Creative Arts in Psychotherapy Treatment Protocol for Children After Trauma
PLoS 1. 2019; xiv(ii): e0210857.
Creative arts in psychotherapy for traumatized children in South Africa: An evaluation study
Nadine van Westrhenen
1 Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
2 Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Holland
Elzette Fritz
3 Department of Educational Psychology, University of Johannesburg, Johannesburg, Due south Africa
Adri Vermeer
four Department of Education and Pedagogics, Utrecht University, Utrecht, The Netherlands
Paul Boelen
1 Section of Clinical Psychology, Utrecht Academy, Utrecht, The netherlands
v Arq Psychotrauma Expert Group, Diemen, The Netherlands
Rolf Kleber
ane Department of Clinical Psychology, Utrecht Academy, Utrecht, Holland
five Arq Psychotrauma Proficient Group, Diemen, Kingdom of the netherlands
Linda Chao, Editor
Received 2018 February 10; Accepted 2019 Jan 3.
- 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 data files. Further information regarding the data are available upon request from the authors (ln.evil@nenehrtsewnavenidan).
Abstruse
Aim
To evaluate the feasibility and result of a ten-session creative arts in psychotherapy group programme 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 condition conducted in South Africa (4 sites).
Methods
125 children aged vii to 13 years were assigned either to the treatment 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 programme and questionnaires assessing posttraumatic stress, posttraumatic growth and behaviour bug both at baseline and follow-up; 23 in the treatment group and 24 in the control group. Adapted hateful differences were analysed using ANCOVA with bootstrapping.
Results
Results showed that both hyperarousal symptoms (d = 0.61) and abstention symptoms (d = 0.41) decreased more in the handling grouping compared to the control group. In that location was no significant issue of the intervention found for reported levels of behavioural bug 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 artistic arts in psychotherapy reducing hyperarousal and avoidance symptoms, only not for other symptoms. Valuable lessons were learned on feasibility of implementing this intervention in a developing context.
Introduction
Trauma exposure
For a country not at war, S Africa is a place with extreme high rates of traumatic exposure, with one of the highest rates of interpersonal violence and domestic abuse in the globe [i]. Violence confronting children is especially pervasive, from severe beatings to sexual violence and rape [1]. Exposure has been reported as loftier as 98.9% for community violence [2] and 54.two% for sexual abuse [3]. The loftier exposure to interpersonal violence increases vulnerability to mental disorders such equally posttraumatic stress disorder (PTSD) [four,five]. Loftier levels of PTSD take been reported amongst poor urban children in South Africa and prevalence estimations have been published of 22.2% and 23.half dozen% [5, six]. Apart from PTSD, children exposed to interpersonal violence are more probable to feel a wide range of agin psychological problems, such equally depression, suicidality, and substance abuse [v,7] and externalizing behaviour problems such as violent and anti-social behaviour [viii].
Apart from negative psychological consequences of corruption and fail, positive alter may also result from traumatic exposure, called posttraumatic growth (PTG) [9]. PTG generally includes five domains; relating to others, personal strength, appreciation of life, spiritual change, and new possibilities [10]. PTG has mostly been studied in adults and there is a growing body of literature describing the phenomenon of PTG in children and adolescents [11, 12].
Child trauma treatment
Different types of interventions have been proven to exist constructive for improving mental wellness in traumatized children. Particularly cerebral behaviour therapy (CBT) has emerged equally one of the nearly effective and widely used treatments [13, 14]. More prove, however, is required in order to constitute the effectiveness of different therapies in the longer term, and for comparability of unlike types of therapy, such as CBT, play therapy, heart movement desensitization and reprocessing (EMDR), art therapy, and psychodynamic therapy [xiii]. Moreover, since nigh studies have been conducted in high-income countries, evidence is required for the applicability of trauma interventions in a depression- and eye-income context [15].
Creative arts therapy is a widespread approach in the treatment of child post trauma disorders. It includes dissimilar modalities of art, music, trip the light fantastic and drama in combination with other approaches to psychotherapy and counselling [16], such as psychodynamic, cerebral, developmental, systems, and narrative therapy. The use of art therapy practise varies and tin can be described on a continuum [17], ranging from using arts every bit an adjunct in verbal psychotherapy to art appointment without verbal analysis, and several gradations in between. Creative arts therapies used as a primary grade of therapy requires graduate-level training in one or more modalities. Artistic arts is also used by counsellors or other qualitied mental wellness professionals in facilitating different stages in psychotherapy [18]. When using creative arts in this style as an adjunct, the key is to empathize the various treatment goals and to carefully select artistic arts activities that can support this procedure [19]. Mental health professionals can be offered training in applying creative arts activities in psychotherapy, simply at all times it is important to avoid challenging ethical boundaries by going across what someone was trained to do.
Research with children plant that the use of art tin can facilitate exposure to traumatic cues in a non-threatening style, allowing for desensitization of anxiety, articulation of affective states [20], and more detailed and emotional narratives [21]. Too, arts-based methods tin can assist children in developing coping skills, self-awareness and aspects of cocky-esteem [22], with the creative process providing a containing infinite in the relationship with the therapist [23]. Facilitating (creative) therapies for traumatized children in a group setting can have additional benefits, because group members tin facilitate trust and disclosure, providing an opportunity for children to realize they are not alone in their problems, and finding peer-support [24, 25]. Artistic arts activities tin can reinforce these grouping benefits past serving as a medium for communication, for instance trip the light fantastic toe/motility can help establish a sense of connection and understanding between people [26], and music provides a medium to communicate and build relations [27].
Although the possibilities of creative arts therapy appear promising, in that location is very little research bachelor on the efficacy of such therapies for children after trauma [28, 29]. Only a few studies have explored the effects of creative therapy for children on successfully reducing posttraumatic stress symptoms [30, 31] and behavioural difficulties [32]. In the Southward African context, to our noesis, only one group art therapy intervention for sexually driveling girls from 8 to eleven years old has been evaluated [33]. This report showed positive results regarding anxiety, depression and traumatic stress symptoms, but no outcome of the intervention was found on levels of self-esteem. Autonomously from this report, methodologically audio studies focusing on the effects of artistic arts therapy on specific event measures are deficient [34].
Written report purpose
The present study aims to assess the possible influence of a artistic arts in grouping psychotherapy programme for traumatized children in South Africa on posttraumatic stress symptoms, behaviour problems and PTG. We performed a non-randomized controlled trial comparison creative arts in psychotherapy with a low-level supportive programme including no fine art and/or psychotherapeutic interventions and hypothesized that a artistic arts in psychotherapy programme (CAP) is more efficacious compared to the command condition in 1) reducing posttraumatic stress symptoms, 2) reducing behavioural problems, and 3) increasing PTG, in children who experienced ane or more traumatic events.
Methods
Design
This was a multicentre non-randomized controlled trial conducted in S Africa (iv sites) with 2 conditions, and including 3 measurements at baseline and follow-up.
Sampling
The study took place at 4 branches of a kid abuse clinic in Johannesburg, South Africa, from January 2014 to June 2016. Children attending this dispensary come up from various communities (mostly townships and breezy settlements) in and effectually Johannesburg, represent dissimilar racial groups (although primarily Black, also Coloured, Indian and White families attend) and speaking different home languages (South Africa has 11 official languages).
125 participants were selected for this report from all children that came for intake at the trauma dispensary, based on the following inclusion criteria: (1) experienced 1 or multiple events of trauma or corruption betwixt three months and twelve months agone; (2) developmental age between 7 and 13 years at the time of enrolment; (three) tin can speak English in guild to communicate with all social workers and peers in therapy. Exclusion criteria were (1) mental retardation, autistic disorder, and blindness, (2) already had whatsoever class of previous trauma treatment. Choice for the dissimilar conditions was washed not-random due to practical considerations relating to the limited availability of participants. One 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 (due north = 74). Other social workers in the clinic continued to refer children to treatment every bit usual, starting with a non-therapeutic court preparation programme whilst awaiting availability for individual play therapy. All children attending this court preparation programme at the clinic coming together inclusion criteria were too invited to participate in the control condition (due north = 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-4-TR characterized PTSD symptoms in the by month. The calibration uses a 4-point Likert scale, 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, abstention, and reexperiencing. Psychometric properties have been published in the Southward African context [36], and the instrument was found 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-up).
Behaviour problems
Behaviour problems were reported by the parents or a shut relative on the Child Behaviour Checklist (CBCL) [37]. This checklist consists of 120 items, assessing emotional and behavioural bug, rated on a iii-point calibration ranging from 'non true' (scored 0) to 'very truthful or often true' (scored 2). The CBCL has three main scales, internalizing, externalizing and full 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 first-class (baseline α = .96, follow-up α = .96).
Posttraumatic growth
PTG was measured with the self-report Posttraumatic Growth Inventory for Children- Revised (PTGI-C-R) [10]. The instrument has x items using a four-point Likert calibration ranging from no alter (scored 0) to a lot (scored 3). Enquiry findings demonstrate validity and reliability of the revised calibration [ten]. Previous studies measuring PTG in low-income settings, although rare, demonstrate positive results [39, 40]. Internal consistency for the full scale in the current sample was institute betwixt α = .70 (baseline) and α = .76 (follow-up).
Conditions
Treatment condition
Children in the handling condition attended the Creative Arts in Psychotherapy (CAP) intervention [41]. CAP was a structured plan of x 90-minute sessions, specifically developed for traumatized children in the age between viii and 12 years. The sessions were facilitated once a calendar week in closed groups of six to eight participants past local social workers trained by artistic arts therapists to acquit arts-based activities in psychotherapeutic practice, and different multimodal activities incorporating visual art, movement, dance, drama, music, and storytelling were used to piece of work towards specific session goals. The programme outline was based on the three phases of the treatment model for severely traumatized individuals [42]. The get-go three sessions focused on establishing safety, and activities included for instance having children mirror each other's dancing to increase connection between group members [43] and reading and discussing a children's story of 'a terrible matter happened' [44]. Sessions four to 6 aimed to facilitate expression of emotions associated with the trauma story and practise emotion regulation by for instance decorating masks to express and distinguish betwixt feelings from the within and what others run into from the exterior. Lastly, the concluding four sessions focused on strengthening coping skills past for example writing and socio-drama activities incorporating the hero'due south 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 grouping did not attend whatever therapy, but 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 preparation for their appearance in court. This program was function of the handling equally usual in the dispensary, after which the children were offered the opportunity to attend individual play therapy. The programme was facilitated past social workers during monthly three-hour open up group sessions, where children could join as long as necessary while the court example preparations were even so ongoing. The children in this command condition attended about 3 sessions (over a two-month catamenia) during the time this study took identify. The sessions were solely focused on the courtroom process, and not on whatever psychosocial impact of the trauma on the customer'south personal life.
Procedure
To detect a alter in the dependent variables betwixt the two conditions, with a two-sided 5% significance level, medium effect size and a power of 80%, a sample size of 64 per group was necessary [46]. Baseline questionnaires were administered on paper prior to the kickoff session of the CAP programme (treatment condition) and during the first monthly courtroom preparation session the child was attention (control status). Follow-up questionnaires were subsequently administered later on the final session of the creative therapy program, and during another court preparation session on boilerplate two months after baseline measurements. In a number of instances there were reading challenges and the questionnaires were administered verbally, and private appointments were arranged to administer questionnaires if the parents and children were not available for the group sessions in which the questionnaires were administered. For those children who did not consummate the total program, post-measurement questionnaires were withal administered, adhering to the intention-to-treat approach.
Ethical approving
Permission for this written report was obtained from the Faculty of Humanities Academic Ethics Commission of the University of Johannesburg. Informed consent and informed assent was obtained from the children and their parents or primary caregiver prior to participation in this written report. Participation was volunteer and confidential. Children in the control group were offered the choice to nourish therapy at the clinic later participating in the court training and support programme, and children participating in the CAP could too later on join the court training and support programme.
Information assay
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 let for subsequent analysis including bootstrapping. Baseline analyses were performed using bivariate analysis, exploring differences on handling condition, gender, race, blazon of trauma and baseline measures of PTSD, PTG and behavioural problems. To explore the treatment upshot, the mean difference score between baseline and follow-up measurements was compared between the different test conditions (treatment vs control) using ANCOVA with ethnicity and type of abuse as covariates. Considering the small sample and not-normal distribution of information, bootstrapping techniques were applied.
Results
Feasibility
From the 125 children initially referred to the programme, 62.four% dropped out in both the handling and control status. Of the four different branches, treatment groups of two branches had to exist terminated prematurely due to loftier dropout rates. One group was facilitated in a place of rubber, and turnover rates of children in this place was very high. For the other co-operative, reasons for drop out were mostly related to accessibility. Parents reported traveling upwards to two hours from home to the clinic and struggled to beget the send costs or were not able to take time off from piece of work to bring the children [47]. The other 2 branches had relatively sufficient turnout over a 2-twelvemonth period. These branches were more centrally located within a specific community. For the control group, monthly turnout was inconsistent. Some parents and children would show up every month, but most children only attended once or twice, and and 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 = three.20) sessions during a menstruum of ten weeks. This equals 8.28 hours of therapy. Six children in the treatment group who received CAP only attended i or 2 sessions out of the prescribed ten.
Participants flow
In total 125 children participated with baseline measurements in the study. Subsequently, social workers referred 74 participants to the handling condition, and 51 participants to the command condition. For the handling status, after participant dropout (n = 42) and exclusion of participants who attended the intervention just did non complete the mail service-measurements (n = nine), a total of 23 participants were included for the analysis of the C-PTSD-C and the PTGI-C-R and a total of 18 participants were included for the assay of the CBCL. The CBCL was completed by the parents and oft the children travelled alone or with a sibling to the clinic, making information technology hard to get hold of the parents for completion of questionnaires. For the control condition, later on dropout (n = 23) and exclusion of those who completed only one out of the iii post-measurements (northward = 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 1).
Flow diagram of progress through the phases of the experimental trial of two groups.
The terminal 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, anile between 7 and xiii (One thousand = ten.fourteen, SD = 1.92). The control group consisted of 24 children, 8 boys and 16 girls, aged between 8 and 13 (M = 10.l, SD = one.32). The final sample of 37 participants for assay of the CBCL consisted of eighteen children in the handling grouping, 2 boys and 16 girls, aged between vii and 13 (M = 9.93, SD = ane.94). The control group consisted of 19 children, 6 boys and 13 girls, aged between 8 and 13 (Yard = 10.30, SD = 1.38). The majority of children in the study had experienced sexual abuse, five children experienced concrete abuse (Tabular array ane).
Table i
| Sample for PTSD & PTG | Sample for CBCL | |||
|---|---|---|---|---|
| Handling (north = 23) | Control (n = 24) | Treatment (n = 18) | Control (northward = xix) | |
| Historic period (years) | 10.14 (one.92) | 10.50 (1.32) | ix.93 (1.94) | 10.30 (1.38) |
| Gender (female) | 20 (87.0%) | 16 (66.7%) | 16 (88.9%) | 13 (68.4%) |
| Ethnicity: | ||||
| African | 22 (95.7%) | 16 (66.7%) | xviii (100%) | 12 (63.2%) |
| Asian | - | 2 (8.3%) | - | two (10.five%) |
| Coloured | 1 (4.3%) | two (8.3%) | - | 1 (5.3%) |
| White | - | iv (16.vii%) | - | 4 (21.1%) |
| Type of trauma: | ||||
| Sexual corruption | 23 (100%) | 17 (70.8%) | 18 (100%) | 14 (73.7%) |
| Physical corruption | - | v (20.8%) | - | three (fifteen.8%) |
| Other | - | 2 (eight.3%) | - | 2 (10.5%) |
Baseline data
The treatment group (M = 26.78, SD = 11.48) and control group (Yard = 33.99, SD = 11.57) differed significantly on PTSD symptoms at baseline (t(45) = -2.143, p < .05). Fisher'due south exact test for the sample of 47 participants did show that there were significantly more black children in the handling group (95.7%) compared to the command group (66.7%; p < .05), and there were also more children that were sexually abused in the treatment grouping (100%) compared to the command group (seventy.viii%; p < .01). Also for the sample of 37 participants, at that place were more black children in the handling group (100%) compared to the control group (63.ii%; p < .01), and more than children had been sexually abused in the treatment grouping (100%) compared to the control group (73.seven%, p < .05). Other variables tested did not differ significantly across conditions.
Evaluation of outcomes
Controlling for the upshot of ethnicity and blazon of abuse in an ANCOVA, bootstrapped adjusted mean differences showed that hyperarousal symptoms significantly decreased in the handling condition between baseline and follow-up (from M = 10.39 to M = 6.77, d = 0.61), where it slightly increased for the control group (from M = 6.73 to Thou = 7.46, d = -0.xv; adjusted mean difference = 4.36, 95% CI 0.36, eight.69). Moreover, abstention symptoms decreased significantly more for the treatment condition (from M = 13.48 to Chiliad = eleven.xiii, d = 0.41) compared to the control condition (from Yard = 11.05 to M = 10.99, d = 0.01; adjusted mean deviation = iv.11, 95% CI 0.03, eight.42), yet the effect size was small. Overall PTSD symptoms, besides as reexperiencing symptoms also decreased in the treatment condition, but not significantly more than in the control condition, come across Tabular array 2.
Table 2
Summary results treatment and control group.
| Handling | Control | Adapted hateful divergence** (95% CI) | |||
|---|---|---|---|---|---|
| Scale (range) | Baseline (mean (SD)) | Follow-up (mean (SD)) | Baseline (hateful (SD)) | Follow-up (mean (SD)) | |
| PTSD symptoms | n = 23 | n = 24 | |||
| Full (0–84) | 33.99 (11.57) | 27.06 (18.18)* | 26.78 (11.48) | 26.84 (12.68) | ix.40 (-0.18, xx.01) |
| Avoidance (0–xxx) | 13.48 (4.78) | xi.thirteen (half dozen.63) | 11.05 (5.15) | 10.99 (4.54) | 4.11 (0.03, 8.42)*** |
| Reexperiencing (0–27) | nine.43 (v.25) | 8.64 (6.42) | 8.75 (3.96) | seven.83 (four.59) | 0.33 (-3.03, 3.60) |
| Hyperarousal (0–24) | 10.39 (4.96) | six.77 (six.72)* | vi.73 (4.twenty) | 7.46 (v.26) | iv.36 (0.36, 8.69)*** |
| Behaviour issues | n = 18 | northward = xix | |||
| Total (0–240) | 62.91 (35.97) | 48.98 (33.66) | 71.35 (37.01) | 51.46 (28.12)* | -13.ninety (-53.28, 20.88) |
| Internalizing (0–78) | 18.81 (11.76) | 14.59 (11.fourteen) | 21.08 (10.45) | fourteen.19 (7.60)* | -v.80 (-xvi.65, 3.91) |
| Externalizing (0–seventy) | 16.68 (10.09) | fourteen.05 (9.75) | twenty.22 (thirteen.45) | 16.15 (11.62) | -ii.12 (-14.23, 8.twenty) |
| Posttraumatic growth | north = 23 | northward = 24 | |||
| Total (0–30) | 22.34 (5.29) | 23.99 (4.42) | xix.75 (five.25) | 23.44 (5.01)* | 1.63 (-2.70, half-dozen.08) |
Behaviour issues besides showed a decrease over fourth dimension in both the treatment condition (from M = 62.91 to M = 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, merely these changes were not statistically significant when compared betwixt conditions. Lastly, PTG increased in both the treatment status (from Thousand = 22.34 to M = 23.99, d = 0.34) and the command status (from G = 19.75 to M = 23.44, d = 0.72), but there was no pregnant difference in this increment between atmospheric condition (Tabular array ii and Fig 2).
Posttraumatic stress symptoms, behaviour problems and posttraumatic growth scores of the treatment and control groups at baseline and follow-up.
The scores are mean total scores.
Discussion
Evaluation of the CAP program showed that compared to the control condition, hyperarousal symptoms decreased significantly more during CAP with a medium effect size for the pre-treatment to follow-up modify scores. Avoidance symptoms likewise decreased more during CAP than in the control status, just the effect size was small. No support was found for our hypothesis that the CAP programme is more efficacious than a depression-level supportive plan in reducing reexperiencing symptoms, behaviour problems and increasing PTG.
In addition to these quantitative findings, the social workers were positive most the intervention. They observed the children moving from the bespeak of being victim to survivors, the children were smiling and interacting more than and demonstrating more confidence. The social workers noticed that the creative activities provided the children a platform to express their emotions and bear witness their talents and the children found empathy from their fellow grouping members and felt supported. Other positive feedback we received was that children were telling us that they were sleeping improve now, and some parents told us that their children became more than playful and showed less resistance at home.
Below we volition discuss the outcomes of the intervention and lessons learned on feasibility by reflecting on barriers in recruitment and retention and discussing methodological limitations.
Therapeutic outcomes
Previous studies highlighted the positive furnishings of creative arts therapy specifically on reducing psychological stress [48], having a soothing chapters [16, 49] and establishing a sense of prophylactic [50]. This may in turn have facilitated decreased hyperarousal symptoms and helped regain or develop healthy emotion regulation after experiencing severe stress. The positive effect 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 plan (CAP) did not diminish reexperiencing PTSD symptoms, behaviour problems and PTG equally successfully. Information technology could be that the therapeutic activities in the treatment protocol did non address all these different outcome measures as purposefully as intended, or perhaps the creative arts activities facilitated by trained social workers were inferior to the commitment of creative arts therapy by trained and credentialed creative arts therapists. Possibly, the lack of a direct trauma-exposure component in the treatment may likewise take affected the outcomes. Currently, there is a fence whether directly facilitating re-exposure in therapy would exist more beneficial [51]. On the one mitt, it has been constitute that trauma-focused treatments show higher effect sizes compared to non-trauma-focused treatments [52], notwithstanding a recent meta-assay showed this departure is rather small and not clinically meaningful [53]. Moreover, exposure therapies are also associated with an early and high dropout and patients having remaining symptoms [54, 55].
Moreover, not all these interventions take been shown to be effective in a context of ongoing adversity such as chronic poverty, community violence and war [15, 56, 57]. Therefore, another explanation for our plan evaluation results may be that the circumstances of ongoing adversity are impeding the potential therapeutic benefits of the intervention. We as well noticed that most trauma handling studies in a developing context accept focused solely on PTSD and internalizing symptoms as outcome measures [15]. Peradventure other outcomes such as externalizing responses, just also resilience, self-confidence, and social support could be more relevant in a setting of poverty, hardships and crime and should exist an essential focus in future studies.
Lastly, a lack of significant therapeutic outcomes for reexperiencing symptoms, behaviour problems and PTG could also be attributed to improvements in the control group. Although the control condition was considered non-therapeutic, it could be that the program did provide the children with certain coping skills, for example on how to bargain effectively with their court appearance and the anxiety effectually this appearance. In this way, both the treatment and control grouping could have addressed self-regulation skills, which is considered an of import 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 too have increased their sense of social support and security. This could take resulted in unexpected therapeutic furnishings in the control condition, decreasing chances of detecting pregnant differences betwixt the study conditions.
Recruitment and retention
Despite the very high rates of corruption 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 high dropout rates of mental health treatment 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 iv different sites, building capacity of skilled wellness care workers through training and supervising social workers, and offering the therapy free of charge [xv, 61]. For two branches this was quite successful, but for two other branches it was withal a challenge to reach the target population. In future, we may await to collaborate with schools or churches to meliorate 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 amid the target population. Many people in S Africa apply traditional explanatory models of health, 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 than traditional practises, past incorporating artistic expressions that are used in traditional rituals such every bit masks, dancing and drumming, the concept of therapy may nonetheless have been also foreign for the community and more teaching 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 bug.
The problem of recruitment and retention, and treatment accessibility and acceptability in crime-stricken and underprivileged settings such as in South African townships and informal settlements deserves even more serious consideration than presumed. Information technology would be effective in these problematic socio-economic circumstances to combine therapy interventions with programmes explicitly focusing on mental wellness education providing an intrinsic motivation for therapy attendance [59]. Such an approach would also fit into the emphasis on social connectivity in trauma care as suggested by several authors on global health [63].
Methodological limitations
Due to several practical challenges in the research project, the study had to be implemented with more than flexibility and therefore less rigor than initially intended. This resulted in inconsistencies in information collection, decreasing the value of bear witness of this study. Clearly, the minor sample size and insufficient possibilities for randomization were a substantial limitation in this study. The current results may not accurately reverberate the possible full potential of the creative arts in psychotherapy programme as mentioned to a higher place.
There were limitations with the sampling in this study. First, only children who could speak English were included in this study. Nonetheless, in S Africa non anybody can speak English language. Furthermore, despite this inclusion criteria we all the same experienced problems with language barriers every bit the English of some children and parents was not sufficient and depression literacy rates also complicated administration of the questionnaires. In order to address these linguistic communication barriers, nosotros introduced translations and visualisations and therapy was facilitated by social workers who spoke the abode language of the children. Second, at the offset of the study there were already differences between the intervention and the control group; for instance the treatment group reported significantly more than PTSD symptoms than the command group. Another difference was that 100% of the children in the treatment group were sexually abused, whereas in the control group this was 70.eight%. Initially, the treatment group included as well children who were physically abused, but they were amongst those who dropped out. Referring to both examples in a higher place and knowing that on boilerplate children who were sexually abused display more severe symptoms of PTSD, possibly parents of children with more severe PTSD symptoms were more willing to participate in the therapy.
In view of the complexity of the Due south African setting in which this report was conducted, we recommend the use of mixed methods for future studies in a like context, incorporating for instance interviews, focus-groups and observational information to add to standardized questionnaires and interviews [64]. In this way, we can enrich the knowledge on how to implement prove-based treatment for traumatized and abuse children in developing countries more than finer.
Conclusion
This pioneering written report conducted in Due south Africa investigated the potential furnishings of a creative arts in psychotherapy intervention plan for traumatized children. Although severe challenges implementing and executing the study express the power of this evaluation study, results also show positive findings. We promise our insights will inspire more work in this expanse. Considering the high need for evidence-based trauma care for children in depression income countries, we recommend more studies to be conducted on the efficacy of creative arts in psychotherapy and the effects of trauma-intervention studies.
Supporting data
S1 File
CBCL datafile.dat.
(DAT)
S2 File
PTSD & PTG datafile.dat.
(DAT)
Funding Statement
The authors received no specific funding for this work.
Data Availability
De-identified datasets are available in the supporting information files. Farther data regarding the data are available upon request from the authors (ln.evil@nenehrtsewnavenidan).
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