Short-term art therapy with seriously emotionally disturbed adolescents

The Arts in Psyc~#?herup~l, Vol. 17, pp. 139-146. Q Pergamon Press plc, 1990. Printed in the U.S.A.

SHORT-TERM

ART THERAPY DISTURBED

TERRY J. TIBBETTS,

WITH SERIOUSLY

0197-4556190$3.00 + .oo

EMOTIONALLY

ADOLESCENTS

PhD, ATR and BETH STONE,

MA, ATR*

allowed special education monies to be utilized for “related” educational services, including psychotherapeutic and other suppo~ive counseling services. Although many local educational agencies (LEAS) allocated such monies for a wide range of therapeutic interventions with SED students within the educational setting (Berkovitz & Seliger, 1985), these efforts encountered multiple difficulties. One was the lack of empirical data demonstrating the effectiveness of such services to SED children (Schwartz & Johnson, 1985). Another problem was the long time often needed for positive results to be seen. More importantly, however, LEAS soon found that the cost of providing these services over a long period was prohibitive. Their response was to limit the amount and frequency of therapeutic services available to SED students. As a result, a continued need exists for a short-term therapeutic intervention that can demonstrate empirical and clinical effectiveness with the SED population. Art therapy within a school setting is one short-term intervention suggested as effective with SED students (American Art Therapy Association, 1985). This method is based upon a growing body of research literature indicating that the use of art therapy, even on a short-term basis, can result in significant clinical change (Williams, 1976). Unlike many other therapies, art therapy is an integrative approach utilizing cognitive, motor, and sensory experiences on both a conscious and

Public Law 94-142 (Education for All Handicapped Children Act) was passed in 1975. This landmark Federal legislation guaranteed all children a “free and appropriate education” regardless of individual handicapping condition. One such condition was identified as “‘serious emotional disturbance,” and defined a child who met any of the following conditions as seriously emotionally disturbed (SED): 1. an inability to learn that cannot be explained by intellectual, sensory, or other health factors; 2. an inability to build or maintain satisfactory interpersonal relationships with peers and teachers; 3. inappropriate types of behavior or feelings under normal circumstances; 4. a general pervasive mood of unhappiness or depression; 5. a tendency to develop physical symptoms or fears associated with personal or school problems. Additionally, any of these conditions, in order to qualify a child as SED, had to be exhibited over a long period of time, to a marked degree, and adversely affect the educational performance of the child (Tibbetts, Pike & Welch, 1986). Because it was recognized that many SED students would require psychotherapeutic and other supportive services in order to benefit from educational instruction, PL 94 142 specifically

*Terry Tibbetts is a clinical child psychologist and Beth Stone is an art therapist consultant at the State of California Department of Education Diagnostic Center-Southern California in Los Angeles. 139

140

TIBBETTS

preconscious level (Stone, 1979). Because it initially appears less threatening to the client, art therapy can increase verbal interaction and therapeutic involvement within a shorter period than more traditional therapeutic approaches (Williams, 1976). Art therapy also appears to increase self-esteem by facilitating self-awareness and overcoming feelings of inhibition in the client (Stone, 1982). Naumburg (1966) emphasized the value of art therapy in strengthening individual autonomy and the ego. The use of short-term art therapy with seriously emotionally disturbed children also appears promising. White and Richard (1971) reported that an eight-week “art counseling” group for pre-adolescent boys was highly effective in building self-image, with these improved gains remaining over a 16month follow-up period. Wolf (1973) reported the use of art therapy on a short-term basis to be highly effective in the treatment of a child exibiting emotional problems, and Virshup (1975), in a IOweek art therapy group with pre-adolescent boys in a residential setting, found significant reductions in hyperactivity and aggression. Similar evidence exists to suggest that short-term art therapy can reduce the severity of trauma and other loss in children (Eth, Arroyo & Silverstein, 1985; Landgarten, Junge, Tasem & Watson, 1978). Although short-term art therapy appears to be a valid approach to therapeutic intervention with SED students, most literature has focused on its use with latency-age and pre-adolescent students. There has been little research to suggest that emotional and behavioral changes can be obtained in the adolescent population. Accordingly, it was the purpose of the current study to provide short-term art therapy to SED adolescents in a public educational setting in order to determine what emotional and behavioral changes would result. Method

The subjects utilized in the study were randomly selected from a population of 130 adolescents enrolled in a Los Angeles County Office of Education Special Class Alternative (SCA) setting. Each subject had been previously evaluated

AND

STONE

by a multidisciplinary Individual Program (IEP) team, consisting of educational professionals and each subject’s parents, that found each child to meet state and Federal guidelines for classification as seriously emotionally disturbed (SED). An extensive information package describing the purpose and procedures of the study was sent to the parents of each child, requesting their signed permission for their child to participate in the study. Only after written permission was obtained was the student allowed to participate. Twenty subjects were selected for the study and placed in two separate groups (experimental and control), with 10 subjects per group. The groups were matched for age, level of cognitive functioning (as measured by standardized tests of intelligence), and sex. The mean age for students in the experimental group was 146, with a mean intelligence standard score of 81.8. The mean age for students in the control group was 14-5, with a mean intelligence standard score of 86.7. Four subjects (two from each group) failed to complete the study for reasons that included expulsion, running away from home, and attempted suicide, leaving eight subjects in each group at the conclusion of the study. Instrumentation The Burks Behavior Rating Scales (BBRS) and the Roberts Apperception Test (RATC), a standardized projective test of personality, were the instruments used. The RATC consists of a standard set of 27 stimulus cards depicting a variety of situations across home, school, and community environments, of which 16 cards, dependent upon sex of the subject, are administered. A standardized format is used to score the responses of the subject across 11 adaptive and clinical scales measuring social and emotional functioning. The BBRS is completed by each student’s teacher, who is asked to rate the subject’s frequency of specified behaviors on a scale of one through five. These ratings are added up and used to determine the significance of the student’s behaviors across 19 areas of behavioral and emotional functioning.

Subjects

in both groups

were administered

the

SHORT-TERM RATC immediately prior to the implementation of the study. The RATC was administered by a counselor from another school district who was skilled in projective testing and was unfamiliar with the purpose of the study. 1 Concurrently, each subject’s teacher was requested to complete the BBRS for that subject. One group was then randomly designated as the experimental group and the other group was designated as the control group. The experimental group was provided with weekly therapeutic services by a professional art therapist. The subjects were seen on an individual basis and the sessions lasted 45 minutes. The control group was provided with weekly socialization sessions by the same professional, with individual sessions lasting 45 minutes. The subjects in the control group did not receive any therapeutic intervention from the professional, and interaction with the professional was limited to topics and interaction not related to social-emotional status. Typical activities during these sessions included playing board games, talking about weekend activities, and taking walks around the school grounds. The art therapy approach utilized in the present study was consistent with the principles of gestalt therapy (Perls, 1969/1978; Rhyne, 1987). The central focus of the art therapist was to assist the subjects in the experimental group to increase in the present their sense of personal power and responsibility by becoming aware of how they blocked their feelings and experiences, particularly anger (Corey, 1982). The approach was non-interpretive, with the participants creating their own direct statements and finding their own meanings in the individual artwork that they created. All subjects in both groups continued to receive their previously established weekly sessions with school psychologists assigned to the SCA program in addition to the services received through this study. All subjects were provided with weekly individual sessions for six weeks, for a total of six sessions per subject. At the end of that time, subjects in both groups were again administered the RATC. Concurrently, each subject’s teacher was

IThe authors

thank

Janice

Nishiyama

for her assistance

ART THERAPY again requested subject.

141

to complete

the BBRS for that

Results Analysis of data through the use of paired t-tests was undertaken for each relevant category of both the RATC and BBRS scales to determine whether there were significant differences (p<.O5) between pre- and post-test scores for either the control or experimental groups (within-group differences). Similar analysis of data using paired t-tests was utilized to determine possible significant differences between pre- and post-test difference scores in the control and experimental group (across-group differences). In order to ensure that across-group differences were due to changes over the course of intervention, rather than pre-intervention test score differences between groups, pre-test scores of the control and experimental groups were compared using unpaired t-tests for each RATC and BBRS category utilized in the study. The results of this statistical analysis indicated no significant pre-test score differences between the control and experimental group on the BBRS and only one significant pre-test score difference between the two groups on the RATC. The results of data analysis are discussed below for each of the two scales utilized in the study. BBRS

differences As noted above, within-group were calculated by means of paired t-tests for each BBRS category utilized. Across-group differences were calculated in the same manner. No significant across-group differences were found in any BBRS category. Two significant within-group differences were found for the experimental group, but no within-group differences were found for the control group. The within-group differences and the mean pre- and post-test scores by group for each BBRS category are noted in Table 1. The experimental group demonstrated statistically significant improvement in Attention Span and Sense of Identity.

in this phase

of the study

TIBBETTS

AND STONE

Table 1 Burks’

RATC

Behavior

Rating

Scales Experimental Group Mean Test Scores

Category Excessive self-blame Excessive anxiety Excessive withdrawal Excessive dependency Poor ego strength Poor intellectuality Poor academics Poor attention Poor impulse control Poor reality contact Poor sense of identity Excessive sense of suffering Poor anger control Excessive persecution Excessive aggressiveness Excessive resistance Poor social conformity

Changes in emotional status were detined as measured changes in the pre- and post-test scores obtained on the RATC. Within-group differences for each RATC category utilized were calculated by means of paired t-tests for each category. Across-group differences were calculated in the same manner. The results indicated statistically significant across-group and within-group differences for several RATC categories. These differences and the mean preand post-test scores by group for each RATC category are noted in Table 2. The experimental group demonstrated significant score reductions in Reliance Upon Others, degree of perceived support available from others in the environment (Support/Other), and their positive expressed feelings about themselves (Support/Child). At the same time, significant reductions were also found in levels of Depression, Rejection and Anxiety. The control group demonstrated no within-group differences, although its direction of post-test change tended to reflect the findings obtained for the experimental group. Across-group differences were found for two variables. The experimental group demonstrated

Control Group Mean Test Scores

Pre

Post

Pre

Post

14.63 14.63 16.38 17.25 22.50 21.00 15.38 17.00 15.75 19.50 12.63 17.63

12.50 14.00 14.75 16.50 20.25 18.63 16.25 14.88* 15.63 17.75 10.38* 18.75

11.63 11.00 18.38 14.50 2 I .75 20.75 15.88 17.88 15.75 14.75 15.13 19.99

10.50 10.00 15.88 13.88 20.75 19.25 16.88 16.25 16.13 13.88 13.00 16.75

18.38 15.75 19.50 17.25 19.99

19.13 15.25 19.13 17.25 18.38

16.13 14.38 17.63 17.25 22.63

14.38 13.38 14.63 14.75 20.50

*p<.o5.

Table Roberts

2 Apperception

Test for Children Experimental Group Mean Test Scores

Control Group Mean Test Scores

Category

Pre

Post

Pre

Post

Reliance upon others Support/other Support/child Limit setting Problem identification Problem resolution I Problem resolution II Unresolved Aggression Depression Rejection Anxiety (1)

1.75 4.25 1.13 2.00 13.00 3.13 2.63 7.50 7.50 3.50 2.88 7.38

1.oo* 2.88* 0.13* 2.50 13.88 2.50 3.00 8.50 6.13 1.25** 2.00* 5.00*

2.13 3.88 1.13 2.50 12.63 3.63 2.88 6.13 6.75 3.00 1.75 5.88

1.63 3.88 0.75 1.88 13.13 3.75 1.88 7.13 7.50 2.63 1.88 5.75

*p<.o5. **p<.o1. (1) No across-group analysis of data was undertaken groups were found to be significantly different.

in this category

because

the pre-test

Across-Group Significance of Differences

.05

.Ol

scores

across

the two

SHORT-TERM significantly greater reduction in its degree of perceived support available from others in the environment (Support/Child) as well as a significantly greater reduction in level of Depression. Discussion Both the control and experimental groups demonstrated overall positive changes across almost all measured categories of behavioral and emotional functioning. Such a finding appears highly reflective of the needs for validation and support that seriously emotionally disturbed adolescents experience and strongly supports research findings that emphasize the primary role of the therapist as listening, accepting, and validating (Carkhuff, 1969; Rogers, 1951). Although several significant RATC emotional category score changes were found, a relative lack of significant behavioral changes were found across BBRS categories. Whereas it is possible that some of the significant RATC category score changes were due to mood lability on the part of the subjects, or state versus trait changes over time (Lanyon & Goodstein, 1982), this would not account for the fact that many other RATC category score changes were found to be nonsignificant. A more likely explanation is that, for this SED adolescent population, changes in emotional functioning appear to precede changes in overt behavior. The tendency toward positive behavioral and emotional change exhibited by both groups on many of the BBRS and RATC categories suggests that the possibility of obtaining significant group differences would be minimal. That such differences were indeed found is striking evidence of the powerful impact that the use of art had upon these subjects, many of whom demonstrated major expressive language deficits, were withdrawn, and/or noncommunicative. A further review of the data suggests several specific hypotheses regarding SED adolescents and the use of short-term art therapy with this population.

BBRS No significant across-group differences were found for any BBRS category utilized. Similarly, no within-group differences were found for the control group. Positive changes were found

ART THERAPY

143

within the experimental group for two categories: Attention and Sense of Identity. The positive experimental group improvement in the Attention category suggests that the use of short-term art therapy with SED adolescents may be of value in attempting to differentiate attentional deficit disorders (ADD) from masked depression (Lesse, 1979). In the latter syndrome, many adolescents who are relatively nonverbal may exhibit their depression in the form of impulsive, distractible, and hyperactive behaviors, resulting in poor attention to task. It would be expected that therapeutic interventions of any length or modality would have little effect upon the behaviors of ADD adolescents inasmuch as neurological immaturity and other biogenic factors are considered to be the primary factors involved in such disorders. However, if the behaviors of the adolescent were symptomatic of a depressive syndrome rather than a neurologicallybased attention deficit disorder, the use of art therapy could reduce the intensity of the depression and its masking behaviors. This would result in an increased capacity for attention to task. Further support for this view is the significant decrease found in the experimental group RATC Depression category score. For those subjects receiving short-term art therapy, attention to task increased while intensity of depression decreased. The BBRS findings also suggest that the use of short-term art therapy with SED adolescents may strengthen a sense of identity to a degree significant enough to be objectively verified through overt behaviors within the educational setting. The role of art therapy in increasing an individual sense of self has been well-documented elsewhere (Landgarten, 1981; McNiff, 1981), and the current data provide further verification of such findings.

RATC No significant within-group differences were found for the control group. Significant withingroup differences for the experimental group were found in three of the eight adaptive behavior categories and three of the four clinical categories. Significant across-group differences were found for two categories: Support/Child and Depression.

TIBBETTS Adaptive behavior categories. Experimental group subjects demonstrated a significant decrease in Reliance Upon Others, suggesting an increased ability to attempt the resolution of problems or difficulties through individual efforts rather than dependence upon others. This emergence of self-reliance appears consistent with the measured increase in Sense of Identity found in the BBRS. A significant decrease in supportive behavior toward others (Support/Other) by experimental group subjects appears similarly linked to issues of identity. Sprinthall and Collins (1984), among others, have commented on the decreasing willingness of adolescents to expend psychological energy on others as they proceed through the developmental task of determining their own identity. The experimental group also demonstrated a significant decrease in the category of Support/Child, responses characterized by positive emotions and expressed pride in self (McArthur & Roberts, 1982). Reduced scores in this category would initially appear contradictory to a hypothesis of increased self-reliance and sense of identity. However, such a contradiction appears related more to the way in which this category is defined by the test. As has been noted elsewhere (Stone, 1979; Wadeson, 1980), art therapy is a highly effective method of bringing unconscious conflicts to conscious awareness within a short period of time. Naumburg (1966) and others have pointed out that art therapy provides a direct channeling of unconscious dynamics into a permanent product that can be neither denied nor disowned. Subjects in the experimental group were thus forced to recognize and to confront emotional issues that had historically been handled through deand other defensive mechnial, projection, anisms. The art therapy process increased the subjects’ awareness of their own emotional conflicts and simultaneously reduced their ability to effectively utilize defensive responses. As a result, subjects developed a more realistic and less defensive-although less positive and selflaudatory-view of self and environment. This hypothesis is further strengthened by the fact that the Support/Child category was the only RATC adaptive behavior category found to have significant across-group differences. Clinical categories. The most significant

AND STONE within-group differences of the study were found for the experimental group in the Depression category (pc.01). By contrast, control group within-group differences in this category were minimal. Depression was also the only RATC clinical category in which a significant acrossgroup difference was found (p< .Ol). These results give clear evidence of the impact of shortterm art therapy with SED adolescents presenting with depressive symptomatology, and suggest that individual short-term art therapy may be the therapeutic intervention of choice with such a population. As previously noted, the decrease in the RATC Depression category for the experimental group was matched by a similar increase in its BBRS Attention category score, whereas control group BBRS and RATC scores in these categories were non-significant. These findings strongly suggest that the use of short-term art therapy with SED adolescents may be of major benefit not only in reducing the severity of depressive disorders but also in differentiating attentional deficit disorders from depression masked by behaviors similar to attentional deficits. Rejection was another category in which within-group improvement was found for the experimental group, indicating that short-term art therapy may be an effective means of reducing the severity of such feelings in SED adolescents. It can be hypothesized that these results may be related to the increase in subjects’ sense of identity and awareness of emotional conflicts, thus reducing the necessity for such material to be disowned and rejected by the self. By contrast, the control group experienced a slight increase in its post-intervention Rejection category score. Significant within-group differences were also found for the experimental group in the Anxiety category, indicating that the use of short-term art therapy was effective in reducing anxiety. Control group within-group differences were minimal. However, it should be noted that it was not possible to evaluate across-group differences for this RATC category due to the fact that preintervention category test scores between the control and experimental groups were found to be significant. Thus, any across-group differences found would not have been necessarily attributable to the art therapy intervention. At the same time, an examination of group mean differences in the Anxiety category indi-

SHORT-TERM cates that the experimental group did demonstrate a much greater reduction in anxiety than the control group. This is, accordingly, an area in which replication or further research would appear highly desirable.

Conclusions Overall, the results of this study indicate that individual short-term art therapy with SED adolescents can have significant impact upon their emotional growth and development, and thus provide educators with an effective means of therapeutic intervention within the school setting. More specifically, the results suggest that such an intervention is effective in increasing a sense of identity in SED adolescents and in assisting them to become more aware of and realistic toward their views of themselves and their environment. The use of individual short-term art therapy appears most effective with those SED adolescents who present with depression as a central feature of their emotional disturbance, and also appears highly useful in reducing the severity of feelings of anxiety and rejection. Less utility is shown, however, for the effectiveness of art therapy, at least on a short-term basis, in having a significant impact in the reduction of overt negative behaviors. The results of this study would also support a hypothesis that significant reductions in negative behaviors by SED adolescents occur subsequent to improvement in emotional functioning. Such a hypothesis would further explain why the use of art therapy in this study was less effective in reducing RATC Aggression scores than any other of the RATC clinical category scores. Aggression, more than any other clinical category, is quasi-behavioral in nature and directly reflects specific behavioral patterns. In attempting to draw conclusions from the data obtained in this study, two cautions need to be stated. The first is that, although the sample size represents one of the larger samples ever utilized for a study investigating the effectiveness of art therapy, it is still relatively small by statistical standards. The findings of the current data, therefore, may be overly susceptible to individualized subject score variations and should not be generalized beyond the specific population utilized in this study. It is hoped that other re-

145

ART THERAPY

search utilizing a larger sample will follow up on the issues raised. A second caution involves the definition of the population used. The psychoeducational definition of SED is mandated by Federal law. However, this definition provides for an extremely wide range of symptomatology ranging from school phobia to schizophrenia. It is thus impossible to state that the total subject pool used for this study was homogeneous or that the subjects’ pathology was more similar than dissimilar. Accordingly, it is hoped that any further research in this area will attempt to provide as homogeneous a SED adolescent sample as possible. The present study has presented evidence strongly suggesting that the use of individual short-term art therapy is an effective method of intervention with SED adolescents, particularly those who present with symptoms of depression, anxiety, and rejection. Analysis of data further suggests that the effectiveness of short-term art therapy with this population appears primarily related to its ability to assist in confronting such adolescents with identity concerns and issues of self, thus reducing defensiveness and other psychological defense mechanisms, and providing a safe environment within which these issues can be therapeutically addressed to reduce the severity of emotional dysfunctioning. References American Art Therapy Association. (1985). Art therapy in the schools: A position paper of the American Art Therapy_ _ Association: Art The&y, 2, 19-21. Berkovitz. I. H.. & Seliaer. J. S. (1985). Exoandine mental he&h interventions ii schools (Vol.’ 1). Dubuque, Iowa: Kendall/Hunt. Carkhuff, R. R. (1969). Helping and human relations: Practice and research. New York: Holt, Rinehart & Winston. Corey, G. (1982). Theory and practice of counseling and psychotherapy. Monterey, CA: Brooks/Cole. Eth, S., Arroyo, W., & Silverstein, S. (1985). A psychiatric crisis team response to violence in elementary schools. In I. H. Berkovitz & J. S. Seliger (Eds.), Expanding mental health interventions in schools (Vol. 1). Dubuque, Iowa: Kendall/Hunt. Landgarten, H. (1981). Clinical art therapy: A comprehensive guide. New York: Brunner/Mazel. Landgarten, H., Junge, M., Tasem, M., & Watson, M. (1978). Art therapy as a modality for crisis intervention: Children express reactions to violence in their community. Clinical Social Work Journal, 6(3), 221-229. Lanyon, R. I., & Goodstein, L. D. (1982). Personality assessment. New York: J. Wiley.

146

TIBBETTS

Lesse, S. (1979). Behavioral problems masking severe depression-Cultural and clinical survey. Americ,an Journal of Psychotherapy. 33, 4&53. McArthur, D. S., & Roberts, G. E. (1982). Roberts Apprrception Trystfor Children Manrcal. Los Angeles: Western Psychological Services. McNiff, S. (1981). The arts and p.sychothrrupy. Springfield, II: Charles C Thomas. Naumburg, M. (1958). Art therapy: Its scope and function. In E. F. Hammer (Ed.), The clinical app/ic,afion c;f’projrcri~~c dral+?ngs. Springfield, II: Charles C Thomas. Naumburg, M. (1966). Dynamically orirnted urt therapy: Its principles and pracricr. New York: Grune & Stratton. Perls. F. S. (1978). Grsfalf therupy ~vrhatim. Lafayette, CA: Real People Press. (Original work 1969) Rhyne, J. (1987). Gestalt art therapy. In J. A. Rubin (Ed.). Appronchrs to urt therapy: Throry and tcchniquc,. New York: Brunner/Mazel. Rogers, C. R. (1951). C/ie,lf-c.c,,7/erc,tl rhcrtlpy. Boston: Houghton Mifflin. Schwartz. S., & Johnson, J. H. (1985). Ps?c.hr,pNrllc)/~‘R?. of c,hi/dhood: A c,/inic,crl-c,xpc,rimrrlral approccc,h (2nd ed.). New York: Pergamon Press.

AND

STONE

Sprinthall, N. A., & Collins, W. A. (1984). Adolescc~rrt psyPark, CA: chology: A developmentul vic>M.. Menlo Addison-Wesley. Stone, B. (1979). Art and psychotherapy: Many advantages and a few cautions. Counsciors Association ofNc+i, South Wale.? Nra,slcttc~r. 5( 1). Stone. B. (1982). Group art therapy with mothers of autistic children. The Arfs in PsychothrJrapy. Y. 31-48. Tibbetts, T. J., Pike, T. R., & Welch, N. (1986). Idrntijicatiotz and trssc.ssmc,nf of the sc,riou.sly emotional~.v disrurhrd c,hi/d. Sacramento, CA: State Department of Education. Virshup, E. (1975). Latency group art therapy: Teaching socialization skills through art. Child Welfare. 54, 624644. Wadeson, H. (1980). Art psychotherapy. New York: Wiley. White, K., & Richard, A. (1971). Art counseling in an educational setting: Self-concept change among pre-adolescent bovs. Jounrul of Sc,hool PsvchoioPv. Y. 21%225. Williams, S. (1976). Short-term art therapy. Amrric,rm Journcrl of‘ Art Thclrapy. IS, 35-41. Wolf, R. (1973). Art therapy in the elementary school setting. Amrric,on Jorrrncrl c!f’Art Therapy. I, l-20.