1 An Evaluation of Art Therapy Interventions in Primary Schools as part of The East Riding TaMHS Project Compiled by Laura Stone; Assistant Psychologist, Art Therapist; Hannah West, PMHW Project Coordinator, Helen Blair, Specialist CAMHS Worker Introduction This report aims to evaluate the effectiveness of Art Therapy as an intervention in primary school settings for pupils with emotional difficulties. All of the Art Therapy mentioned in this report was conducted by a fully qualified Art Therapist as part of the Targeted Mental Health in Schools (TaMHS) initiative. The report evaluates both individual and group work conducted in four different primary schools, as well as a Therapeutic Art Group cofacilitated by a Teaching Assistant (TA) with the hope that the groups, based on Art Therapy principles, can be continued within the school following the closure of the TaMHS project. The Therapeutic Art Group follows a structured session plan designed to enable facilitation of the group by staff within the school. As part of the TaMHS project, the GL Emotional Literacy, pupil and teacher checklists were completed for a range of pupils including those who received an Art Therapy intervention. It is the results of these GL assessments which are being used to evaluate the effectiveness of the Art Therapy interventions. In addition, for one of the Art Therapy groups, the Strengths and Difficulties Questionnaire (SDQ) was used pre and post intervention. This will also be discussed. Group Art Therapy The teacher checklist was conducted pre and post intervention for a total of 28 pupils who had taken part in an Art Therapy group. Out of these 28 pupils, 18 showed an improvement in score (64%). A one tailed, repeated measures t test was conducted to investigate the statistical significance of the difference between pre and post emotional literacy scores. The p value gained, of 0.01, is significant at the 5% level. This indicates that it is unlikely (1% probability) that this difference is due to chance. This indicates that Art Therapy groups are effective in improving emotional wellbeing, according to teacher s answers to the GL teacher checklist. The graph below demonstrates the improvement in teacher checklist scores: A Bar Chart to Show Pre and Post GL Emotional Literacy Teacher Checklist Scores Teacher Checklist Scores Pre intervention Post intervention Pupils
2 Of the pupils who took part in the groups, pre and post intervention pupil checklist data was available for 18 pupils. Out of these 18 pupils, 15 showed an improvement in score (83%). A one tailed, repeated measures t test was conducted to see if the difference between pre and post intervention scores was significant. The p value gained, of 0.02 is significant at the 5% level. This suggests it is unlikely that this difference is due to chance and is more likely (98% likelihood) that this difference is due to the Art Therapy group. This indicates that Art Therapy groups are effective in improving emotional wellbeing according to pupil s self-reported answers to the GL pupil checklist. The graph below demonstrates the improvement in pupil checklist scores: A Bar Chart to Show Pre and Post Pupil Checklist Scores 120 Pupil Checklist Scores Pre intervention Post intervention Pupils Individual Art Therapy The teacher checklist was conducted pre and post intervention for three pupils who had received individual Art Therapy. This is a very small sample size and is therefore difficult to generalise the findings from. However, out of these three pupils, two showed an improvement in score and one pupil s score stayed the same. Although this is a very small sample of pupils, the results are positive and support the effectiveness of individual Art Therapy interventions. Due to the small number of pupils, it was felt that a test of statistical significance would not be useful. Group and Individual All teacher checklist data for pupils who had received an Art Therapy intervention, regardless of whether individual or group, was combined. There was pre and post assessment data available for 31 pupils, out of these 20 showed an improvement in score (65%). A one tailed, repeated measures t test was conducted to investigate the statistical significance of the difference between pre and post intervention scores. The p value gained, of is significant at the 1% level. This suggests it is extremely unlikely (less than 1% probability) that this difference is due to chance. This finding shows strong support for the effectiveness of Art Therapy as an intervention for improving emotional wellbeing, according to GL Emotional Literacy teacher checklist scores. Strengths and Difficulties Questionnaires SDQ assessments were completed by teachers before and after pupils took part in an Art Therapy group. Pre and post data was available for all six pupils who took part in this specific group. All six pupils scores were lower for the post assessments than for the pre assessments. Unlike the GL assessments, a decrease in score for the SDQ is positive and suggests improvement in emotional wellbeing. This indicates therefore that all six pupils (100%) involved in this group showed an improvement in their emotional wellbeing
3 according to teacher s answers for the SDQ. A one tailed, repeated measures t test was conducted to investigate the statistical significance of the difference between the pre and post scores. The p value of 0.01 is significant at the 5% level and therefore suggests that it is very unlikely (1%) that this difference is due to chance. This again supports the effectiveness of Art Therapy groups in improving the emotional wellbeing of pupils. The graph below demonstrates the improvement in pupils SDQ scores: A Bar Chart to Show Pre and Post Intervention SDQ Scores SDQ Score Pre intervention Post intervention Pupils Conclusions Overall, the results show support for the effectiveness of Art Therapy in improving pupil s emotional wellbeing. The results seem to be consistent regardless of whether the intervention was individual or group work, whether assessments were completed by teachers or pupils self-reports, between different schools in which the sessions were conducted and even across two different measures of emotional wellbeing, the GL Emotional Literacy Checklist and the SDQ. It can be suggested therefore that according to these results, Art Therapy is an intervention which is successful in improving children s emotional wellbeing.
4 CASE STUDIES By Hannah West Enabling Change through Art Therapy A nine year old disruptive child who had participated in an art therapy group was identified for further work on an individual basis for 12 sessions. The child had taken the Alpha male position in the group and spent his time acting out relationship difficulties with one girl in particular; he had been uninterested or unable to engage in the art making process. The child seemed emotionally and developmentally very young and his need to represent events in a concrete way and inability to symbolise implied that he had not progressed through all the necessary stages as a younger child. As he had relied so heavily on others in the group and had not been able to access his creativity, I wondered whether the work would be possible. In the individual sessions role play remained central to his working out and I was consistently placed in the role of the wife. The main theme and difficulty in the work was around endings and the end of every session was unsatisfactory and characterised by an escalating sense of anxiety. I offered situations which allowed him to play creatively with his hands in paint as a very young child might, and fear around making his mark was overcome without it being consciously confronted head on. His surprise at finding a tree! in his unintentional mark making, and having confirmation from me that he had made a tree, seemed to mark the beginning of his self belief. His confidence built and he produced a large collection of very primitive images of which he was very proud. In the last few weeks the sessions returned to being dominated by role play and issues around endings were magnified. The turning point came for this child when I reacted very differently to the anxiety at the end of the session, giving him an option for an alternative ending. Instead of reacting to his need to spoil the ending by feeling wound up and then attempting to appeal to his reason, I playfully embraced his need to run away and made it acceptable for him to do so. This seemed to facilitate his ability to accept endings and allow them to occur. This change coincided markedly with his role play in which his stories, instead of ending in relationship conflict, worked through difficulties and found resolutions. The penultimate session ended with a celebration meal created out of paper, plastercine and paint, with a toast for the first ending I haven t spoiled. A marked positive difference was noted in the child s behaviour and level of social and emotional awareness by his mother and teachers. His name disappeared from the book in which lunch time staff record those who are disruptive at dinner time, where previously he had an almost daily presence, and he began to receive positive behaviour comments and rewards and to value these as recognition of himself as a good person.
5 School Attitudes to, and Support for Therapeutic Group Work A comparison between two art therapy groups which were run concurrently and with the same approach, by the same therapist, in two primary schools in the same cluster School A was situated in an urban area with a predominantly disadvantaged demographic. The school already had a healthy whole school SEAL programme and ran Silver SEAL groups on an ongoing basis and a termly Family SEAL programme. School B was situated in a more affluent rural area and the approach to SEAL was whole school, with no small group or family aspect. Some small group work was carried out by a local authority Advisory Teacher. In school A, staff facilitated the children to look forward to the group, showing a very positive attitude towards the Art Therapy group this in turn perhaps transferred to parental support. Most parents attended at least one meeting and all parental consent forms and checklists were returned. The children looked forward to the work very much and a grounded and focussed group was formed. The mix of children were well considered, being in the same age group and from the same class may have helped them to form a group which functioned well, resulting in positive change in the way the children felt according to pupil self assessments. In school B, though the Head s attitude to TaMHS was positive and welcoming and the need for the work was felt, it was also believed that some parents would be reluctant to support TaMHS due to stigma issues. School chose to present the work in a low-key way as art sessions and chose not to refer to art therapy due to fear of refusal of consent. School did not ask parents to fill in emotional well-being checklists for their child and no parents attended the meetings offered. The children chosen for the group seemed confused and suspicious at the initial session, not knowing what they were doing there, they were uninformed and unprepared. Staff CPD relating to the intervention was not prioritised, one out of three sessions was undertaken and only one staff feedback form was returned. The culture of the group was uncontained and disruptive. The need for further work with an individual from the group was highlighted but was not followed up by the school as there was a reluctance to inform parents. Although there were undoubtedly other factors, the contrast between these two schools seems to highlight the difference a forthright and transparent attitude to SEAL and a commitment to the wider SEAL programme can make, providing prepared fertile ground for therapeutic work.
6 The Importance of the Physical Context for Targeted Emotional Well Being Work A comparison between two art therapy groups which ran concurrently and with the same approach, in two different rooms in a primary school The primary school was one with a very proactive and thorough attitude towards emotional well being work, with a dedicated Nurture Room and staff team. Twelve children were selected for two Therapeutic Art Groups which ran for eight weeks; one took place in the Nurture Room and one in a Food Technology class room. A TaMHS practitioner ran each group assisted by a member of the school Nurture Team. The children in the group which took place in the Nurture Room were aged between 5 and 8. The group suffered many unplanned inconsistencies. Despite a Do Not Disturb sign on the door, the group was invariably interrupted numerous times by school staff and children for various reasons and the HLTA assisting the group, who was also the Nurture Room manager, was often called upon in person and via walkie-talkie, to attend to urgent matters. The experience for the children in this group was less special, less safe in psychological terms. If you promise children privacy, time and attention but then some of these things are not forthcoming there is a breach of trust. It is not a massive breach in everyday terms but it is in terms of expecting EHWB to flourish, and the process was not as smooth as with the second group in this example. Their time in the group was more akin to the usual time in the nurture. They saw that sometimes adults were busy with more important things than them. The experience for the Nurture room manager was also less special and she actually said at one point that she saw little difference in the group time and ordinary Nurture room time. The children in the group which took place in the Food Technology room were aged 8 and 9. The group was not interrupted in any way. The TA assisting was able to switch off her walkie-talkie and remain attentive to the needs of the group. The group was quick to gel, and the children soon felt comfortable with each other. The children voiced their appreciation of the group and saw it as a special time. A comment made by one of them as they had a celebratory drink and biscuit having finished the sessions was We re just like a family sitting round a table together. Although the ages of the children in the groups must have been a contributing factor, the contrast between the two groups highlighted that a confidential uninterrupted space and constant adults are important factors facilitating a feeling of containment and a therapeutic context.
7 Staff Training and Sustainability Therapeutic art groups delivered as training and research development for a resource for use by TAs in school As a response to Teaching Assistants and Learning Mentors requesting guidance on using art therapeutically in small group work, the TaMHS team and school staff worked together to deliver groups based on different creative therapeutic models in a number of primary schools. A model of working and a resource for schools to enable TAs to deliver art based therapeutic groups has evolved out of this work. TaMHS practitioners co-working over time with TAs meant the model evolved to combine elements of the directive ways of working which TA s are familiar with and the containing space of the therapeutic relationship and context. In the development of this model, five Teaching Assistants have experienced delivery alongside an Art Therapist, of a therapeutic art group of between eight and twelve sessions long, with a total of 35 children. The weekly sessions were immediately followed by up to an hour of individual mentoring / CPD for the TA. It is hoped that TAs will continue to use the resource with an assistant, passing on their skills to others. A Case Study Highlighting a Gap in Service Provision One to one work with a child with attachment issues A child referred for the Art Therapy group for disruptive attention seeking behaviour was assessed by the TaMHS therapist as unsuitable for group work, but appropriate for one to one intervention. The child received weekly hour long sessions for ten weeks with a TaMHS Art Therapist. Attachment issues were identified and the child responded well to the intervention. Teaching staff reported improvements and the child identified an increased feeling of well being but also requested that the sessions continue. The therapist s post intervention report advised that after an assimilation period, if the child s needs increased, this would indicate that the child needed longer term attachment work. When the new school term was underway, school requested that the child receive further individual work through TaMHS, however due to stigma issues, parents were not informed of the therapist s recommendation which made further intervention from TaMHS impossible. However, had the parents been informed of the findings and wanted to refer the child for long term attachment work, there would have been no available service, other than temporarily TaMHS, offering this kind of work. The child s symptoms did not reach the criteria for a referral to core CAMHS and long term work is not available through the PMHW. This case highlights the need for TaMHS in schools, but also for that service, or the PMHW, to provide longer term work in cases which do not qualify for a tier three service.
8 An Art Therapy Group Used to Assess When the Bereavement Process is Working and When a Child Needs Extra Help Contrasting the experiences of two bereaved children in a group Six children aged eight and nine who had lost a parent either through death or family separation were selected to take part in an Art Therapy group in order to assess their position in the natural grieving process. The group was well attended, enjoyed and valued by the children. One child engaged in the art making process joyfully but usually found that he tackled large scale projects, finding them hard to finish. It became a recurring realisation for him that difficult things take a very long time and can be hard work. This child was able to use the group as support in tackling difficult projects and to feel okay about the ones which were unachievable in the timeframe. He worked with size and scale, many of his images contained a protecting, all seeing presence which was much bigger than him self and was watching over him. He put himself in the role of the super-hero as rescuer and as the magician, playing with the mystery of things disappearing and there being more to things than meets the eye, were also important themes. All this child s images contained strong symbolic meaning showing an engagement in a healthy process of thinking about, and coming to terms with loss. The child seemed well supported to think about his bereavement in helpful ways and showed a healthy willingness to talk to trusted peers and adults about it. In contrast, another child, who also enjoyed the sessions, did not engage strongly with the art materials or the therapeutic process. Some of his pictures contained symbolic meaning and were focused around destruction, conflict and fear, but did not embody expressed feeling. The child did talk to the TA in the sessions and conveyed angry concerning thoughts. Anger is a normal stage in the bereavement process, however this child seemed to be putting on a brave face and not accessing and expressing his feelings. The cut out heads he made which he then sealed into an envelope and said they were fighting inside, were perhaps symbolic of his thoughts (head) being cut off from his feelings (heart and body) and his anger being trapped inside. This child was referred for further work on an individual basis and a recommendation of a series of Drawing and Talking sessions was made, ideally with the TA he had built a relationship with in the group.