Data on Art Therapy for Students Who Have Experienced Trauma
PLoS One. 2019; 14(two): e0210857.
Creative arts in psychotherapy for traumatized children in Southward Africa: An evaluation study
Nadine van Westrhenen
1 Department of Clinical Psychology, Utrecht University, Utrecht, Kingdom of the netherlands
2 Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
Elzette Fritz
3 Department of Educational Psychology, University of Johannesburg, Johannesburg, South Africa
Adri Vermeer
4 Department of Education and Pedagogics, Utrecht University, Utrecht, The Netherlands
Paul Boelen
1 Department of Clinical Psychology, Utrecht University, Utrecht, The netherlands
5 Arq Psychotrauma Expert Group, Diemen, Holland
Rolf Kleber
one Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
5 Arq Psychotrauma Expert Group, Diemen, Holland
Linda Chao, Editor
Received 2018 February ten; Accepted 2019 Jan three.
- Supplementary Materials
-
S1 File: CBCL datafile.dat. (DAT)
GUID: DE4398D2-23ED-4FE0-9CAC-21A8D1FD9D95
S2 File: PTSD & PTG datafile.dat. (DAT)
GUID: B8053980-6F91-479C-947E-7897154A46E2
- Data Availability Statement
-
De-identified datasets are available in the supporting information files. Further information regarding the data are bachelor upon request from the authors (ln.evil@nenehrtsewnavenidan).
Abstruse
Aim
To evaluate the feasibility and result of a 10-session creative arts in psychotherapy grouping plan on posttraumatic stress symptoms, behavioural problems, and posttraumatic growth, in children who experienced a traumatic event.
Design
A multicentre non-randomized controlled trial with a treatment and a control status conducted in Southward Africa (iv sites).
Methods
125 children aged 7 to 13 years were assigned either to the handling condition receiving creative arts in psychotherapy or a control condition with a low-level supportive programme without treatment. Attrition rates were 63.4% and in total 47 children completed the plan and questionnaires assessing posttraumatic stress, posttraumatic growth and behaviour problems both at baseline and follow-upwards; 23 in the treatment group and 24 in the command group. Adjusted mean differences were analysed using ANCOVA with bootstrapping.
Results
Results showed that both hyperarousal symptoms (d = 0.61) and avoidance symptoms (d = 0.41) decreased more in the treatment group compared to the command group. At that place was no significant event of the intervention found for reported levels of behavioural issues and posttraumatic growth.
Conclusion
In spite of severe challenges implementing and executing this pioneering study in underprivileged areas of South Africa, support was found for creative arts in psychotherapy reducing hyperarousal and abstention symptoms, but non for other symptoms. Valuable lessons were learned on feasibility of implementing this intervention in a developing context.
Introduction
Trauma exposure
For a state not at war, Southward Africa is a identify with extreme high rates of traumatic exposure, with one of the highest rates of interpersonal violence and domestic abuse in the world [1]. Violence against children is especially pervasive, from severe beatings to sexual violence and rape [i]. Exposure has been reported as high as 98.nine% for customs violence [ii] and 54.two% for sexual abuse [3]. The high exposure to interpersonal violence increases vulnerability to mental disorders such as posttraumatic stress disorder (PTSD) [4,five]. High levels of PTSD take been reported among poor urban children in South Africa and prevalence estimations have been published of 22.ii% and 23.6% [five, six]. Apart from PTSD, children exposed to interpersonal violence are more likely to experience a wide range of adverse psychological bug, such equally depression, suicidality, and substance corruption [v,7] and externalizing behaviour problems such every bit violent and anti-social behaviour [8].
Apart from negative psychological consequences of abuse and neglect, positive alter may also event from traumatic exposure, called posttraumatic growth (PTG) [9]. PTG more often than not includes v domains; relating to others, personal force, appreciation of life, spiritual modify, and new possibilities [10]. PTG has mostly been studied in adults and there is a growing torso of literature describing the phenomenon of PTG in children and adolescents [xi, 12].
Kid trauma handling
Different types of interventions accept been proven to be effective for improving mental health in traumatized children. Particularly cognitive behaviour therapy (CBT) has emerged as ane of the most effective and widely used treatments [13, 14]. More prove, withal, is required in club to plant the effectiveness of different therapies in the longer term, and for comparability of different types of therapy, such as CBT, play therapy, eye movement desensitization and reprocessing (EMDR), art therapy, and psychodynamic therapy [13]. Moreover, since virtually studies take been conducted in loftier-income countries, evidence is required for the applicability of trauma interventions in a low- and middle-income context [15].
Creative arts therapy is a widespread approach in the handling of child post trauma disorders. It includes dissimilar modalities of art, music, trip the light fantastic toe and drama in combination with other approaches to psychotherapy and counselling [xvi], such as psychodynamic, cognitive, developmental, systems, and narrative therapy. The apply of fine art therapy practise varies and tin can exist described on a continuum [17], ranging from using arts as an adjunct in verbal psychotherapy to art engagement without verbal analysis, and several gradations in betwixt. Creative arts therapies used as a primary form of therapy requires graduate-level training in ane or more modalities. Artistic arts is also used past counsellors or other qualitied mental wellness professionals in facilitating different stages in psychotherapy [xviii]. When using artistic arts in this way as an adjunct, the key is to sympathise the various handling goals and to carefully select creative arts activities that tin can support this process [19]. Mental health professionals tin can be offered training in applying creative arts activities in psychotherapy, just at all times it is important to avoid challenging ethical boundaries by going beyond what someone was trained to do.
Research with children plant that the utilise of art can facilitate exposure to traumatic cues in a not-threatening manner, allowing for desensitization of anxiety, articulation of affective states [xx], and more detailed and emotional narratives [21]. Besides, arts-based methods can assist children in developing coping skills, self-awareness and aspects of self-esteem [22], with the artistic process providing a containing space in the human relationship with the therapist [23]. Facilitating (creative) therapies for traumatized children in a group setting tin have additional benefits, because group members can facilitate trust and disclosure, providing an opportunity for children to realize they are not lone in their problems, and finding peer-support [24, 25]. Creative arts activities can reinforce these grouping benefits by serving as a medium for communication, for instance dance/movement can assistance found a sense of connection and understanding betwixt people [26], and music provides a medium to communicate and build relations [27].
Although the possibilities of creative arts therapy appear promising, there is very little research bachelor on the efficacy of such therapies for children afterward trauma [28, 29]. Only a few studies have explored the effects of artistic therapy for children on successfully reducing posttraumatic stress symptoms [30, 31] and behavioural difficulties [32]. In the South African context, to our cognition, but ane group art therapy intervention for sexually abused girls from 8 to 11 years old has been evaluated [33]. This written report showed positive results regarding anxiety, depression and traumatic stress symptoms, only no event of the intervention was plant on levels of self-esteem. Autonomously from this written report, methodologically audio studies focusing on the effects of creative arts therapy on specific outcome measures are scarce [34].
Study purpose
The present written report aims to assess the possible influence of a creative arts in group psychotherapy programme for traumatized children in Due south Africa on posttraumatic stress symptoms, behaviour bug and PTG. We performed a not-randomized controlled trial comparing creative arts in psychotherapy with a low-level supportive programme including no art and/or psychotherapeutic interventions and hypothesized that a creative arts in psychotherapy programme (CAP) is more efficacious compared to the command condition in 1) reducing posttraumatic stress symptoms, ii) reducing behavioural problems, and 3) increasing PTG, in children who experienced i or more than traumatic events.
Methods
Design
This was a multicentre non-randomized controlled trial conducted in South Africa (4 sites) with two weather condition, and including three measurements at baseline and follow-upward.
Sampling
The study took place at four branches of a child corruption clinic in Johannesburg, South Africa, from Jan 2014 to June 2016. Children attending this clinic come from various communities (mostly townships and informal settlements) in and around Johannesburg, represent unlike racial groups (although primarily Black, also Coloured, Indian and White families nourish) and speaking different home languages (South Africa has 11 official languages).
125 participants were selected for this study from all children that came for intake at the trauma clinic, based on the following inclusion criteria: (1) experienced one or multiple events of trauma or abuse between three months and twelve months ago; (two) developmental age between vii and 13 years at the fourth dimension of enrolment; (three) tin can speak English in social club to communicate with all social workers and peers in therapy. Exclusion criteria were (1) mental retardation, autistic disorder, and blindness, (ii) already had any form of previous trauma handling. Selection for the different conditions was done non-random due to applied considerations relating to the limited availability of participants. 1 group of social workers who were trained in the CAP programme invited all children meeting inclusion criteria during their intake at the clinic to participate in the therapy (north = 74). Other social workers in the dispensary continued to refer children to treatment as usual, starting with a non-therapeutic courtroom grooming programme whilst pending availability for individual play therapy. All children attending this court preparation programme at the dispensary meeting inclusion criteria were besides invited to participate in the control condition (northward = 51).
Outcome measures
Posttraumatic stress symptoms
Posttraumatic stress symptoms were measured by the Child PTSD Checklist (C-PTSD-C) [35]. This self-study measure is a 28-item checklist that rates DSM-IV-TR characterized PTSD symptoms in the by month. The scale uses a iv-point Likert calibration, ranging from 'non at all' (scored 0) to 'all the time' (scored 3), with higher scores indicating more severe PTSD symptoms. The C-PTSD-C has three subscales: Hyperarousal, avoidance, and reexperiencing. Psychometric backdrop have been published in the South African context [36], and the musical instrument was plant to be a reliable and valid measure out of PTSD symptoms. Internal consistency for the scale in the current sample was good between α = .78 (baseline) and α = .90 (follow-upwardly).
Behaviour problems
Behaviour problems were reported past the parents or a close relative on the Child Behaviour Checklist (CBCL) [37]. This checklist consists of 120 items, assessing emotional and behavioural problems, rated on a 3-signal scale ranging from 'non true' (scored 0) to 'very true or often true' (scored 2). The CBCL has iii main scales, internalizing, externalizing and total problems, as well as eight sub-scales comprising specific behaviour domains. Research using the CBCL has demonstrated its sound reliability and validity beyond multiple cultural settings [38]. Internal consistency in the current sample was excellent (baseline α = .96, follow-up α = .96).
Posttraumatic growth
PTG was measured with the cocky-report Posttraumatic Growth Inventory for Children- Revised (PTGI-C-R) [10]. The musical instrument has 10 items using a four-point Likert scale ranging from no change (scored 0) to a lot (scored 3). Research findings demonstrate validity and reliability of the revised scale [10]. Previous studies measuring PTG in low-income settings, although rare, demonstrate positive results [39, 40]. Internal consistency for the full calibration in the electric current sample was found between α = .lxx (baseline) and α = .76 (follow-up).
Conditions
Treatment condition
Children in the treatment status attended the Creative Arts in Psychotherapy (CAP) intervention [41]. CAP was a structured program of x 90-minute sessions, specifically developed for traumatized children in the age between 8 and 12 years. The sessions were facilitated once a week in closed groups of six to eight participants by local social workers trained by creative arts therapists to deport arts-based activities in psychotherapeutic practice, and dissimilar multimodal activities incorporating visual fine art, motility, dance, drama, music, and storytelling were used to work towards specific session goals. The programme outline was based on the three phases of the treatment model for severely traumatized individuals [42]. The beginning three sessions focused on establishing safe, and activities included for instance having children mirror each other's dancing to increase connexion between grouping members [43] and reading and discussing a children's story of 'a terrible thing happened' [44]. Sessions four to six aimed to facilitate expression of emotions associated with the trauma story and practise emotion regulation by for example decorating masks to express and distinguish between feelings from the inside and what others see from the exterior. Lastly, the final four sessions focused on strengthening coping skills past for instance writing and socio-drama activities incorporating the hero's journey [45] and making music together using drums and other music instruments. Overall, the intervention aimed to ameliorate identification and communication of emotions, interpersonal skills and intrapersonal connectivity and resilience to cope with future crisis, increase PTG, and reduce posttraumatic stress symptoms.
Control condition
The control group did not nourish any therapy, only a so called 'court training and back up program'. This non-therapeutic programme focused on providing children and parents skills, emotional support and legal noesis in grooming for their appearance in court. This plan was part of the treatment equally usual in the clinic, later on which the children were offered the opportunity to nourish individual play therapy. The programme was facilitated by social workers during monthly iii-hour open up group sessions, where children could join equally long as necessary while the court example preparations were still ongoing. The children in this control status attended about 3 sessions (over a 2-month period) during the time this written report took place. The sessions were solely focused on the court process, and not on any psychosocial impact of the trauma on the customer's personal life.
Procedure
To find a alter in the dependent variables between the two conditions, with a ii-sided 5% significance level, medium event size and a power of fourscore%, a sample size of 64 per group was necessary [46]. Baseline questionnaires were administered on newspaper prior to the kickoff session of the CAP plan (treatment condition) and during the first monthly courtroom preparation session the kid was attending (control condition). Follow-up questionnaires were subsequently administered later the final session of the creative therapy programme, and during another courtroom preparation session on average 2 months after baseline measurements. In a number of instances there were reading challenges and the questionnaires were administered verbally, and individual appointments were arranged to administrate questionnaires if the parents and children were not available for the group sessions in which the questionnaires were administered. For those children who did non complete the full programme, post-measurement questionnaires were still administered, adhering to the intention-to-care for approach.
Ethical approval
Permission for this report was obtained from the Faculty of Humanities Academic Ethics Committee of the Academy of Johannesburg. Informed consent and informed assent was obtained from the children and their parents or primary caregiver prior to participation in this study. Participation was volunteer and confidential. Children in the control grouping were offered the option to attend therapy at the clinic afterward participating in the court preparation and support plan, and children participating in the CAP could also afterwards join the court preparation and support programme.
Information analysis
Analyses were conducted using IBM SPSS statistics 22. Missing data on item level were replaced using multiple imputation. The multiple imputations appeared similar and comparable, and therefore one imputation was selected to allow for subsequent analysis including bootstrapping. Baseline analyses were performed using bivariate analysis, exploring differences on treatment condition, gender, race, type of trauma and baseline measures of PTSD, PTG and behavioural problems. To explore the treatment effect, the mean divergence score between baseline and follow-upwards measurements was compared between the different test atmospheric condition (treatment vs command) using ANCOVA with ethnicity and blazon of corruption as covariates. Considering the minor sample and non-normal distribution of data, bootstrapping techniques were applied.
Results
Feasibility
From the 125 children initially referred to the programme, 62.4% dropped out in both the treatment and command condition. Of the four different branches, treatment groups of two branches had to exist terminated prematurely due to high dropout rates. I group was facilitated in a place of safety, and turnover rates of children in this place was very loftier. For the other co-operative, reasons for drib out were mostly related to accessibility. Parents reported traveling up to two hours from home to the clinic and struggled to afford the send costs or were not able to accept time off from work to bring the children [47]. The other two branches had relatively sufficient turnout over a 2-year menstruum. These branches were more centrally located within a specific community. For the command group, monthly turnout was inconsistent. Some parents and children would show up every month, merely nigh children merely attended once or twice, so disappeared off the radar.
Despite the challenges with attrition and inconsistent turnout, a total of 23 children completed the CAP programme. These children received an average of 5.52 (SD = 3.xx) sessions during a period of 10 weeks. This equals viii.28 hours of therapy. Half dozen children in the treatment group who received CAP but attended one or two sessions out of the prescribed x.
Participants flow
In total 125 children participated with baseline measurements in the study. Afterwards, social workers referred 74 participants to the treatment condition, and 51 participants to the control condition. For the handling condition, after participant dropout (north = 42) and exclusion of participants who attended the intervention simply did not consummate the post-measurements (due north = 9), a total of 23 participants were included for the analysis of the C-PTSD-C and the PTGI-C-R and a total of eighteen participants were included for the assay of the CBCL. The CBCL was completed past the parents and frequently the children travelled solitary or with a sibling to the clinic, making information technology difficult to get hold of the parents for completion of questionnaires. For the control condition, after dropout (n = 23) and exclusion of those who completed only one out of the three post-measurements (n = 4), analyses were conducted with a sample of 24 participants for the C-PTSD-C and the PTGI-C-R, and 19 participants for the CBCL. A summary of the participants' menstruum through the different projection stages is provided (Fig one).
Flow diagram of progress through the phases of the experimental trial of two groups.
The final sample of 47 participants for analysis of the C-PTSD-C and the PTGI-C-R consisted of 23 children in the handling group, 3 boys and 20 girls, aged between 7 and xiii (M = 10.14, SD = 1.92). The control grouping consisted of 24 children, eight boys and 16 girls, aged between 8 and xiii (M = 10.50, SD = one.32). The final sample of 37 participants for assay of the CBCL consisted of xviii children in the treatment group, 2 boys and sixteen girls, aged between 7 and 13 (M = 9.93, SD = i.94). The control group consisted of 19 children, half dozen boys and xiii girls, aged betwixt 8 and xiii (M = 10.thirty, SD = 1.38). The bulk of children in the study had experienced sexual abuse, five children experienced physical abuse (Table 1).
Table i
| Sample for PTSD & PTG | Sample for CBCL | |||
|---|---|---|---|---|
| Treatment (n = 23) | Control (due north = 24) | Treatment (n = 18) | Control (n = nineteen) | |
| Age (years) | x.14 (i.92) | 10.50 (1.32) | 9.93 (1.94) | 10.30 (i.38) |
| Gender (female) | 20 (87.0%) | 16 (66.7%) | 16 (88.9%) | xiii (68.4%) |
| Ethnicity: | ||||
| African | 22 (95.7%) | 16 (66.vii%) | 18 (100%) | 12 (63.ii%) |
| Asian | - | 2 (8.iii%) | - | 2 (ten.5%) |
| Coloured | one (4.3%) | ii (8.three%) | - | 1 (5.iii%) |
| White | - | iv (sixteen.7%) | - | 4 (21.1%) |
| Type of trauma: | ||||
| Sexual abuse | 23 (100%) | 17 (70.8%) | 18 (100%) | 14 (73.7%) |
| Physical abuse | - | 5 (20.8%) | - | 3 (15.8%) |
| Other | - | 2 (viii.3%) | - | 2 (10.v%) |
Baseline data
The treatment grouping (M = 26.78, SD = 11.48) and control group (M = 33.99, SD = 11.57) differed significantly on PTSD symptoms at baseline (t(45) = -2.143, p < .05). Fisher'south verbal test for the sample of 47 participants did bear witness that there were significantly more black children in the treatment grouping (95.7%) compared to the control grouping (66.7%; p < .05), and there were likewise more children that were sexually abused in the treatment grouping (100%) compared to the control group (70.8%; p < .01). As well for the sample of 37 participants, in that location were more black children in the treatment grouping (100%) compared to the control group (63.2%; p < .01), and more children had been sexually abused in the treatment group (100%) compared to the command group (73.7%, p < .05). Other variables tested did not differ significantly across conditions.
Evaluation of outcomes
Controlling for the issue of ethnicity and type of abuse in an ANCOVA, bootstrapped adjusted mean differences showed that hyperarousal symptoms significantly decreased in the treatment condition between baseline and follow-upward (from G = 10.39 to M = 6.77, d = 0.61), where it slightly increased for the command group (from Thou = six.73 to 1000 = 7.46, d = -0.fifteen; adjusted mean deviation = 4.36, 95% CI 0.36, 8.69). Moreover, avoidance symptoms decreased significantly more for the handling status (from M = 13.48 to Yard = xi.xiii, d = 0.41) compared to the control condition (from Chiliad = 11.05 to M = 10.99, d = 0.01; adapted mean difference = 4.eleven, 95% CI 0.03, 8.42), nonetheless the result size was pocket-sized. Overall PTSD symptoms, besides as reexperiencing symptoms also decreased in the treatment status, but not significantly more than in the command condition, meet Table 2.
Table ii
Summary results treatment and control grouping.
| Treatment | Control | Adjusted hateful difference** (95% CI) | |||
|---|---|---|---|---|---|
| Scale (range) | Baseline (mean (SD)) | Follow-upwardly (mean (SD)) | Baseline (mean (SD)) | Follow-upwards (mean (SD)) | |
| PTSD symptoms | n = 23 | n = 24 | |||
| Total (0–84) | 33.99 (11.57) | 27.06 (18.18)* | 26.78 (11.48) | 26.84 (12.68) | 9.40 (-0.xviii, 20.01) |
| Avoidance (0–xxx) | 13.48 (4.78) | xi.13 (6.63) | eleven.05 (5.xv) | 10.99 (four.54) | iv.11 (0.03, 8.42)*** |
| Reexperiencing (0–27) | ix.43 (5.25) | 8.64 (half-dozen.42) | eight.75 (3.96) | 7.83 (4.59) | 0.33 (-3.03, 3.60) |
| Hyperarousal (0–24) | ten.39 (4.96) | six.77 (6.72)* | 6.73 (iv.20) | 7.46 (5.26) | 4.36 (0.36, viii.69)*** |
| Behaviour problems | due north = 18 | n = xix | |||
| Total (0–240) | 62.91 (35.97) | 48.98 (33.66) | 71.35 (37.01) | 51.46 (28.12)* | -13.90 (-53.28, 20.88) |
| Internalizing (0–78) | xviii.81 (11.76) | 14.59 (11.14) | 21.08 (10.45) | 14.19 (vii.60)* | -5.80 (-16.65, 3.91) |
| Externalizing (0–70) | 16.68 (10.09) | xiv.05 (9.75) | 20.22 (13.45) | 16.xv (11.62) | -2.12 (-14.23, eight.20) |
| Posttraumatic growth | due north = 23 | n = 24 | |||
| Full (0–30) | 22.34 (v.29) | 23.99 (4.42) | 19.75 (5.25) | 23.44 (5.01)* | 1.63 (-2.70, half-dozen.08) |
Behaviour problems as well showed a decrease over time in both the treatment condition (from M = 62.91 to Yard = 48.98, d = 0.40) and the control condition (from M = 71.35 to M = 51.46, d = 0.61), and internalizing behaviour decreased more than externalising behaviour, simply these changes were not statistically significant when compared between weather condition. Lastly, PTG increased in both the treatment condition (from One thousand = 22.34 to Thousand = 23.99, d = 0.34) and the control status (from Grand = 19.75 to K = 23.44, d = 0.72), but in that location was no pregnant difference in this increment between conditions (Table 2 and Fig 2).
Posttraumatic stress symptoms, behaviour problems and posttraumatic growth scores of the treatment and command groups at baseline and follow-upwardly.
The scores are hateful full scores.
Discussion
Evaluation of the CAP program showed that compared to the control status, hyperarousal symptoms decreased significantly more than during CAP with a medium issue size for the pre-treatment to follow-up modify scores. Avoidance symptoms besides decreased more during CAP than in the command status, but the issue size was small. No support was found for our hypothesis that the CAP programme is more than efficacious than a low-level supportive programme in reducing reexperiencing symptoms, behaviour problems and increasing PTG.
In improver to these quantitative findings, the social workers were positive virtually the intervention. They observed the children moving from the point of existence victim to survivors, the children were smiling and interacting more than and demonstrating more conviction. The social workers noticed that the artistic activities provided the children a platform to express their emotions and show their talents and the children found empathy from their fellow group members and felt supported. Other positive feedback we received was that children were telling the states that they were sleeping better at present, and some parents told us that their children became more playful and showed less resistance at home.
Below we will discuss the outcomes of the intervention and lessons learned on feasibility by reflecting on barriers in recruitment and retentiveness and discussing methodological limitations.
Therapeutic outcomes
Previous studies highlighted the positive effects of creative arts therapy specifically on reducing psychological stress [48], having a soothing chapters [16, 49] and establishing a sense of safety [50]. This may in turn have facilitated decreased hyperarousal symptoms and helped regain or develop healthy emotion regulation after experiencing severe stress. The positive upshot of group therapy and activities facilitating emotional expression and working through the traumatic experience may have contributed to reduced avoidance symptoms.
The creative arts in psychotherapy programme (CAP) did non diminish reexperiencing PTSD symptoms, behaviour problems and PTG as successfully. Information technology could be that the therapeutic activities in the treatment protocol did not address all these different consequence measures as purposefully as intended, or maybe the creative arts activities facilitated by trained social workers were inferior to the delivery of creative arts therapy by trained and credentialed creative arts therapists. Mayhap, the lack of a direct trauma-exposure component in the treatment may also accept affected the outcomes. Currently, at that place is a debate whether straight facilitating re-exposure in therapy would be more benign [51]. On the 1 hand, information technology has been constitute that trauma-focused treatments prove higher outcome sizes compared to not-trauma-focused treatments [52], yet a recent meta-assay showed this difference is rather pocket-size and not clinically meaningful [53]. Moreover, exposure therapies are also associated with an early on and loftier dropout and patients having remaining symptoms [54, 55].
Moreover, non all these interventions have been shown to be effective in a context of ongoing arduousness such every bit chronic poverty, customs violence and state of war [15, 56, 57]. Therefore, some other explanation for our programme evaluation results may exist that the circumstances of ongoing adversity are impeding the potential therapeutic benefits of the intervention. We besides noticed that most trauma handling studies in a developing context take focused solely on PTSD and internalizing symptoms as event measures [15]. Perhaps other outcomes such equally externalizing responses, only also resilience, self-confidence, and social support could be more relevant in a setting of poverty, hardships and law-breaking and should be an essential focus in hereafter studies.
Lastly, a lack of significant therapeutic outcomes for reexperiencing symptoms, behaviour problems and PTG could also exist attributed to improvements in the control grouping. Although the command condition was considered non-therapeutic, it could be that the program did provide the children with certain coping skills, for instance on how to deal effectively with their courtroom appearance and the anxiety effectually this appearance. In this way, both the treatment and control group could take addressed self-regulation skills, which is considered an important mechanism for processing the sensory experience of trauma in the body [58]. The presence of other children in the control condition who all went through a similar traumatic event and the help of social workers in the programme could also have increased their sense of social back up and security. This could have resulted in unexpected therapeutic furnishings in the command condition, decreasing chances of detecting significant differences between the study weather condition.
Recruitment and retention
Despite the very loftier rates of abuse and trauma exposure in South Africa and their negative psychological consequences [1], few children enrolled and completed the creative therapy programme. Unfortunately, these difficulties in reaching patients and loftier dropout rates of mental health handling are well-known issues in a depression and middle income context [59, 60].
Our implemented intervention programme aimed to explicitly accost previously reported structural barriers with availability and accessibility of services by working from a decentralized location in and around the townships at 4 different sites, edifice capacity of skilled wellness intendance workers through training and supervising social workers, and offer the therapy free of accuse [15, 61]. For 2 branches this was quite successful, but for ii other branches it was nonetheless a challenge to reach the target population. In hereafter, we may expect to collaborate with schools or churches to improve accessibility and aim to shorten the 10-week programme to decrease travel time and possibly reduce dropout rates.
Moreover, acceptability of the treatment may have remained a problem amidst the target population. Many people in S Africa utilise traditional explanatory models of wellness, referring to spiritual causes of ill health such as ancestors, for which they seek the help of a traditional healer instead of a medical or psychological professional [62]. Although the creative arts in psychotherapy tried addressing the gap between the western and more traditional practises, by incorporating artistic expressions that are used in traditional rituals such every bit masks, dancing and drumming, the concept of therapy may notwithstanding have been too strange for the customs and more education is needed in this area. Moreover, in a context of extreme poverty, priorities could have been with finding food and shelter rather than seeking help for mental health issues.
The problem of recruitment and retentivity, and treatment accessibility and acceptability in crime-stricken and underprivileged settings such as in Southward African townships and informal settlements deserves fifty-fifty more serious consideration than presumed. It would be constructive in these problematic socio-economic circumstances to combine therapy interventions with programmes explicitly focusing on mental health education providing an intrinsic motivation for therapy attendance [59]. Such an arroyo would also fit into the accent on social connectivity in trauma care as suggested past several authors on global health [63].
Methodological limitations
Due to several practical challenges in the research projection, the report had to exist implemented with more flexibility and therefore less rigor than initially intended. This resulted in inconsistencies in data collection, decreasing the value of testify of this study. Conspicuously, the small sample size and insufficient possibilities for randomization were a substantial limitation in this study. The current results may not accurately reflect the possible full potential of the creative arts in psychotherapy plan as mentioned above.
There were limitations with the sampling in this report. Outset, only children who could speak English were included in this written report. However, in South Africa not everyone tin speak English language. Furthermore, despite this inclusion criteria we still experienced problems with language barriers equally the English of some children and parents was not sufficient and low literacy rates also complicated administration of the questionnaires. In order to address these language barriers, we introduced translations and visualisations and therapy was facilitated by social workers who spoke the dwelling house linguistic communication of the children. Second, at the start of the study in that location were already differences between the intervention and the control group; for case the treatment group reported significantly more PTSD symptoms than the control group. Another divergence was that 100% of the children in the handling grouping were sexually abused, whereas in the control group this was 70.8%. Initially, the handling group included as well children who were physically abused, but they were among those who dropped out. Referring to both examples higher up and knowing that on boilerplate children who were sexually driveling display more severe symptoms of PTSD, perhaps parents of children with more severe PTSD symptoms were more willing to participate in the therapy.
In view of the complexity of the South African setting in which this study was conducted, we recommend the use of mixed methods for hereafter studies in a similar context, incorporating for instance interviews, focus-groups and observational data to add to standardized questionnaires and interviews [64]. In this mode, we can enrich the cognition on how to implement bear witness-based treatment for traumatized and abuse children in developing countries more effectively.
Conclusion
This pioneering written report conducted in South Africa investigated the potential furnishings of a artistic arts in psychotherapy intervention programme for traumatized children. Although severe challenges implementing and executing the report express the power of this evaluation study, results also show positive findings. Nosotros hope our insights will inspire more work in this area. Because the loftier need for bear witness-based trauma care for children in depression income countries, we recommend more studies to exist conducted on the efficacy of creative arts in psychotherapy and the effects of trauma-intervention studies.
Supporting information
S1 File
CBCL datafile.dat.
(DAT)
S2 File
PTSD & PTG datafile.dat.
(DAT)
Funding Statement
The authors received no specific funding for this work.
Information Availability
De-identified datasets are available in the supporting information files. Further information regarding the information are available upon asking from the authors (ln.evil@nenehrtsewnavenidan).
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