Assessment and Outcomes in the Arts Therapies

A Person-Centred Approach

Caroline Miller

• Publisher: Jessica Kingsley Publishers
• Year: 2013
• ISBN:
  9780857007889
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

There is increasing pressure on therapists to provide details of structured assessments and to report therapy outcomes to funders, employers and co-workers. This edited volume provides a series of case studies, with varied client groups, giving arts therapists an accessible introduction to assessment and outcome measures that can be easily incorporated into their regular practice.

The book provides demonstrations, within a practice-based evidence framework, of how measures can be tailored to the individual client's needs. The case studies show assessment and outcome models for music therapy, art therapy and dramatherapy used with a range of client groups including people with intellectual disabilities, Autism Spectrum Disorders, Multiple Sclerosis and Parkinson's Disease and those suffering from depression, Post-Traumatic Stress Disorder or coping with bereavement.

Chapter 1

Overview

Caroline Miller

Key words: assessment, outcomes, person-centred, practice-based evidence, standardized, individually designed, arts therapies specific assessments

This chapter looks at some of the rationale for assessment and at a selection of assessment approaches. It ends with a summary of each of the chapters in which case studies are used to demonstrate a number of ways of approaching assessment.

When we make an initial assessment with a client, we need to consider our purpose in any particular situation. Assessments may be made according to a codified diagnostic system, such as the Diagnostic and Statistical Manual IV (DSM IV 1994), where clients are assessed to establish whether they meet criteria for disorders classified within that system. There may be standardized forms of assessment for these DSM diagnostic categories, for example, the Beck Depression Inventory (Beck, Steer and Brown 1996), or for specific problems, such as self-esteem, which can be assessed using the Rosenberg Self Esteem Scale (Rosenberg 1965). The focus of an assessment might be to establish the client’s suitability to benefit from particular therapy approaches, for example, cognitive behavioral therapy (CBT), art therapy, dramatherapy, or to use particular arts therapy assessment measures to help determine which treatment models to use within a particular modality (Corcos 2002; Dent-Brown 2004; Feder 1998; Forrester 2000; Gilroy, Tipple, and Brown 2012; Jennings 2011; Landy et al. 2003; Pendzik 2003; Johnson 1980; Johnson, Pendzik and Snow 2012; Rubenstein 2006; Snow and D’Amico 2009). Assessment may be conducted in order to document change or to demonstrate therapy effectiveness. Assessment may take place in an initial session or over a series of sessions; in either case, most therapists carry out some kind of ongoing review of the therapy and where it might go next. We may be assessing for dual or multiple purposes. Blackman (2000) writes of a dual process of assessment occurring throughout her work with clients with grief issues, which involves ‘observation and monitoring of the client’s process of grief and their progression within this’ and ‘assessment of the client’s ability to use the various mediums and tools of dramatherapy and the development of this ability’ (p.20).

For arts therapists, it might be that an arts therapy assessment is part of a range of assessments offered by a multidisciplinary team to help with a decision about which member of the team will undertake which element of therapy, and with a view to all approaches fitting together for the benefit of the client. The setting might determine the need for assessment or for the type of assessment. For example, an agency may offer an overarching goal of assisting clients in working towards independent living. A team of therapists may then help each client assess their own needs in meeting such a goal. This could be different from an assessment requested by parents who are willing to pay for an individual child with autism to explore relationship, and communication, with an arts therapist, in a very open-ended way. So assessments can be defined by therapeutic approaches and the training of the therapist, by agency protocols, by clients’ stated goals or self-defined problems, or by individuals other than the clients, such as teachers or parents/carers. Assessments may then be functional, situational, problem focused, diagnostic, or even multi-purpose.

In any of these situations, the basic reason for the assessment is to establish a baseline or a map of where the client is, in relation to a problem or situation, at a given point in time. Ideally the assessment then has some relation to, or bearing on, the treatment to follow, with the establishment of some agreed purpose and approach to be taken in this therapy. In turn this opens up the possibility to set up criteria, which will help structure the therapy and enable monitoring of process and progress. For example, in working with a group of children with autism the stated aims might be: to increase collaborative interaction, to improve positive self-image, and to increase direct verbal communication between group members. Further examination of these aims can lead to the identification of specific measurable and/or observable criteria around these aims. This process will be illustrated in the case studies that follow. Assessment could include information gathering around a set of criteria from a number of sources such as the child, the parents, the school, or other agencies. With an adult, a significant other or staff in a care setting might be included. Therapist observation in the assessment interview or process would occur in each case. There may be a re-assessment against the selected criteria part way through the therapy, and the therapist would check for change against the same criteria at the end of the treatment. In this way the assessment process and the criteria established as a result of this, form the outcome measures to be used with this client.

Assessment is part of the initial therapy process, and may take place over several sessions or at particular intervals during the course of therapy. The need for ongoing assessment during the course of therapy is described by Valente and Fontana (1997): ‘during the dramatherapy process, the monitoring of client progress provides the therapist with the feedback needed if the therapeutic process is to remain sensitive to the client’s current needs’ (p.23). Assessment at the end of therapy allows therapist and client to see the progress and changes that have been made.

We would argue that therapists already engage in these processes with clients, but that often this is an informal and internal process carried out by the arts therapist, which may lack, or appear to lack, clear clinical direction, and which may limit communication with the client and with other professional people involved. To be able to provide a structure and rationale to this process should increase confidence for the therapist and the client in each of these situations. For example, an art therapist reflected on her work with a child and wondered whether she needed to use an established measure for child depression. She was concerned about communicating with her colleagues in a way that honored the art therapy process with her client, and she was also concerned about using the word depression as a loose and undefined label in the absence of clear checking against the DSM criteria for depression. In her reflection she clarified that the therapeutic work needed to focus on issues of empowerment and emotional expression; she also indicated an awareness of safety matters as she had already asked the mother of the child to be alert to any changes or deterioration in the child’s mood or behavior, and asked the mother to contact her if these were observed. The therapist had established these ideas in five sessions with the child, without using formal approaches. She had engaged the child in art therapy and sandplay therapy, which the child enjoyed, and which led to the development of a good therapeutic alliance and good degree of trust. Reports from the mother indicated that the child had become withdrawn and emotionally inexpressive at home and in school. In the therapy sessions the child began to reveal feelings of guilt, anxiety, hopelessness, powerlessness, and sadness, and that she had many worries. She told the therapist that she cried a lot and that she had difficulty sleeping. Matching her phenomenological account to the DSM criteria for depression, it was clear that she met criteria for depression and that the therapist had been coming to this conclusion through the therapy process as it unfolded. Referring to the DSM then, as well as art therapy, the therapist found a way to communicate clearly to her colleagues in a multidisciplinary team, her concerns about the child and the rationale for these concerns. The therapist then had clarity to express what guided her work with this child and criteria against which to measure progress, which were specific for this child, whether or not a DSM diagnosis was made.

This example illustrates the dilemma outlined by Hyland Moon (2002) about the language we use to speak about our clients and their work.

Our ability to use a form of communication intrinsic to the practice of art therapy requires that we be, to some degree, multilingual. In addition to the requirement that we have skills in both verbal and non-verbal communications, we must also know how to speak in other languages, often straddling seemingly contradictory terminology and value systems. (p.242)

DIFFERENT KINDS OF ASSESSMENT APPROACHES

Individually designed outcome measures

The example above gives a framework for setting up suitable criteria for individual clients. Criteria for assessment and for measuring outcomes can be developed directly from the phenomenology of the client. In most of the following case studies, criteria are designed around each client’s needs and the work they will do with the therapist to meet these needs. In some cases, appropriate existing measures have been used. Outlining problem areas, discussing therapy goals, and matching these to ongoing assessment criteria in collaboration with the client can help to strengthen the therapeutic relationship and the working alliance. Some therapists may create an assessment approach that provides a framework for them to adapt to different clients and different needs. Chapters 9, 11, and 13 illustrate the use of an open art interview, which is adapted to assess a child with autism, a child subjected to domestic violence, and individual children taking part in group therapy. The improvisational music therapy assessment, in Chapter 12 is another example.

Arts therapies assessments

A number of specific arts therapies assessments are now available and some of these are described here. In general there has been a shift with standardized assessments, and with specific arts therapies assessments, towards honoring and utilizing a more subjective approach in terms of capturing the experience of the client and working with this, rather than relying on therapist interpretation.

Dramatherapy: six keys of assessment in dramatherapy

Pendzik (2003) gives an overview of assessments in dramatherapy and describes her own six keys for assessment in dramatherapy. The six keys are:

1.The passage between ordinary reality and dramatic reality

2.The quality and style of dramatic reality

3.The characters and roles that populate it

4.The plot, themes, conflicts, and other contents

5.The response to dramatic reality from the outside

6.Metareality – or the unmanifested subtext.

(Pendzik 2012)

Pendzik (2012) describes the first five as being:

…associated with dramatic reality and its relation to ordinary life; the sixth key provides the space for a dimension that is usually subconscious and hidden…the first two refer more specifically to topics connected to form; the second two…deal mainly with…content-related material. (p.199)

In this approach to assessment Penzdik has isolated a key component in dramatherapy, which is dramatic reality. The model requires a clear need for therapist observation and interpretation within the terms defined by the therapist. Pendzik uses the six keys, in part, to identify the main area for focus in the therapeutic work, with the six keys providing the categories for assessment. She suggests that the model is useful for individuals or groups, and that it allows the description of the work in dramatherapy terms.

The Play and Story Attachment Assessment (PASAA)

The PASAA ‘involves observation, information gathering, discursive questionnaires and story sharing’ (Jennings 2011). The PASAA mainly focuses on attachment-based Neuro-Dramatic-Play ‘in order to determine attachment needs that could be addressed through dramatherapy or play therapy’ (p.45). Jennings has developed this from her Embodiment, Projection, Role model, which she has used extensively since 1990. The PASAA model focuses on detailed information from pre-birth, through the birth and early stages of life, and is closely linked to therapy that matches each developmental stage. Jennings states:

The PASAA assessment comes in three parts: part (1) events and information remembered by the participants, parents, friends and relatives; part (2) responses to sensory, musical and play materials (sensory, rhythmic and dramatic p...

Table of contents

• Cover
• Of Related Interest
• Title
• Copyright
• Contents
• Tables and Figures
• Acknowledgements
• Introduction by Caroline Miller
• Chapter 1 Overview by Caroline Miller
• Part 1 Working with Adults
• Part 2 Working with Children
• Conclusion by Caroline Miller
• Contributors
• Bibliography