased from 20.0% at baseline to 19.2% at fol-
low-up. Concurrently, the proportion of participants
reporting feeling “free from anxiety” increased from
50.0% at baseline to 65.4% at follow-up.
According to teacher reports, participants who had
severe difficulties in school decreased from 16.7% to
11.5%. Participants with overall positive self-concept
increased from 26.7% at baseline to 38.5% at follow-up
(see Figure 2). Participants’ self-concept scores regard-
ing their intellect and behavior in school decreased
from baseline to follow-up. These findings were not
statistically significant.
Process Evaluation Results
Several themes emerged from the FGD regarding the
data collection process. ATI clinicians felt that probing
clients about their experience of trauma during data
collection was at times challenging to navigate outside
the context of the art therapy session. For example, on
a question that asks participants whether they have
considered suicide, one clinician said it “brought up a
lot for all of us. . . . It brings up a lot of clinical ques-
tions, and it might be better to ask that question in
context [of therapy].”
Additionally, clinicians reported language barriers
to be particularly challenging in the evaluation pro-
cess, saying they found the tools to be “difficult lin-
guistically and culturally.” Whereas clinicians usually
have the aid of art materials during therapy sessions
to decrease language barriers, during data collection
FIGURE 1 Emotional and Behavioral Difficulties of BATP
Participants Compared to a National U.S. Adolescent Sample
SOURCE: Substance Abuse and Mental Health Services
Administration (2012).
NOTE: BATP = Burma Art Therapy Program.
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6 HEALTH PROMOTION PRACTICE / Month XXXX
participants struggled with key words, leading data
collectors to sometimes offer unstandardized defini-
tions. Clinicians were able to reconcile some of these
challenges at follow-up through additional training
and altering instructions on the assessment tools.
Continued conversations with ATI clinicians
revealed that while the quantitative tools captured
some of the effects of trauma and the impact of art
therapy on their client population, they did not capture
other effects, such as the unique experiences of growth
and building of clients’ strengths. They specifically
noted that while one major advantage of art therapy
rests in its positive reframing abilities, the measure-
ments chosen mainly assessed participants from a def-
icit-based approach, therefore not capturing the full
impact of art therapy.
This finding suggests that the evaluation’s instru-
ments should have included more art-based assess-
ments, such as the Diagnostic Drawing Series (DDS), a
diagnostic art tool designed by art therapists in 1988
(Cohen, Hammer, & Singer, 1988). The DDS is based on
the theory that drawings reflect internal states of the
artist. ATI had considered including the DDS in the
original evaluation plan but had some difficulty inte-
grating the DDS’s qualitative data within the framework
of a more formal quantitative assessment.
Art-based assessment tools use analysis of structural
elements of the artwork, therefore avoiding language
barriers often experienced with more traditional assess-
ment tools. Follow-up questions can act as a qualitative
assessment of participants’ drawings and allows par-
ticipants to express themselves freely, giving the clini-
cians additional insight into the clients’ status. When
assessments are art-based, they resemble a typical art
therapy session and do not disrupt the clinical flow of
therapy. Additionally, employing art-based assess-
ments would give therapists more space to discuss cli-
ents’ difficult memories in context.
In short, art-based assessments like the DDS could
have been better used to evaluate the impact of art
therapy on symptoms while avoiding language barriers
and helping explain the quantitative findings of the
other tools with qualitative findings. Evaluators could
work to incorporate the data from qualitative assess-
ments, such as the DDS, into assessments in a more
meaningful way in the future.
Finally, clinicians also pointed out that therapeutic
gains often require long-term treatment and that, in
their experiences, symptoms of depression may tem-
porarily increase during treatment. This theory may
be supported by the literature, as a recent study on the
impact of symptoms of depression on PTSD treatment
outcomes showed that experience of transient depres-
sion spikes are not uncommon and were not associ-
ated with either better or worse treatment outcomes
(Keller, Feeny, & Zoellner, 2014). Therefore, clinicians
felt this evaluation would have benefited from both a
longer intervention period to more accurately capture
the effects of art therapy and the addition of tools that
offer a more holistic assessment of trauma and art
therapy.
>
DISCUSSION
This article set out to examine the impact of an art
therapy program on mental health outcomes among
refugee adolescents from Burma, as well as identify
gaps in the current methods of evaluating the effects of
trauma. Our findings show that refugee clients of ATI
have experienced significant trauma and have a high
FIGURE 2 Pre–Post Comparison of Positive Self-Concept Among BATP Participants From October 2013 to March 2014
NOTE: BATP = Burma Art Therapy Program.
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Rowe et al. / THE BURMA ART THERAPY PROGRAM EVALUATION 7
prevalence of depressive symptoms, as well as other
school and social difficulties. Follow-up analysis
showed mixed results. Anxiety was reduced; however,
symptoms of depression increased slightly but were
not statistically significant. Clinicians reported it was
common during the initial stages of art therapy for
depression symptoms to temporarily increase as cli-
ents began to open up and explore their trauma. It is
likely that the effects of art therapy would have been
more accurately measured given a longer treatment
period.
This evaluation revealed that while quantitative
deficit-focused assessment tools can assess some of the
impacts of art therapy and trauma, additional art-based
qualitative tools, such as the DDS, are necessary to
reflect the full range of impact from art therapy. While
the tools used here have been successfully employed in
other evaluations of interventions targeting trauma-
tized and refugee adolescents, they were not sufficient
to capture the positive-framed mechanisms of art ther-
apy or to address the language and cultural barriers
inherent in working with refugee populations.
Additionally, the data fell short in capturing the experi-
ences of personal growth that may occur as a result of
art therapy and processing trauma.
>
CONCLUSIONS
This evaluation supports the use of art therapy as a
promising psychotherapy for young refugee popula-
tions and highlights the need for evaluations that accu-
rately map onto the mechanisms of art therapy. While
the tools we used captured trauma and some of its
effects, our process evaluation through FGDs with cli-
nicians revealed that language and cultural barriers
could have hampered the tools from fully capturing the
effects of both the trauma and the therapy. The effects
of trauma and the benefits of art therapy in this popula-
tion could be better assessed by adding tools that avoid
language barriers and focus on growth. Accurate evalu-
ation could be accomplished by incorporating results
of an art-based assessment tool, including a tool that
measures PTG and adding a qualitative interview or
FGD that allows participants to express themselves in
their own words.
Studies have measured PTG in refugee populations
using the quantitative Posttraumatic Growth Inventory
developed by Tedeschi and Calhoun (1996) across differ-
ent populations (D. Hussain & Bhushan, 2011; Taku
et al., 2008). Borwick et al. (2013) used in-depth qualita-
tive interviews to explore PTG with refugees from Burma
living in Australia. These studies speak to the resilience
of trauma survivors and shed light on promotive factors
for PTG, including community support and sharing
experiences. While it is crucial to document depression,
anxiety, and PTSD in refugee populations, it is equally
important to understand how positive mental health is
facilitated both through traumatic experience and thera-
peutic intervention. Using the Posttraumatic Growth
Inventory or a qualitative tool to measure PTG with ado-
lescent refugees will more accurately capture the impact
of art therapy and therefore add to the body of research
and practice. Future evaluations should focus on the
strides clients make in art therapy and the personal
growth they experience as a result of trauma.
It is only through high-quality program evaluations
that use accurate and sensitive tools that art therapy
will continue to examine and document its effective-
ness at addressing mental health needs. The expansion
of art therapy provides a unique opportunity for refu-
gee youth populations to benefit from a transcultural
and positive-framed approach to mental health.
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... Therefore, the role of psychosocial, therapeutic, and mental health interventions is found crucial in managing PTSD symptoms in refugee children and youth (Giacaman et al., 2007;Al-Hroub, 2015;Almoshmosh, 2016;McLaughlin and Al-Hroub, 2016), and adults (Palic and Elklit, 2011). Research showed that therapeutic practices that rely on non-verbal treatment, such as art therapy, may promote healing refugee learners affected by war (Harris, 2009;Rowe et al., 2017;Zubala and Karkou, 2018). ...
... However, the authors did not provide enough information regarding the description of the materials. In the study conducted by Rowe et al. (2017), the researchers provided sufficient information regarding dosage and the process evaluation framework during the intervention phase but there was insufficient information regarding the materials used and the detailed process was missing regarding the art therapy techniques used. Similarly, DroŽdek et al. (2014) provided a table showing the phases of intervention with the content but did not provide enough materials to describe the specificity of the intervention. ...
... The study carried out by Feen-Calligan et al. (2020) clearly described how participants were assigned to either the treatment or the control group. In their study, Rowe et al. (2017) reported that participants had access to other mental health resources, which is a threat to internal validity. In four of the studies (i.e., 50%), researchers did not indicate whether participants in the baseline condition had access to any of the intervention components (Van Wyk et al., 2012;Ugurlu et al., 2016;Moosa et al., 2017;Schouten et al., 2019). ...
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... Art is convenient for children and adolescents because they prefer to express their experiences nonverbally more than adults do (Rowe et al., 2017). An important benefit of the arts in spiritual care is the opportunity to experience or regain a sense of joy. ...
... After three weeks, the individuals reported in a follow-up that their levels of anxiety and stress had decreased (Lindsey et al., 2018). Rowe et al. (2017) conducted with 20 refugee adolescents, found that an art therapy program effectively decreased the refugees' anxiety and increased their self-esteem (Rowe et al., 2017). ...
... After three weeks, the individuals reported in a follow-up that their levels of anxiety and stress had decreased (Lindsey et al., 2018). Rowe et al. (2017) conducted with 20 refugee adolescents, found that an art therapy program effectively decreased the refugees' anxiety and increased their self-esteem (Rowe et al., 2017). ...
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This research was conducted to determine the effect of calligraphy on the anxiety and depression levels of adolescent psychiatric patients. It was conducted with adolescent psychiatric patients ages 14–17 in Turkey’s Eastern Anatolia Region. They were allocated a calligraphy (n = 40) or a wait-list (n = 39) group. Those in the calligraphy group participated in 60-min calligraphy sessions for three weeks. The state anxiety levels of adolescents who applied calligraphy decreased gradually when compared with adolescents in the control group. The difference between the third-week mean post-test state anxiety scores of the adolescents in the calligraphy and control groups was significant (t = 2.34, p = .02). The trait anxiety scale and depression scale mean post-test scores of the adolescents in the calligraphy group were lower than in the control group. The difference between two groups was significant. Calligraphy can be potentially used as a beneficial method for reducing anxiety and depression.
... Preliminary literature review findings suggest a research-practice gap: flexible methods practiced in the field in the past 10 years, primarily funded and run by nongovernmental organizations (NGOs), are not necessarily reflected in the few research papers published about creative arts therapies interventions for refugee and asylum-seeking children. This gap is also mentioned in several of the publications (e.g., Kalaf & Plante, 2019;Rowe et al., 2017;). Out of the 106 publications, a significant amount refers to creative arts therapies as part of multi-level and interdisciplinary interventions developed for refugees and asylum-seekers. ...
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"This paper seeks to explore the topic of art therapy interventions with refugee and asylum-seeking children and their parents, with a specific focus on how art therapists engage displaced parents in their child’s therapy process. Preliminary literature review findings, in preparation for a comprehensive scoping review, suggest that there is a research-practice gap on the topic of engaging refugee and asylum-seeking parents in their children’s art therapy processes. Flexible methods practiced in the field in the past 10 years, primarily funded and run by nongovernmental organizations (NGOs), are not necessarily reflected in the few research papers published about creative arts therapies interventions for refugee and asylum-seeking children. Out of 106 publications (including grey literature such as NGO manuals and reports, book chapters, case studies, and conference papers), a significant amount refers to creative arts therapies as part of multi-level and interdisciplinary interventions developed for refugees and asylum-seekers. Among these, most publications found are manuals and reports describing case vignettes or multi-level practice guidelines, rather than peer-reviewed publications about research. These literature review findings form the first stage of a larger research project which seeks to develop evidence-based guidelines regarding parent-child art therapy among refugees and asylum-seekers, using the first two phases of the Medical Research Council’s (MRC) recommendations for complex intervention development. In doing so, the research seeks to address the global need for evidence-based, culturally humble, and resilience-focused psychosocial support interventions for displaced populations."
... Most of the emphasis has been on addressing PTSD and other severe mental health disorders among humanitarian entrants by using interventions such as Cognitive Behavior Therapy, Narrative Exposure Therapy, and Eye Movement Desensitization Processing (Kip et al., 2020). However, there has been a growing interest in developing and trialing group-based interventions to enhance the resilience and acculturation process of immigrants (Khawaja & Ramirez, 2019), as the use of expressive and creative therapies can provide an important medium for engagement with mental health services (Dieterich-Hartwell & Koch, 2017;Kalibatseva & Leong, 2014;Rowe et al., 2017). It is essential that such programs accommodate the unique issues and cultural and linguistic needs of CALD communities (Kirmayer et al., 2011). ...
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... Evaluation with a qualitative approach is able to provide a more holistic assessment of interventions and produce meaningful data, because the data search process starts from internal components such as staff, funders, collaborators and competitors through a process of in-depth attention, empathic understanding and suspension of the researcher's prejudices about the topics discussed (Rowe et al., 2017;Theresa1, 2018). The research method for this program evaluation is based on the need to answer evaluation questions related to aspects of input (antecedent), process (transaction), and impact (outcomes) (Stake, 1967). ...
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The purpose of this research is to evaluate the input stages of antecedents, transactions process, and outcomes in education and training as one of the programs in SETUKPA LEMDIKLAT POLRI. This type of research is qualitative using the Countenance Stake evaluation model which consists of three stages, namely: antecedents, transactions, and outcomes. The subjects in this study consisted of 30 trainees who were selected by purposive sampling. Data were collected through interviews, and observations. The results showed that at the antecendent evaluation stage, educators are still lacking in innovating online learning planning adjustments with models or learning schemes that are planned in advance. At the transaction evaluation stage, indicators of online learning strategies and interactive online learning do not meet the evaluation standards. The training participants stated that it was less than optimal and the synchronous interaction that occurred in the online KBM conducted by the Setukpa Lemdiklat Polri. At the outcome evaluation stage, indicators of student satisfaction with online learning, not meet the specified standards. This can be seen from the absence of a discussion forum to measure the satisfaction of online learning activities that are followed by students and the absence of online learning assessments by Gadik in the Setukpa Lemdiklat POLRI environment.
... The results found significant improvements in psychological and physical symptom indices compared to controls; hence they concluded that mindfulnessbased art therapy is a promising intervention for symptom relief, Hilton's previous presentation [7] and manuscript [8] included a literature review listing research on art therapy and identified there were numerous clinical research studies that report art therapy benefit as it relates to a number of clinical objective and subjective outcomes. Positive outcomes were reported for people with psychosis [9], for healing trauma among refugee youth [10], stroke patients in their rehabilitation process [11], Alzheimer's disease and other dementias [12], non-psychotic mental health disorders [13], type 1 diabetes mellitus [14] and depression and cognitive function of the elderly [15]. ...
... Theorists have therefore suggested that action-oriented modalities like the creative arts and play therapies may be more suited to the relational style of boys (Haen, 2011), and that such approaches may also be more accessible for young people across racial groups because they do not privilege verbalization in the way that many empirically supported treatments do (Haen, 2019;Lin & Bratton, 2015). Researchers have further suggested that qualitative data may more adequately capture the impact of arts-based approaches with young people than quantitative outcomes (Rowe et al., 2017). ...
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This qualitative study examines the experience of adolescent males of color engaged in a 12-week, school-based art therapy intervention. Participants were 78 ninth graders from limited resource communities attending an all-boys high school in the South Bronx, New York. The population was naturally divided into three groups based on levels of potential academic competency. At the conclusion of the intervention, participants completed a written questionnaire to ascertain their perspectives on art therapy, the pieces they created, and how process and product related to emotions. Qualitative coding revealed nine themes, which provided a sense of differential impacts of the intervention by academic grouping. Findings suggest that art therapy targets a range of needs for high school students, from those who are successful and feel positively in school to those who struggle within the academic setting.
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Background: An unprecedented number of people around the world are experiencing forced displacement due to natural or man-made events. More than 50% of refugees worldwide are children or adolescents. In addition to the challenges of settling in a new country, many have witnessed or experienced traumatic events. Therefore, refugee children and adolescents are at risk of developing mental health problems such as post-traumatic stress disorder, and require appropriate and effective support within communities. Objectives: To assess the effectiveness and acceptability of community-based interventions (RCTs only) in comparison with controls (no treatment, waiting list, alternative treatment) for preventing and treating mental health problems (major depression, anxiety, post-traumatic stress disorder, psychological distress) and improving mental health in refugee children and adolescents in high-income countries. Search methods: Databases searches included the Cochrane Common Mental Disorders Controlled Trials Register (all available years), CENTRAL/CDSR (2021, Issue 2), Ovid MEDLINE, Embase, six other databases, and two trials registries to 21 February 2021. We checked reference lists of included study reports. SELECTION CRITERIA: Studies of any design were eligible as long as they included child or adolescent refugees and evaluated a community-based mental health intervention in a high-income country. At a second stage, we selected randomised controlled trials. Data collection and analysis: For randomised controlled trials, we extracted data relating to the study and participant characteristics, and outcome data relating to the results of the trial. For studies using other evaluation methods, we extracted data relating to the study and participant characteristics. W derived evidence on the efficacy and availability of interventions from the randomised controlled trials only. Data were synthesised narratively. Main results: We screened 5005 records and sought full-text manuscripts of 62 relevant records. Three randomised controlled trials were included in this review. Key concerns in the risk of bias assessments included a lack of clarity about the randomisation process, potential for bias is outcome measurement, and risk of bias in the selection of results. Primary outcomes There was no evidence of an effect of community-based interventions when compared with a waiting list for symptoms of post-traumatic stress (mean difference (MD) -1.46, 95% confidence interval (CI) -6.78 to 3.86: 1 study; low-certainty evidence), symptoms of depression (MD 0.26, 95% CI -2.15 to 2.67: 1 study; low-certainty evidence), and psychological distress (MD -10.5, 95% CI -47.94 to 26.94; 1 study; very low-certainty evidence). There were no data on adverse events. Secondary outcomes Three trials reported on short-term changes in child behaviour, using different measures, and found no evidence of an effect of the intervention versus a waiting list (low to very low certainty). None of the trials reported on quality of life or well-being, participation and functioning, or participant satisfaction. Authors' conclusions: There is insufficient evidence to determine the efficacy and acceptability of community-based mental health interventions for refugee children and adolescents.
Article
Objective Post-traumatic stress disorder (PTSD) is characterised by a range of symptoms including acute stress, flashbacks and avoidance of situations that trigger trauma. Women from Arabic-speaking backgrounds have been shown to have a higher likelihood of developing PTSD due to life stressors experienced. Method This paper aimed to provide an overview of the experiences and social circumstances of Arab women experiencing PTSD in Australia. Results Family, gender roles, religion, mental health stigma, trauma, re-settlement challenges, acculturation and discrimination were some of the factors explored in this review. The paper also aimed to review evidence-based treatment for PTSD such as cognitive behavioural therapy, narrative exposure and eye movement desensitisation therapy and whether these westernised approaches can extend to women from Arab backgrounds. Directions for culturally appropriate interventions and how to adapt treatments to suit the needs of individuals from the Arab community experiencing PTSD are discussed as well as considerations for specifically supporting women from Arab backgrounds who need treatment. Conclusions Future avenues for research are canvassed and discussed within. KEY POINTS What is already known about this topic: • (1) Women from Arabic speaking backgrounds in Western countries have been shown to have a higher likelihood of developing PTSD due to the life stressors that they have experienced. • (2) Particular life stressors include migration and acculturation stressors, marginalisation, financial concerns, family responsibilities and for some, family violence which can exacerbate distress and contribute to the expression of PTSD symptoms. • (3) No effective PTSD treatments for Arab populations in general, let alone Arab women have been identified in research. What this topic adds: • (1) Effective mental health treatment for Arab women must take into consideration certain cultural values such as family, women’s role/status and stigmas around mental health. • (2) Some of the main factors to consider include beliefs and values, communication and language, shame, strict gender roles and religious healing. • (3) There is a significant need for immediate future research to be conducted for this community.
Article
Background The effect of interventions based on the creative arts for children and adolescents exposed to traumatic events was estimated for measures of post-traumatic stress disorder (PTSD) and other psychological symptoms. Method Using a pre-registered protocol, relevant journal articles were identified through searches of: PsycInfo; Psychology and Behavioural Sciences Collection; CINAHL and PsycArticles. Data were pooled using a random effects model, and effect estimates were reported as Hedges’ g. Results Pooled effect estimates indicated that arts-based interventions significantly reduced PTSD symptom scores compared to pre-intervention (15 studies, g = −.67, p < .001) and a control group (7 studies, g = -.50, p < .001). Significant reductions were also found for measures of negative mood, but results were mixed for externalizing problems and anxiety. Conclusions Despite variations in study quality, intervention approaches and types of trauma experience, the results tentatively suggest that creative arts-based interventions may be effective in reducing symptoms of trauma and negative mood.
Article
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There are no valid and reliable cross-cultural instruments capable of measuring torture, trauma, and trauma-related symptoms associated with the DSM-III-R diagnosis of posttraumatic stress disorder (PTSD). Generating such standardized instruments for patients from non-Western cultures involves particular methodological challenges. This study describes the development and validation of three Indochinese versions of the Harvard Trauma Questionnaire (HTQ), a simple and reliable screening instrument that is well received by refugee patients and bicultural staff. It identifies for the first time trauma symptoms related to the Indochinese refugee experience that are associated with PTSD criteria. The HTQ's cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations.
Article
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AbstractA salutogenic approach explored themes of strength and well‐being in life stories of Burmese refugees (N = 18) in Australia. Previous refugee studies have tended to focus on negative responses to traumatic events (e.g. posttraumatic stress disorder, depression). To widen the scope of refugee related research the focus of the current study was informed by a salutogenic perspective, exploring sources of strength that may facilitate well‐being. Semi‐structured narrative interviews explored: the participant's life before fleeing Burma, the journey of exile, and post‐migration in Australia. Eight women and 10 men (M age = 39 years) were interviewed and transcriptions analysis of narratives was conducted using Interpretative Phenomenological Analysis (IPA), with major themes being explicated. Super‐ordinate themes pertaining to strength during times of hardship were identified and explicated as: support from interpersonal relationships, the pivotal role of values, a sense of future and agency, and reliance on spiritual or religious beliefs. Results indicate the existence of sources of strength that may contribute to human responses in times of hardship. Recognition and reflection of strengths may be incorporated into therapeutic and resettlement approaches for people from refugee backgrounds.
Book
The Wiley Handbook of Art Therapy is a collection of original, internationally diverse essays, that provides unsurpassed breadth and depth of coverage of the subject. The most comprehensive art therapy book in the field, exploring a wide range of themes. A unique collection of the current and innovative clinical, theoretical and research approaches in the field. Cutting-edge in its content, the handbook includes the very latest trends in the subject, and in-depth accounts of the advances in the art therapy arena. Edited by two highly renowned and respected academics in the field, with a stellar list of global contributors, including Judy Rubin, Vija Lusebrink, Selma Ciornai, Maria d' Ella and Jill Westwood. Part of the Wiley Handbooks in Clinical Psychology series.
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This article describes the concept of posttraumatic growth, its conceptual foundations, and supporting empirical evidence. Posttraumatic growth is the experience of positive change that occurs as a result of the struggle with highly challenging life crises. It is manifested in a variety of ways, including an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life. Although the term is new, the idea that great good can come from great suffering is ancient. We propose a model for understanding the process of posttraumatic growth in which individual characteristics, support and disclosure, and more centrally, significant cognitive processing involving cognitive structures threatened or nullified by the traumatic events, play an important role. It is also suggested that posttraumatic growth mutually interacts with life wisdom and the development of the life narrative, and that it is an on-going process, not a static outcome.
Article
Objective: We know little about how change unfolds in depression symptoms during posttraumatic stress disorder (PTSD) treatment or how patient characteristics predict depression symptom change. This study examined critical transition points in depression symptoms during PTSD treatment, namely, depression sudden gains, which are rapid symptom improvements and transient depression spikes, which are transient depression worsenings. Social support, one of the strongest predictors of PTSD development, was examined as a predictor of depression symptom discontinuities. Method: At pretreatment, 200 participants (76.6% female; 64.9% Caucasian; age M = 37.1, SD = 11.3 years) completed measures of PTSD severity (PTSD Symptom Scale-Self-Report), depression severity (Beck Depression Inventory), general social support (Inventory of Socially Supportive Behaviors; Social Support Questionnaire), and trauma-related social support (Social Reactions Questionnaire). During 10 weeks of prolonged exposure (PE) or sertraline, depression was assessed weekly. Results: Overall, 18.0% of participants experienced a depression sudden gain, and 22.5% experienced a transient depression spike. The presence of a depression sudden gain predicted better treatment outcome, β = -4.82, SE = 1.17, p = .001, 95% CI [-6.79, -2.90]. Higher perceptions of negative trauma-related reactions, albeit modestly, were associated with experiencing a transient depression spike (r = .18, p = .01). There were no differences in rates of depression sudden gains or transient depression spikes between treatments. Conclusions: Encouragingly, rapid improvements in depression symptoms are beneficial for PTSD treatment outcome, but transient spikes in depressive symptoms do not strongly influence outcome. Understanding symptom discontinuities may help us to personalize current PTSD treatment options.
Article
The six cluster scales of the Piers-Harris Children's Self-Concept Scale were examined for reliability and independence. Half of the 155 sixth to eighth graders completing the scale were receiving some special education services. Results suggested the cluster scales showed adequate reliabilities with alphas ranging from .74 to .83, but the scales were quite highly intercorrelated with a mean r of .54. Removal of all overlapping items from the cluster scales reduced the interscale correlation mean to .44, with only a small drop in internal consistencies. Removal of overlapping items seems to be a favorable procedure if relative independence between self-concept dimensions is desired.
Article
Refugees are a vulnerable class of immigrants who have fled their countries, typically following war, violence, or natural disaster, and who have frequently experienced trauma. In primary care, engaging refugees to develop a positive therapeutic relationship is challenging. Relative to care of other primary care patients, there are important differences in symptom evaluation and developing treatment plans. To discuss the importance of and methods for obtaining refugee trauma histories, to recognize the psychological and physical manifestations of trauma characteristic of refugees, and to explore how cultural differences and limited English proficiency affect the refugee patient-clinician relationship and how to best use interpreters. MEDLINE and the Cochrane Library were searched from 1984 to 2012. Additional citations were obtained from lists of references from select research and review articles on this topic. Engagement with a refugee patient who has experienced trauma requires an understanding of the trauma history and the trauma-related symptoms. Mental health symptoms and chronic pain are commonly experienced by refugee patients. Successful treatment requires a multidisciplinary approach that is culturally acceptable to the refugee. Refugee patients frequently have experienced trauma requiring a directed history and physical examination, facilitated by an interpreter if necessary. Intervention should be sensitive to the refugee's cultural mores.