Centre for creative therapies – homeless mental health pilot web

Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

October 2015

Prepared by Anne Eustace Eustace Patterson Ltd Psychology at Work

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First Fortnight - Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

Table of Contents Gratitude 3 Chapter One: Introduction 5 Chapter Two: Research Methodology 9 Chapter Three: Research Results 11 Chapter Four: Conclusions & Pointers for Consideration 33 Bibliography 45 Appendix One 46 Appendix Two 47

Gratitude

I am grateful to the Art Psychotherapy Project team for their open and generous contribution to the research process. Eithne McAdam and Louise Quinn entered into the spirit of constructive exploration during the evaluation and courageously welcomed the questions and reflections on their art psychotherapy practice. I thank them for their welcome, their openness and their good work producing case stories and reflections.

I firmly note and appreciate the gentle, respectful and professional ways in which they work with their clients in general and in particular the way in which they encouraged their clients to participate in this research. The conversations with clients were an insightful and affirming element of the methodology. I express my gratitude to JP Swaine for trusting in the evaluation and guiding the process from a distance. Thank you to the management and staff of Haven House for hosting the research visits and all Crosscare personnel who responded to the call to give feedback. I express gratitude also to the eight clients who attended one to one interviews with me as part of the research process.

Anne Eustace October 2015

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The real goal of a therapy is not a cure, for the human condition is not a disease. Yes, real, resistant problems of daily life can and must be addressed and the resources of consciousness brought fully to bear on their resolution. But the real gift of a therapy, or of any truly considered life, is that one achieves a deepened conversation around the meaning of one’s journey – a conversation without which one lives a received life, not one’s own, a superficial life, or a life in service to complexes or ideologies.

James Hollis, What Matter most: Living a more considered Life

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First Fortnight - Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

Chapter One: Introduction

This chapter sets the scene for this evaluation report. It describes the Art Psychotherapy Project and the context in which it operates. It also notes main messages from recent literature documenting research into Art Psychotherapy.

1. Background to the Art Psychotherapy Project First Fortnight is committed to the principle of creativity in recovery. The Art Psychotherapy project represents a development of the charity into the provision of a creative therapy service to compliment their arts based social change agenda.

The project serves adults with mental health difficulties and dual or multiple diagnoses who are also experiencing homelessness or at risk of this. The primary aim is the reduction of symptoms of mental ill health through the provision of Art Psychotherapy. The target for the phase of the project1under review was to support 60 people.

The service is based on site in Haven House in North Dublin2. These premises are provided by Haven House pro bono under a Memo of Understanding. The service is available three days a week and employs two art psychotherapists each working 2.5 days. The project is managed by the Director of First Fortnight who was also the senior mental health social worker attached to the ACCES Team at the time of this research. The Art Psychotherapists are employed by First Fortnight Ltd.

2. Objectives of the Art Psychotherapy Project The Project was driven by the need to provide a specific mental health intervention to the client group. The stated intention of the pilot was the provision of art psychotherapy services from the mental health arts charity First Fortnight. The specific target group during the first year were clients from the two community mental health teams designated to work with homeless persons, i.e. the ACCES team and The Program for the Homeless. The referral base was broadened in subsequent years to all homeless service providers in Dublin.

There are certain supports available to clients through the service providers such as Dublin Simon, Focus Ireland, Merchants Quay Ireland and others. These include one to one counselling, RADE (Recovery through Art, Drama and Education), art classes and relaxation therapies. However, there are few mental health specific supports available. The Program for the Homeless offers a day service with nursing and occupational therapy staff and a clinical psychologist3. ACCES recently commenced offering psychological and occupational supports to patients.

The Art Psychotherapy Project offers one individualised session per week to clients with a fully qualified Art Psychotherapist (IACAT registered).

The project objectives are: • To meet an unmet need in mental health provision in Ireland as no Art Psychotherapy is provided in any formal, consistent or evaluated project within the Community Mental Health Model in homelessness.

• To achieve a reduction of symptoms of mental ill health through the provision of Art Psychotherapy.

• To support the progression of service users out of homelessness and into secure tenancy.

1 As stated in the Genio project documentation 2 Haven House on Morning Star Avenue in Dublin is a short term homeless accommodation supporting people and strengthening their living skills.

3 The clinical psychologist is a new addition to the Programme for the Homeless clinical team recruited in summer 2015.

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• To challenge the perceptions that art classes given as standard program activities in generic mental health day centres or day hospitals constitute Art Therapy.

• To meet the needs of the homeless mental health population with a therapeutic modality known to have a proven effectiveness with those with limited insight into their mental ill health, below average literacy and high levels of suspicion towards establishment figures.

• To begin a research basis for Art Psychotherapy Provision as part of the recovery aids available in the community.

Success for the project was defined as 35-40 clients receiving up to 25 sessions of art psychotherapy with a continued rate of 70% attendance. Anticipated benefits or outcomes were described as significant improvement in well being, self-esteem and resilience (or similar positive feedback gained in post therapy interviews).

3. Funding of the Art Psychotherapy Project The project is funded by Genio, the HSE and DCC.

4. Summary Description of the Project The project commenced in December 2012 and met its first clients in February 2013.

Individual therapy is offered to the designated target group i.e. CMHT referrals. Initially an open studio group was available for Haven House residents before referral was widened to include Haven residents. The open group was discontinued due to lack of engagement and one to one therapy was deemed the optimal modality at that point in time. There are still possibilities around the group model and it may have future potential which the Centre for Creative Therapies is open to.

• At the time of this research 49 clients had been referred into the service • By May 2015 the service had worked with 34 clients o 21 male o 13 female o Youngest 24 years o Oldest 63 years o Average age 41 years • The diagnoses included paranoid schizophrenia, bi-polar disorders, depression, acquired brain injury, various psychoses often coupled with addictions and/or substance misuse.

• The maximum number of sessions engaged in by any one client was 64 • The average attendance was 75%.

• The average length of therapy was 25 sessions.

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First Fortnight - Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

5. What the Literature Says Art therapy is based on the idea that the creative process of art making is healing and life enhancing and is a form of non verbal communication of thoughts and feelings4. In harmony with other forms of psychotherapy and counselling it encourages personal growth, increases self understanding and assists in emotional reparation.

Art psychotherapy is used in a wide variety of settings. According to Malchiodi (1998) art therapy can help individuals to create meaning and achieve insight, find relief from over whelming emotions or trauma, resolve conflicts and problems, enrich daily life and achieve an increased sense of well being.

Adrian Hill first coined the term art therapy in 1938. Art therapy is a long term intervention that seeks to find ways to use art to deliver psychological therapy to those otherwise ineligible because of psychological, physical or developmental barriers. It is a pragmatic modality. According to Springham and Brooker (2013) art psychotherapy is a small and young profession and they urge us to be mindful of this when striving to build a reliable data set when looking at effectiveness.

Art therapy has been promoted as a means of helping people who may find it difficult to express themselves verbally to engage in psychological treatment.

Frances O’ Brien (2008) describes the unique benefit of art therapy. ‘The art process is a right brain activity, it accesses the right hemisphere’s emotional memory, at the same time the relationship with the therapist activates the left hemisphere. Words are found by the therapist to make meaning, gradually, integrating left and right hemispheres and unifying the explicit construction of narrative that accompanies the implicitly emotional experience of ‘making’ in art psychotherapy’ Peter Cockersell (2011) believes that the perspectives of psychoanalysis and psychology could have a lot to offer our work with people experiencing homelessness and poor mental health, both in terms of understanding the problems and of promoting practice which helps resolve them. He has tested his hypothesis with adults facing chronic exclusion St Mungo’s in London. He argues that offering appropriate clinical interventions alongside existing social ones can begin to transform the situation of many homeless people caught in the ‘revolving door’ of hostels, prison, hospitals and streets. He advocates that alongside the need for housing there is a need for a range of psycho-social interventions – housing first and other supports, including therapies, second, third, etc. The action research conducted at St Mungo’s showed positive indicators of success for psychotherapeutic interventions.

The MATISSE5 study is significant in its efforts to assess the effectiveness of arts therapies and contribute to the development of evidence bases. Through this and other work an evidence base is slowly emerging that is providing useful and growing intelligence around the value, benefits and utility of art therapy. The indications are that when appropriately used and in harmony with good practice art psychotherapy may result in improved mental health and reduction of negative symptoms. The methodological guidance that this and other similar research alerts us to is arguably most useful to the Centre Creative Therapies and organisations pioneering similar work in Ireland. This guidance draws our attention to the importance of robust methodologies, clear thinking and purposeful planning when attempting to build a bank of evidence about a particular therapy.

The learning to date is that most trials and pilots of arts therapies share methodological weaknesses in that samples are small and follow up periods tend to be short. This can curtail the real value and capacity to understand and influence positive change and strengthening of practice in the field. It is important to be mindful of such factors when setting out to gather meaningful and clear evidence that will usefully and reliably inform future work for the greater good.

4 American Art Therapy Association, 1996 5 The MATISSE Study: A randomised trial of group art therapy for people with schizophrenia. Crawford, M.J., et al. BMC Psychiatry 2010.

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The Centre for Creative Therapies is alert to the research pointers arising from recent literature and is preparing and positioning to be as responsible as possible in this regard. This is evident in their attention to detail and sensitivity in terms of action research, use of psychometric scales and case stories to track progress and learn from their work with clients. This, coupled with reflective practice and supervision, confirms commitment to continuous improvement of service to the client group.

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First Fortnight - Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

Chapter Two: Research Methodology

First Fortnight committed to an independent evaluation of the art psychotherapy provided within the Centre for Creative Therapies. With this intention an external researcher was contracted to complete the research.

The approach to the evaluation was characterised by the following: • Initial exploration and clarification of needs, expectations and logistics in consultation with the Project Director.

• Close collaborative and supportive working with the Project Director and the Art Psychotherapists examining existing data and devising a sensitive, robust and appropriate evaluation methodology with due regard for the participants and their life situations.

• Review of all existing/secondary data, including baseline and post therapy measures (e.g. Warwick Edinburgh Mental Well Being Scale, Rosenberg Self Esteem Scale and the Conor Davidson Resilience Scale), client profile data, attendance and participation records, referral reports, previous progress reports and any other relevant data held with the Centre for Creative Therapies.

• Consultation with all relevant stakeholders and in particular the Art Psychotherapists and a sample of their clients6.

• Offering a sensitive and supportive approach to all participating individuals and groups and guaranteeing full confidentiality in the treatment of all data seen and gathered.

• Honouring ethical commitments to confidentiality and constructive and appreciative methodologies.

The methodology was action research oriented and included a blend of qualitative and quantitative techniques described below.

Brisk review of a selection of literature A selection of recent literature was reviewed. The purpose was to place the research in context, deepen the definition of art psychotherapy and learn from its practical applications in other projects and places similar to the Centre for Creative Therapies.

Review of project records, client profiles, referral forms, scales, etc.

The researcher reviewed the project records and files. This included referral forms and results of administration of the three baseline measures used. These measures include the Connor Davidson Resilience Scale, the Warwick Edinburgh Mental Well-Being Scale and the Rosenberg Self Esteem Scale. The Project employed this battery of standardised psychometrics following recommendations from the Mental Health Foundation in the UK. Consultations with the Project Team The researcher met formally with the Project Manager and the art psychotherapists at three junctures during the evaluation time frame (Spring/Summer 2015). These meetings coincided with the beginning, middle and end of the research process. The purpose was to gather the views of 6 The methodology for the one interview with clients was informed by the research of Springham and Brooker 2013 and their use of reflective questions and audio imaging.

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the project team and in particular to draw out good practice and learning from the pilot phase.

Client Case Stories The therapists each completed four in depth case stories as part of the evaluation process. The purpose of this qualitative methodology was twofold. The first was to tune into art psychotherapy in action and to encourage the therapists to showcase their techniques, depth of professional competence and the regularity and flow to the work. The second intention was to illustrate the client story and the range of aspects that may emerge in any given case. The therapeutic practice holds consistent whilst the story will vary.

Client Consultations The researcher met with a sample of clients (8 or 24%). These were one to one purposeful meetings. All clients received a letter from the project inviting them to express their interest in attending a meeting with the researcher with a view to offering their feedback in confidence. The art therapists followed up with telephone calls to their clients, reassuring them of the research process, its independence and confidentiality. Twelve clients agreed to participate in the process and eight attended for interview on the day. The interviews were one to one confidential conversations lasting between twenty and thirty minutes depending on the client’s capacity and willingness to engage. (Please see Appendix for guide to interview topics) Baseline Measures There were three psychometrics used to track client’s mental well being during the pilot. These were the Connor Davidson Resilience Scale, the Warwick Edinburgh Mental Well-Being Scale (WEMWBS) and the Rosenberg Self Esteem Scale (RSES). The intention was to administer these with each client at assessment stage and then at other junctures during and post therapy.

For the purposes of this research the scales were administered at two junctures with a sample of eight clients, pre and post therapy. The results of both administrations were compared. Shifts in results are noted and discussed.

Consultation with Referral Organisations All the relevant referral organisations that surround the Centre for Creative Therapies were invited to participate in the evaluation process. Named contacts within each were issued an e-invitation which was followed up by a telephone call from the researcher. Ten representatives from the range of referral organisations contributed to the research process. This was achieved through confidential telephone interviews conducted by the researcher. The interviews were one to one, confidential and lasted between 45-60 minutes. (Please see Appendix for guide to interview topics)

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First Fortnight - Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

Chapter Three: Research Results

This chapter lays out the results of the research. This includes consultations with referral organisations, client case stories and themes emerging through interviews and discussions with the Project Team.

3.1. Results of Consultations with External Organisations At the time of the research (early summer 2015) a total of ten organisations were connected with the Art Psychotherapy Service and nine had referred clients to the service. Forty nine individual clients had been referred into the service. Thirty front line workers are involved with the referral process. These include social care workers, project, support workers (10), social workers (2) key workers (11), medical practitioners, e.g. General Practitioners (GPs) and Psychiatric Registrars (5) and community mental health workers (2).

The majority of the referrals were made by Crosscare and the ACCES Team.

• Crosscare (20) • The Community Mental Health ACCES Team in Parkgate Hall (19) • Dublin Simon Aftercare (2) • DePaul (2) • Ushers Island Programme for the Homeless (funded by the HSE) (2) • The Salvation Army (York House) (1) • Sonas (1) • Housing First (1) • Sophia Housing (1) The researcher issued an email to all the above organisations inviting their confidential participation in the research process. The researcher then conducted confidential telephone interviews with representatives from the above organisations. A total of ten interviews were completed.

The interviews lasted between thirty and forty five minutes and were semi structured around the following topics: • Awareness of CCT and Art Psychotherapy • Understanding of CCT and Art Psychotherapy • Fit of Art Psychotherapy within the suite of services and supports for the target group, i.e. adults with mental health difficulties and dual or multiple diagnoses who are also

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experiencing homelessness or at risk of this?

• Sense of the benefits of and difference made by the Art Psychotherapy • Nature of current role and case load • Referral process and practice • Administration/appreciation of the measures o Connor Davidson Resilience Scale o Warwick- Edinburg – Mental Health Well Being Scale o Rosenberg Self Esteem Scale Summary of Findings The content of the consultations with representatives from the referring organisations (i.e. key workers, mental health workers, registrars, etc.) was analysed thematically. The results are presented below.

Awareness of CCT and Art Psychotherapy The majority of respondents became aware of the Art Psychotherapy through the original promotional drive that was initiated at the beginning of the pilot. Some recalled meeting the therapists and/or attending briefing sessions led by the Art Therapists. Most are familiar with the therapists and hold promotional material (e.g. leaflets) about the therapy on site in their services and in view of clients.

Some noted that their clients tend not to notice leaflets and posters and respond better to their sharing of descriptions of supports and services available to them. This suggests that some clients benefit from being positively informed and encouraged by their key worker/practitioner to consider supports such as that offered by the art psychotherapy.

Some referrers felt that they could deepen their awareness of the service on offer. They hinted that they were under utilising it.

Understanding of CCT and Art Psychotherapy There was a range of understandings and some variation in interpretation of the Art Psychotherapy service, what it offers and may achieve. It is noticeable that there are strong advocates of therapy and those who are a little more hesitant and/or cautious. Those who have therapeutic qualifications and/or have experienced therapy themselves and/or witnessed a good experience of therapy tended to be more positive, expansive and detailed in their expression of their understanding. This affirms the experience of the Art Psychotherapists who have noted more referrals from referrers with background experience of therapy and that their referrals have been given sufficient consideration.

Those who showed hesitancy or caution are open to being convinced of the nature and value of the art therapy.

Some referrers expressed appreciation of the art aspect of the therapy and believe it to be attractive to their clients. This is because it is perceived as gentler and less intense and perhaps less overtly demanding than more traditional talk therapies, e.g. counselling.

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‘The art part diffuses the fear’ Some noted that their clients already use art as a way to help them cope and achieve a sense of calm. A number of services distribute art packs7 to those clients that express an interest in art. This may or may not lead onto suitability and/or an expression of interest in attending art psychotherapy. It was pointed out that some clients may have a concern that they must be good at art to attend the therapy. This is a possibility as it was borne out in consultations with a small number of clients. Most practitioners go with the flow trusting that their clients are the best judge of their own needs.

There are signs that some referrers were a little uncertain of who precisely the service is targeted at and the specificity of the referral criteria. For example, is the therapy specifically for clients with a dual diagnosis and/or open to clients who are experiencing more general mental health difficulties but without a diagnosis? Some feel the service is a little out of sight and this may mean it is also out of mind. Questions arose about the capacity of the service, i.e. how many clients can it accept and work with at any one time?

This suggests that it has not quite bedded down yet in the awareness of all referring organisations as a possible therapy for their clients.

Some articulated an understanding of clear boundaries and distinctions between art, art classes and art psychotherapy. This was not widely spoken about or understood. It seems that this holds true for both referrers and clients and may warrant further attention and communication. Some were curious about the actual process of the therapy, its steps and flow and most importantly the way it ends. They wondered about how the ending comes about, how it is known and communicated to the client and how well the client is helped to understand this ending. This seems a valid curiosity as clients are also curious about endings and so too are therapists, in general. This draws attention to good practice and the therapeutic techniques to be alert to and prepare for positive endings.

All these are important questions as they shape our universal understanding and appreciation of therapy. The way in which the art psychotherapy is understood and valued, by referrers, influences the way in which they communicate and promote it within their service and to their clients. This in turn influences the outcomes.

Overall, there was a call for greater awareness and understanding of art therapy, what it offers and its capacity and potential as an intervention. There was also a call for more guidance about referral and the referral criteria.

Fit of Art Psychotherapy within the suite of services and supports for the target group Respondents expressed gratitude for and appreciation of the Art Psychotherapy service. It is considered a valuable intervention for adults with mental health difficulties who are also experiencing homelessness or at risk of this. It is deemed different, specialist, professional and necessary. All noted that the therapy is delivered by qualified therapists. Some commented that the therapy fits well alongside other therapies such as counselling and yet it is different and deeper. Some were curious about its fits alongside interventions such as CBT, anger management and other talk therapies. This suggests that there it is worth continuing to communicate the nature of the art therapy, its distinctive features and capacity to complement and fit within the broad suite of services available to support the target group.

This research confirms that referrers are careful and discerning in who they refer and to where.

They apply appropriate due diligence. A first requirement is that they know and trust the therapy and have confidence in the therapists. The results show that the Centre for Creative Therapies 7

These are simple packs containing paper and colouring pencils.

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has laid a foundation of trust amongst the community of organisations that serve the needs of the client group. This trust is achieved through a blend of communication, qualifications and the tone/ethos that the art psychotherapy has cultivated since its inception. It has generated an appreciation of art and of therapy and opened up discussion of the value of both.

This research indicates that there is a belief that the art psychotherapy, as it currently stands, is most suitable for clients/patients who fit certain criteria and in particular show stability across a few domains. These criteria are noted intuitively and/or directly in the client’s behaviour, demeanour and situation. These criteria are: • Client has a mental health diagnosis and/or is experiencing mental health difficulties, this can include a self declared diagnosis in some cases • Client shows signs of creativity in general and an interest in art making • Client shows signs of readiness, e.g. any or all of the indicators listed below.

• Client is exhibiting stability, has moved beyond crisis and is not psychotic or chaotic • Client demonstrates capacity to engage, potential to attend and follow through with the process • Client shows some signs of willingness in tune with their capacity • Client is experiencing difficulties communicating and seeking a safe place to practice expression • Client is clean and clear of harmful, addictive substances and/or managing any addictions and long out of treatment for any addictions • Client prefers and/or is likely to benefit from one to one work • Client is seeking an outlet where they are contained and safe • Client is already engaged in a wellness recovery action plan There is also an area of unknowing and referrers cite instances where they sometimes simply do not know whether an intervention such as art therapy will suit a client. In such instances their instinct and intuition kicks in and they call it one way or another. The trust that has built up around the art psychotherapy service allows freedom for this. Referrers feel that they can trust that their clients will be treated well, held safely, given time and some space until the next step becomes a little clearer for them and concerned others.

Benefits of and difference made by the Art Psychotherapy All those interviewed believe that their clients benefit from attending art psychotherapy. Some were certain and vigorous in their noticing and naming of an array of benefits and outcomes. Others were more hesitant and feeling that there is some mystery attached to the benefits and that this information belongs to the client. Some were especially hesitant and uncertain about naming/ claiming specific outcomes and/or attributing these to the therapy. Some simply did not know.

Most believe that it is impossible, at this point, for us to know and/or claim definitive or ultimate outcomes.

Some practitioners have ways, within their own practice, of checking in with their clients and discussing the therapy with their client. This is a conversation piece that is done gently, with full confidentiality allowing the client to lead and share how things are going for them. This works well for all parties when handled sensitively and well.

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First Fortnight - Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

The broad suite of benefits to their clients/patients noticed and noted by referring organisations is listed below. These benefits or outcomes are presented in tune with the flow of the process and outcome continuum. All lend themselves to tracking and/or tracing with the correct instruments.

• Engagement • Attendance • Enjoyment and wishing to return for more – this is considered a valuable and progressive outcome as it shows that they client is relaxing into enjoying the process and choosing to return for more enjoyment • Relaxation, practicing relaxing, experiencing/embodying and understanding the feeling of being relaxed • Release/relief (even if temporary) from problems and thoughts of their problems • Support to process life events/situations ‘able to place the past in the past a bit more/better than before’ • Feeling, trusting and using the safe space to work through things • Feelings of being of value, received and listened to on a one to one basis for an extended period time.

• Feeling of being supported • Activation of ability to notice, enjoy and sustain a therapeutic relationship with another human being • Strengthened communication skills achieved through practicing being with someone for a period of time and being guided to communicate in calm, bounded and supported ways.

• Self regulation and sense of stability (generated through regular attendance and the process of the therapy) • Enhanced coping skills • Increased resilience • Creativity and opportunity for expression • Enhanced sense of well being • Positive shift in self confidence and self awareness • Goal setting and attainment A small number noted that their clients found the therapy challenging (in a good way) and worked through this with the support of the therapist(s). Some expressed concerns about the possibility of the therapy opening up something in the clients that might be troubling or in some way unmanageable. So far these fears have been unfounded and yet they require noting as they alert us to thoughts and fears about the process. Others were naturally and appropriately protective of their clients, some who have had poor past experiences of other therapies, e.g. counselling.

Referrers are watchful of the way their clients are treated, how they are communicated with and respected. They are particularly vigilant around transition points such as beginnings and endings and seek safety and goodness for their clients. Their observation of the art psychotherapy, from a distance, has reassured them of the therapists’ steady, professional and supportive way of working with the target group. Some expressed surprise and delight at the subtle shifts in stability, confidence and renewed signs of contentment that they noticed in their clients after the therapy.

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One referrer noted the value of the therapist as a positive female role model for his client who had heretofore only experienced male therapists. Another expressed appreciation for the time invested in her client and the chance the therapy offered her in terms of being noticed as a human being, an individual in the safe one to one therapeutic setting. Another noticed significant positive changes in her client directly attributable to the therapy. She noted that her client made great strides ‘she loved the art psychotherapy - she learned to contain her personal story, to trust the therapist and then herself. She began to communicate better and this extended into her life outside the therapy’8.

The feedback conveys a firm sense of confidence in the therapy. One referrer stated that she can tell that her client ‘is being held safe and well’ within the therapy. Another recounted the lift and validation that she felt when she happened to overhear a small group of clients chatting about the therapy, with one explaining it to the others in light and positive tones. It was a conversation piece that was different, enlivening and moved them to discuss a new topic, share views and open to possibilities.

Referral process and practice Some referred in the early stages of the Project, in first flurry of promotion and then this petered out. Others are well tuned into the Project and refer regularly in accordance with the needs of their clients. The highest frequency of referral is from Crosscare and the ACCES Team.

All those interviewed work with a case load of clients/patients at any one time. These caseloads can range between five and one hundred. The percentage referral from any given case load to the Art Therapy is around 20%. This suggests that organisations are carefully selecting who they encourage to attend the therapy. It is also noted that not all those clients that were referred ended up attending the therapy. There is a process of selection and self selection at each stage of the process. An estimated 60% proceed to attend.

All those interviewed are aware of the referral process and steps. There is acceptance of the referral form and the completion of the measures. All knew the names of the therapists and considered them approachable and communicative. Many cited that there was good and useful communication with the therapist(s) during the referral process. The results point to a number of steps in the sequence and practice of the referral process as it currently stands. These flow as follows: Step One: Awareness Raise awareness of the Art Psychotherapy service, e.g. leaving brochures and leaflets at reception and opportune spots for clients to notice and pick up as they wish. Some organisations proactively inform and brief their clients about the art psychotherapy. Others discern its appropriateness and then offer to their clients.

8 This client attended the feedback sessions with the researcher and confirmed the positive experience of the art psychotherapy and its impact in her life.

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Step Two: Selection Referrers notice and select clients, from their caseload, in accordance with some or all of the criteria cited earlier. Clients also select in or out of the process at all stages. The choice to engage (or not) in the therapy is the clients.

Step Three: Informing Referrers tell their clients about the therapy and invite them to consider attending.

Some practitioners/key workers are more directive than others in the way they inform and encourage their clients to attend. There seems to be a continuum at play that ranges from leaving the client decide through gentle coaxing/encouraging to more directive encouraging style.

Step Four: Consideration/decision making Allowing clients to think about the therapy, what it means and to make their own decision about attending. Clients may decline to proceed with the therapy after initial selection, assessment and consideration.

Step Five: Referral Contacting the Centre of Creative Therapies, receiving and completing the referral documentation. The referral process and form helps to ensure that the referrer and the client understand that they are referring to art psychotherapy rather than an art class. There is a certain amount of responsibility placed on the client and referrer in completing the form which helps in entering the therapeutic relationship. For the client it helps to bring to mind the things that he/she may wish to work with and/or talk about with the therapist.

Step Six:

First Appointment/Assessment Arranging a first appointment with the Centre for Creative Therapies and completing the initial assessment. This also includes completion of the three baseline measures. Clients are also invited to sign a consent form. This step is usually completed by the Project Manager. It is an important interim step that separates the assessment from the first therapy session.

Step Seven: Therapy Commences The client begins the therapy with a clear contract of what it entails, beginning, middle and ending.

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The majority of referrers noted and accepted that once the therapy commenced that they stepped back and let the process unfold.

Administration/appreciation of the measures There were mixed views about the three measures used in the assessment process9. On balance most were positively disposed towards the measures as baseline assessment tools.

The strengths noted are the perceived robustness of the scales as standardised and recognised measures of self esteem, resilience and well being. The majority of respondents trust in their clinical value and appreciate their potential to gain some insight into the client’s makeup and to track client well being and psychological state in some way(s).

Some expressed confidence in the capacity of the scales as an initial assessment tool to build a picture of the client over time that will serve to support his/her treatment. Some found the scales and the information generated by them interesting and different from the way they would normally communicate with their clients. One person noted that their client enjoyed completing the scales, considering their responses and seeing them written down.

A small number of services (3) use similar measures in their work with clients. None use the same scales. None were formally briefed and/or trained in the use of the three measures.

The concerns about the measures were: • Lack of clarity and trust in what the scales are endeavouring to measure or gauge about clients.

• Concerns about the rating scales and how the results might be interpreted – are they reliable and robust?

• Preference for a more iterative assessment process, face validity, with less of a ’test’ look that may engender fear and/or negative connotations for clients of past assessments.

• Concerns about the impact of the scales on the client including sensitivity about the questions asked and thoughts that may be invoked by their content.

• Some concerns around client understanding of the measures (intellectual and literacy capacity) as they are being administered and this raises questions about the truth and robustness of the responses.

• A wish for sturdier understanding of the purpose, fit and utility of the measures. This could be achieved through specific briefing and training.

• Concerns about sensitivity and use of the measures and rating scales with the client group, i.e. ‘another form to fill’. Some referrers are jaded by forms and are reluctant to ask clients to complete yet another one. Thus the purpose and utility of the scales must be made abundantly clear lest the process become imbued with tedium and doubt.

9 Scale

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The Connor Davidson Resilience Scale, the Warwick Edinburgh Mental Well-Being Scale and the Rosenberg Self Esteem First Fortnight - Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

There are noticeable differences in the ways the measures are introduced to clients and in the way that they are administered. All administer the measures with the client and yet some complete the measures for the client, i.e. write in the responses while others encourage clients to complete themselves, with support and guidance. None of the referring organisations retain copies of the completed scales for their own use in monitoring and tracking their client’s progression and well being. All hand over their paper work in trust to the Centre for Creative Therapies. Only one kept copies of the results of the scales and did so in confidential locked filing cabinet.

Overall the variation in confidence and understanding of the measures is in need of attention.

There is risk of confusion and this could disturb the process of referral and ultimately impact on therapeutic engagement. This links to the totality of the referral and assessment processes and reaffirms the need for constant communication of clear guidelines to the wide range of potential referring organisations. This fits with good practice integrated care and support.

3.2. Client Case Stories Four detailed case stories were completed by the art psychotherapists as part of this research process. This section presents the distilled essence of the case stories, deliberately omitting personal detail so as to honour confidentiality. Occasional quotes are included to convey a reality.

The purpose is to offer insight into the work of the therapists, the nature of the therapy and the way it unfolds with the target group.

Insight into the Cases The case stories are about four clients, three male and one female. The age range is 29 to 49 years. All four were referred to art psychotherapy by organisations working within the homeless sector in Dublin city centre including the homeless community mental health team (CMHT).

All four cases have a clinical mental health diagnosis including post traumatic stress disorder (PTSD), schizophrenia, formal thought disorder, a history of self-harm, suicide attempts and/or depression. All had some history of substance misuse, including alcohol dependence, prescription medication and/or heroin addiction. One was on a methadone programme and one had ceased to use alcohol in recent years. Two have a history of offending and undergone periods of hospitalisation.

All have limited structure and little routine to their days. All have a history of social isolation, sensitivity, homelessness, poor and/or broken family relationships and very few social supports.

At least one has no formal education and low literacy levels.

All showed an interest in art and a keenness to try art psychotherapy.

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‘Connie was particularly suitable for art psychotherapy because of the level of trauma she had experienced; in the beginning she found it difficult to speak about her experiences and would sometimes start a narrative only to become completely confused, overwhelmed and embarrassed.

During the art work Connie began to work through her feelings, externalise and examine them in a safe way. As the therapy progressed she began to put words to her feelings and eventually weave together a narrative of her experiences’.

Features of Art Psychotherapy Practice The case stories draw attention to features of good practice art psychotherapy practice. These are described below with some quotes to illustrate the nature and extent of the process. This is mindful of the reality that each client’s story is different and yet the pillars of practice including environment, technique, timing (e.g. beginning, middle and end) and presence hold constant.

Environmental aspects, e.g. the room, the space, safety The room is called the quiet room and was initially used as a small sitting room or quiet space for clients. The room is used solely as an art therapy room. A long bookshelf in the room holds the art materials and there are two trestle tables in front of a window with blinds for privacy and shade.

There are two chairs positioned at the table and two more comfortable arm chairs away from the table. Some clients come in and sit on the comfortable chairs and then transition to the table. One or two clients always chose to sit and work at the table.

Elements of the Art Psychotherapy Process The following are core elements of the art psychotherapy process: • Review of client assessment (including Holistic Needs Assessment where appropriate) and any other relevant secondary information gathered in confidence from the referring organisation(s) • Therapist Preparation, before and after a session, including setting up the room and the art materials and clearing the space for the therapy. This includes the therapist’s own preferred mental preparation to receive the client and structure the session: The Clinical Practice Guideline for people prone to psychotic states reinforces that, ‘It is essential that the art psychotherapy space should be respected and free from interruptions’ and that ‘Art psychotherapy sessions should take place at a regular time and place’10 ‘Adam’s sessions were in the morning and I ensured that I had no clients directly before or after his session. I prepare by having a filling breakfast and no coffee, I clear my administration work beforehand. I meditate and do some grounding techniques in the twenty minutes before the 10 Brooker et al 2007:40

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session. When Adam missed a session without notifying me, I would often knit during the time in which I would wait for him to appear. I would make artwork with him in mind’.

• Open discussion of client’s expectations and wishes for the therapy • Therapists technique and way of being and working with the client with specific reference to: o Non directive approach o Allowing client to settle down, explore the art materials, careful use of silence and conversation. o Establishment and maintenance of clear boundaries e.g. time and timing of sessions, room the same each week, precise flow to the session and preparation for endings. o Containment for the client and security through focus on the concrete aspects of the artwork, the physicality of the materials, their textures and the colours. o Noticing of patterns, changes in client’s behaviour, presentation, cleanliness, attendance, punctuality, emotional state, etc. o Therapist’s demeanour, self awareness and self care. This is where the importance and value of regular supervision comes into play. This offers a safe space for the therapist to debrief, reflect on cases, to discuss challenges, self doubt, projection, transference and any concerns with a qualified psychotherapy supervisor. This external supervision is the central pillar of good practice as it facilitates the learning, growth and strengthening of the therapist. This in turn transfers to the client in that all learning is integrated into the therapist’s practice. o Use of the art, the materials and ways in which it can work within the therapy ‘The art materials often act as a ‘transitional object’ in the Winnicottian sense and working with the chosen materials may ease feelings of anxiety’

Benefits Noted Through the Case Stories The belief is that when someone engages in art therapy they are seeking to make some changes in their lives.

According to the case stories the most noticeable changes that occur are improvements in self image, self esteem and self awareness. The artwork has the capacity to be symbolic and can open up the client’s ability to put things in perspective, externalise feelings and to work/play with metaphors. There are noticeable improvements in client’s personal relationships and their ability to interact with others. This can range from the way the person interacts with professionals to family members and peers. This has a ripple impact on their lives in general. It can support sustained tenancy. When a client becomes better at communicating with professionals and expressing their needs it seems easier for them to gain the supports necessary to maintain a secure tenancy.

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The following is an insight into the benefits that the therapists noted for their clients: • Relationship Building ‘There is something very valuable in being able to be with another person and have things unsaid and still be able to be in the room with them. The art psychotherapy works at the client’s pace. With some types of trauma that are incomprehensible it is good to offer an alternative way of expressing what has happened or what feelings remain. During his therapy Eoin turned to other art forms such as poetry working with the work of other artists to help him ‘make sense’ of those intangible aspects of his experience’.

‘I noticed continued attendance and Mark started talking about more serious issues and events in his life rather than surface day to day issues. His building of a relationship with me the therapist was a significant step when interpersonal relationships have been difficult’.

‘I noticed that Peter was able to maintain a relationship, to repair and return after ruptures and to acknowledge what had happened’.

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• Self Care & Confidence ‘I noticed that Mary began to shower every week before her art therapy session. Towards the latter part of therapy she began to take more care of her appearance and decided to go to her GP with some health concerns that she had been ignoring. She also began to take time out of her house in the daytime and looked into joining clubs and the library. The level of detail and the length of her list of aims grew’.

• ‘I noticed increased confidence in Peter’s interactions with me. When reviewing the therapy with him he described things as ‘better now’’.

• Managing Emotions ‘I noticed Eoin begin to acknowledge the hostility and anger he had first displayed in his art therapy sessions’.

‘I noticed that Eoin was very invested in art making and was able to use the time to express how he was feeling about stressful life events both past and present. He reported that he enjoyed and valued the time in therapy. Despite his anger he managed to control this within the setting’.

• Sustained Tenancy ‘I noticed the Mark’s relationship with his mental health team and therapist strengthened.

His offending behaviour appeared reduced. His ability to attend and communicate about his therapy demonstrates an ability to be consistent and indicated an ability to maintain a tenancy with the correct supports in place. Towards the end of therapy Mark gained a place in long term supported accommodation. He benefited from an accepting and consistent relationship and towards the end of therapy he re-established relationships with significant others in his life’.

Challenges The case studies reveal a range of challenges that the therapists may encounter during the course of the therapy. These include challenges in getting started, managing non attendance, client motivation, noise and silence, the slowness of the modality, managing the therapy process, e.g. boundaries, transference and counter transference, maintaining continuity, preparing for and managing the endings with clients.

The following quotes offer some insight in the nature and depth of the challenges mentioned above. All these challenges are discussed during supervision during which the therapists seek ways to address them and strengthen their practice.

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• The Modality ‘The art psychotherapy engages those clients that find interacting with others difficult. It can be a creative outlet in sometimes an otherwise bleak landscape for people. It can be slow mainly due to the long term damage experienced by the individuals prior to using the service. It has to be carefully placed within realistic expectations of the recovery model. It is best when it is part of a team approach and where there are a number of links to the client and a number of people involved in their care or at least one whom they interact with and trust. It is important also that there is a way of contacting the clients if there are patterns of missed attendance, that the client at least has a phone so you can speak to them directly’.

‘Sometimes it is challenging to get people started in art therapy, the motivation levels of many of our clients is quite low. In such instances the help of key workers and other stakeholders in the client’s life is immensely valuable. Having a contact person for our clients really helps to get the therapy off the ground and to a good start’.

‘I value and respect the art work - it has the power to unearth the client’s somatic memories and deeply rooted feelings and emotions. This can be both an enlightening and unsettling experience as the artwork can represent things that the client has not yet been able to put words to. The therapy works courageously with this and supports the client in a safe environment’.

• Maintaining Continuity ‘Maintaining continuity with the work can be challenging when clients cancel or do not attend. When the client makes contact to cancel there is a positive aspect that the client was able to make contact and follow a reasonable procedure. It is more difficult is the client doesn’t have a phone or if their number changes constantly and the therapist is unable to speak with them directly. It was also difficult to maintain boundaries safely with volatile clients in a community setting’.

• Managing the Environment ‘The environment outside the therapy room is difficult to control in that the hostel is busy and often noisy as a result. This unsettles clients from time to time’.

• Preparing for and Managing Ending ‘Ending with some clients can be challenging as this is another boundary that may be perceived and/or experienced as punitive or rejecting. Clients are aware that therapy is structured and that it will end at some agreed point. There are instances when clients wish the therapy and the relationship to continue. This can bring up feelings such as frustration, anger, loss and disappointment. This requires care and attention and sometimes drawing in the surrounding support of key workers to create a safe space and transition for the client’.

‘Sometimes it is difficult to come to a consensus around ending with clients who have little 24

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support and very few close relationships in their lives. For some clients it can be useful to discuss cases with the wider team and put supports in place for the transition point when therapy ends’.

3.3.

Client Feedback

Eight clients participated in the feedback interviews with the researcher. Six were male and two were female. All had a mental health diagnosis e.g. schizophrenia, depression, organic mania.

Six had travelled especially for the feedback interviews and two lived on site at Haven House. The age range was 18 through to 60+ years.

The interviews occurred in a bright, clean and purposefully designed calm space in Haven House.

The therapists had carefully prepared the room, conscious of seating, space, light, air, comfort and privacy. All attended voluntarily and seemed in good form on the day. Two (who had disengaged from the therapy) seemed eager to please and less certain than those who had attended and completed their therapy.

The intention was to activate gentle and yet firm conversations with the clients about their experience of the art psychotherapy. The researcher sat in the room and meditated quietly in advance of the sessions. She sat at ease during the sessions and guided the conversation.

She held no pen or paper. She sat purposefully still and invited in the conversation. After each meeting she made notes in a structured template11 under specific headings. The results are presented thematically below.

Words clients used to describe the process of art therapy, what they enjoyed and the way the therapist worked with them.

‘The art matters and at the same time it does not. It is something to do. I came and worked with the clay on the days when I could not speak’.

‘Sometimes there was a lot of silence’.

‘Subtle, she (the therapist) is subtle in the way she helps me see things differently’.

‘She helps me be more positive about myself, see myself positively. I want to be able to describe myself using positive words and to think positive thoughts about myself’.

‘She knows when to speak and when to let me be (quietly working away with clay). She knows’.

‘She is kind, everyone here is kind’.

‘She is bright, cheerful. She has a sense of humour, we laugh and I like laughing.

She listens to me’.

‘She is like a friend and yet different from an ordinary friend, I can tell her things that I know will go nowhere else. This helps me let go of things, and feel free. I have told her lots of things, for the first time and now I feel lighter’.

‘Company, I enjoyed the company. I used to have more company at an earlier stage in my life and socialise and that is now gone’.

11

See Appendix One for full template.

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Changes noticed in themselves that clients attributed to the art therapy and their art making.

All expressed appreciation of the therapy and gratitude towards the art therapist(s). Three talked of their eagerness to give back or give a gift to their therapist. One client said that he is giving back to society in small ways (e.g. through talks about his experience of mental illness) as an expression of his gratitude.

• I feel my confidence has changed and I am free. To me confidence is about freedom, my freedom.

• I am in my clothes, I am dressed, I came here to meet with you today, even though I am nervous as I have never met you before. I have butterflies in my stomach and still I am here.

• I am minding myself better. I am attending my GP. I am better organised in my life and my home. I am thinking about my relationships. I am considering myself more and my needs.

• I am working and I am happy working. I am in a new relationship and I feel loved.

• It helped me to jump out of the homeless and helpless mindset • It is the kindness that I recall and appreciate.

• I write now, every day and it helps me.

• I want to come back to the therapy now I want to give more to it (client who disengaged prematurely from the art psychotherapy).

• I want to be able to say positive things about myself, instead of negative ones (client who disengaged from the art psychotherapy).

Two clients seemed unable for and avoided the questions about how they had changed and how they were feeling. This part of the conversation passed without angst and was let be.

Observations of the Researcher Most clients mentioned the art and how much they loved and enjoyed it. Each had a different medium that they very clearly and distinctly enjoyed. For example one loved working with clay, another loved creative writing, another liked chalk and one preferred only to work in pencil and with no colour.

Some clients were more focused than others on their art making and what they created and how good or not they believed this was. This engendered pride and a little bit of anxiety for some. One client seemed to confuse the art therapy with being good at art. Others did not mention the art.

Most mentioned the ending of the therapy and how this had unfolded for them. Most were comfortable enough about the ending and understood and accepted this. It was evident that they had worked this through with their therapist. Three had chosen to disengage and all expressed a 26

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wish to return to the therapy12.

All value the time and presence offered by the therapy. All notice the way that the Art Psychotherapist is with them. Each had a different way and level of articulation of this and yet the common theme was appreciation.

The case studies and conversations with the case study clients reveal that there were different levels of engagement and appreciation. This fits naturally with the variation across clients in terms of their diagnoses, capacity and situation.

3.3. Results of Analysis of Pre and Post Measures The results of the three scales were examined for the eight service users who completed at two junctures. The results show more positive shifts than negative across all three scales. The results also show the possible usefulness and benefits of more careful use of these scales in monitoring and tracking clients over time. Each of the scales is standardised and recognised in mental health research elsewhere.

There is scope for more robust use of the scales as standard tracking measures within the Centre for Creative Therapies and sister organisations. The analysis below serves as an indicator of this potential in evidence based research and comparison studies.

The Connor- Davidson Resilience Scale This scale contains twenty five positive statements, e.g. able to adapt to change, coping with stress strengthens and I like challenges. Respondents are invited to indicate their experience of each statement over the last month on a five point scale (not true at all, rarely true, sometimes true and true nearly all of the time). The table below sets out the analysis of results. Five out of the eight clients show positive upward shifts in their resilience ratings.

Those clients with less positive shifts are noted to have more severe mental health diagnoses and circumstances. These and other factors (including ongoing medical, psycho social and environmental) warrant consideration in our analysis and reporting of results. Such is the sensitivity of the client group and the call for ongoing consistent ethical and clinical governance in all aspects of the work.

12 This may be true or reflect an eagerness to please on the day. Either way it is worth following through and re offering the therapy to these clients. The researcher discussed this with the therapists and they are aware of possibilities and re activating the therapy as appropriate for these clients.

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Shift Up

Shift Down

Remain Same

Client One

13

2

10

Client Two

14

2

9

Client Three

3

10

12

Client Four

10

11

4

Client Five

16

4

5

Client Six

8

11

6

Client Seven

12

2

11

Client Eight

0

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5

The Warwick Edinburgh Mental Well Being Scale This measure contains fourteen positively worded statements about feelings and thoughts. The respondent is invited to describe their experience of each feeling or thought over the last two weeks using a five point scale (none of the time, rarely, some of the time, often and all of the time).

The table opposite sets out the analysis of results. Four out of the eight clients show positive upward shifts in their well being ratings. For example one respondent shifted from indicating that he ‘has been feeling loved’ rarely to ‘all of the time’. The results for two clients show shifts downwards in their self reported mental well being. This fits with observations made on the day of feedback and the therapist’s assessment of those clients.

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Client One

Shift Up 13

Shift Down 0

Remain Same 1

Client Two

10

1

3

Client Three

1

10

3

Client Four

4

6

4

Client Five

12

0

2

Client Six

8

1

5

Client Seven

3

6

5

Client Eight The Rosenberg Self Esteem Scale13 This measure contains ten statements (mixed wording five positive and five negative).

Respondents are asked to indicate their agreement with each statement on a four point Likert scale (strongly agree, agree, disagree, and strongly disagree). The scoring range is 0-30, with 30 indicating the highest score and self esteem level. In general population studies the average Rosenberg self esteem score is 15.

The table below presents the Rosenberg scores for the sample of eight clients across two administrations. The results show positive shifts for five out of seven clients. Of those clients who show a negative shift in their self esteem scores they also show a shift downwards in their resilience scores. Again, this fits with observations made on the day of client feedback and the therapist’s assessment of those clients.

13. Rosenberg, 1965. The Morris Rosenberg Foundation, University of Maryland, USA. The scale may be used without explicit permission. The author’s family like to be kept informed of its use.

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Rosenberg Self Esteem Scale (RSES) Examination of Difference in Scores over time

Client One Client Two Client Three Client Four Client Five Client Six Client Seven Client Eight

First Score on RSES

Second Score on RSES (9/15)

Shift (+ or -)

7 7 12 13 6 22 19 --

20 12 11 19 16 20 20 19

Positive shift Positive Shift Negative Shift Positive Shift Positive Shift Negative Shift Positive Shift

By way of further example the shifts on one statement ‘I take a positive attitude to myself’ were examined. The results in the table below show a positive shift for five out of eight clients on this one statement. The others remained the same across both administrations of the scale and in each instance they agreed with the statement.

Rosenberg Self Esteem Scale (RSES) ‘I take a positive attitude to myself’ Shift Up Client One Yes (from disagree to Agree) Client Two Yes (from disagree to Agree) Client Yes (from disagree to Agree) Three Client Four Client Five Yes (from strongly disagree to disagree) Client Six Yes (from disagree to Agree) Client Seven Client Eight 30

Shift Down

Remain Same

Yes (from strongly Agree to agree)

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Yes (agree)

3.3. Project Team Feedback The researcher met with the project team on four occasions during the research period (May – October 2015). These consultations centred on discussing the nature of the art psychotherapy, referral mechanisms, client case stories, progression, learning and challenges.

Overall, the Project Team are satisfied with the way the Art Psychotherapy has unfolded. In particular they value the host premises and the good relationships built up with Crosscare and Haven House. They also appreciate the network of appropriate contacts and goodwill that have been built up with the range of referral organisations within the homeless sector.

The main learning has been in relation to developing the inwards referral and client assessment process, meaningful use of the scales and managing the challenges that come with individual client cases. This is the nature of the work which is supported through regular team meetings, peer support and external supervision. All of these themes are discussed within the body of this report.

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Chapter Four: Conclusions & Pointers for Consideration

This chapter shares the conclusions of the evaluation of the pilot Art Psychotherapy Project. It returns to the original intentions and stated objectives and draws attention to progression and learning in relation to each.

A set of recommendations are offered as pointers for decision makers in their deliberations around optimal ways to respond to the needs of adults with mental health difficulties and dual or multiple diagnoses who are also experiencing homelessness or at risk of this.

4.1. Conclusions Art therapy is grounded in the premise that the creative process of art making is healing and life enhancing and is a form of non verbal expression of thoughts and feelings14. Based on the client feedback this research concurs with the above. The therapy currently serves as a dedicated place for service users to consciously attend, be present, communicate and benefit from a specialised therapy. It offers a safe space, an assigned time of containment and company through a professionally structured modality. This is a portal to enrichment of their lives beyond the routine and ingrained patterns of their current existence.

This research builds on and validates the findings of action research conducted with a similar client group in St Mungo’s, London15. The results further affirm that delivering art psychotherapy adds a new dimension to supports to enable clients with mental health diagnoses to move themselves on and out of their current situations and enhances their capacity to cultivate positive change in their lives. It is important that the art psychotherapy is located within a structure and suite of other services that are serving the needs of the target group.

The Process There is trust and respect for the art psychotherapy service as it is currently constituted. The process is appreciated and honoured by all and considered mysterious and uncharted territory by some. This is evident through feedback from service users and referral organisations.

There is something inherently good about art psychotherapy. It is different and fresh. The art brings the possibility of colour, light and creativity into a landscape that seems laden with perceptions of bleakness and greyness. The psychotherapy invites in new energies, different thinking and possibilities of potential resolution and/or acceptance of psychological difficulties. It also carries some fears, for some, of encountering darkness or difficulty that may seem impossible to bear. This raises questions, for some as to how appropriate it is to draw out such possibilities.

The clients interviewed for this research showed a knowing of the potential of art psychotherapy.

The lighter, brighter and gentler energies that surround the project are attributable to the Art Psychotherapists. They are the face of the project and its centre piece. They are considered professional in their way of working and operate in harmony with universal good practice. Their qualifications are known and valued. The combined softness and firmness of the intervention are appreciated. The results show that attendance and engagement with the art psychotherapy have the power to activate, facilitate and support positive shifts in a client’s sense of self, well being, resilience and self care. There are still unknowns around the capacity of the intervention 14 15

American Art Therapy Association, 1996.

Peter Cockersell. Journal of Public Mental Health. Vol. 10 No. 2 2011, pp 88 – 98.

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to hold and work through the unexpected that may emerge. This calls for ongoing monitoring, communication and education to reassure of the robustness of the modality.

Outcomes This research notes a range of possible positive outcomes as a result of and/or related to the art psychotherapy. These outcomes vary from client to client and sit on a continuum starting with initial engagement, moving through attendance and progressing to noticeable positive shifts in self awareness, stability and self confidence. All of these outcomes are of value and in harmony with each client’s individual needs and situation. Attendance is a pivotal indicator of motivation and all other indicators stem from this.

Repeat and regular attendance is determined by many factors not least the client’s internal motivators, activated, in some part, with encouragement, acknowledgement and acceptance (from key workers and significant supportive others) and the relationship that begins to establish between the client and the therapist.

The art psychotherapy process is necessarily slow with quantum leaps from time to time and yet not always guaranteed or even possible. Some clients will seem to remain the same and that may well be a positive outcome for them in terms of stability, company and containment or other measures of well being not yet known.

There is general consensus and a prevailing belief that engagement with the therapy is a good thing, as is regular and reliable attendance and returning for more therapy. These outcomes are the first tier and are immensely important and significant for the target group. There are times where merely having something constructive, wholesome and nurturing to do and choosing to do it is a good outcome Such outcomes may well be of equal or possibly more value when set alongside the quantum leaps that have been made by some clients as described in the next section.

This research indicates that the early outcomes of engagement and attendance are indicators that a client is on the pathway towards stability and/or positive change. This is in harmony with other research on human progression and propensity to change. Naturally, it is necessary to be alert and conscious around these claims and seek to check and validate them with further attention, careful monitoring and measurement. It is certainly possible and acceptable to attribute the good results noted in this research in some quantity to the art psychotherapy and work completed by both clients and therapists in unison. The value of conscious wrap around support and the encouraging influence of the referring organisations and in particular key workers are also playing a part in any positive outcomes noted.

There are a number of factors at play and thus collegiality is noted as a core pillar of good practice (see figure two). Good collegiality within and across the organisations that serve the needs of the client group encourages communication and facilitates integration and continuity of care.

Finally the part played by the client in their own care and shifts in outlook and well being is central.

In the words of one client when asked what made the therapy work for him ‘happenstance, my perseverance, doing the (therapeutic) work, presence and kindness of the therapist and her subtle questioning helped me to see things in a different way over time and to eventually jump out of a homeless mindset’. We return faithfully to the mysterious formula of the readiness of the client to engage coupled with the therapist’s presence, alertness and technical competence to nurture, cultivate and encourage those energies in the client. The art making is a lever and catalyst contributing to this process.

There are examples of clients manifesting significant positive change in their lives that they attribute to their experience of the art psychotherapy. These stories were verified through the triangulated methodology whereby client, referrer and case stories converged to offer a pretty full 33

picture of how the therapy unfolded. We also pay our respects to three clients who passed away in recent times. Each left an impression on the therapists and their presence in this study is noted.

The research indicates that the success of the therapy is determined by four inter related factors as displayed in Figure One. With further monitoring and continued research into the process and impact of art psychotherapy more will be revealed and confirmed about this inter play. This in turn will inform the nature and content of the therapeutic practice and any necessary refinements to ensure continuous improvement in our response to the needs of the target group.

Figure One - Factors Influencing Positive Outcomes The core elements of good practice noted in the art psychotherapy cluster within four headings as depicted in the figure two below:

Figure Two: Good Practice Art Psychotherapy 34

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Return to Original Stated Objectives There were six stated objectives for the art psychotherapy project at the outset. These are revisited here with an overall comment as to the extent to which each has been met. Further detail is found within the body of this report.

• To meet an unmet need in mental health provision in Ireland as no Art Psychotherapy is provided in any formal, consistent or evaluated project within the Community Mental Health Model in homelessness.

The art psychotherapy project has tested the practicality and impact of providing such a specific mental health support to the target group. The results of this review indicate that the therapy is working well and that most clients are responding. There is consistent referral into the therapy with some organisations referring more than others. There are signs of a widening out from the original referral intentions or expectations beyond the ACCES Team and Program for the Homeless. There is scope for more strategic communication and promotion of the service to ensure clarity of intent and fit.

• To achieve a reduction of symptoms of mental ill health through the provision of Art Psychotherapy.

The early indicators from this research show that the art psychotherapy is well received and has had a positive impact on the mental health and well being of many of those who attend.

The impact varies along a continuum of outcomes with some clients manifesting more pronounced positive shifts than others. Over time and with strengthened monitoring and tracking of progress we will gain greater clarity around the precise power (and limitations) of the therapy to reduce, stabilize and/or enhance mental health and well being.

• To support the progression of service users out of homelessness and into secure tenancy.

The early indicators from this research show that art psychotherapy offers clients an opportunity to progress along a continuum towards stable and sustained tenancy. This is achieved through the company, containment and therapeutic techniques applied through the therapy. The client feedback shows that clients have been supported to restore, strengthen and sustain relationships and their capacity to stabilize and in some cases secure and/or sustain tenancy. This seems to work best when the suite of services are working together to support the client and the art psychotherapy is located firmly and clearly within this suite. In practice this calls for good communication and relationships between the therapists and their colleagues in the referral organizations. The signs are that the Centre for Creative Therapies has built a firm foundation of good relationships in this regard.

• To challenge the perceptions that art classes given as standard program activities in generic mental health day centres or day hospitals constitute Art Therapy.

The results of this research confirm that not everyone is aware of the nuanced distinctions between the different interventions, education, recreational and other types of therapy and psychotherapy that may support human growth and development. The Centre for Creative Therapies is unique and the art psychotherapy is a new and unfamiliar modality to most. The consultations reveal that most people are interested in art psychotherapy.

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They seek to understand more about it, what it is, where it fits and how it can help. This offers an opportunity for the Centre for Creative Therapies to continue to raise awareness of the nature, depth and potential of art psychotherapy as a way to treat and support mental health and well being. • To meet the needs of the homeless mental health population with a therapeutic modality known to have a proven effectiveness with those with limited insight into their mental ill health, below average literacy and high levels of suspicion towards establishment figures.

The results of this research indicate that there is a place for art psychotherapy and it has the power to meet the therapeutic needs of a certain cohort of people who are experiencing mental ill health and homelessness or at risk of this. This is with a number of provisos relating to fit and location of the art psychotherapy, precise referral criteria and ongoing monitoring and tracking of results. These are discussed and outlined firmly in the recommendations that follow. • To begin a research basis for Art Psychotherapy Provision as part of the recovery aids available in the community.

This research satisfies the above objective in that it lays the ground work for a sturdy ongoing body of evidence based research for the art psychotherapy project into the future.

It is important that this is followed through with maximum use of the tracking measures, collaboration with referral organisations and sharing of research results to inform good practice.

4.2. Recommendations The following recommendations arise out of the conclusions of the research.

These recommendations are set out in the spirit of responding as best we can to the needs of adults with mental health difficulties and dual or multiple diagnoses who are also experiencing homelessness or at risk of this.

1. Continue the art psychotherapy, as it is currently provided by the Centre for Creative Therapies, subject to provisos as outlined below.

2. Strengthen the evidence generating/research component within the Centre for Creative Therapies by advancing the noticing and tracking, i.e. strengthen the internal monitoring processes. Note and be alert to the concern expressed that clients might get stuck in the process or that it might open up something. Strengthen awareness and understanding of the techniques and tools of art therapy to work with these situations as they arise within a particular case. Reassure surrounding organisations, and in particular referring staff, that this is part of the process and show that the therapists are equipped to work with clients through the range of eventualities and frailties that may emerge. This is the essence of good practice therapy. Strengthening the research component to the work will also generate robust data to show what works and what does not, e.g. number of sessions, ways of working with certain clients, managing endings, etc.

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3. Rearticulate the purpose and intention of the art psychotherapy and communicate this strategically. This includes generating ways to activate exposure of relevant decision First Fortnight - Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

makers and front line workers to the therapy and its way of working. Ensure that this is clear and that the specific referral criteria are communicated (see recommendation 7 and 8).

4. Activate careful and measured promotion of the service to secure its presence and fit within the range of services for homeless people. Build relationships and inform key workers and practitioners about the art psychotherapy. Do this in a steady and measured way with a clear statement of the potential suite of outcomes and any limitations. Share the learning from the work of the Centre for Creative Therapies in inspirational ways whilst honouring client confidentiality.

5. Convey clearly the fit and place of the art psychotherapy within the continuum of care, i.e. for particular clients at a particular stage and in tune with specific criteria.

Consider the possibilities of re introducing group sessions as a taster or additional offering into the future.

6. Work to ensure careful and appropriate referral. This will be achieved by clearly and continuously communicating the referral criteria to relevant stakeholders. This is with particular emphasis on front line workers who are likely to refer into the service.

7. Strengthen the clarity and precision of the referral criteria that relevant workers in the surrounding organisations will use to determine who they refer into the Centre for Creative Therapies. These should include the following which may be refined and/or prioritised with the support of further evidence in time: o Client has a mental health diagnosis and/or is experiencing mental health difficulties or a specific mental illness, this can include a self declared diagnosis in some cases o Client shows signs of creativity in general and an interest in art making o Client shows signs of readiness, e.g. any or all of the indicators listed below o Client is exhibiting stability, has moved beyond crisis and is not psychotic or chaotic o Client demonstrates capacity to engage, potential to attend and follow through with the process o Client shows some signs of willingness in tune with their capacity o Client is experiencing difficulties communicating and seeking a safe place to practice expression o Client is clean and clear of harmful, addictive substances and/or managing any addictions and long out of treatment for any addictions o Client prefers and/or is likely to benefit from one to one work o Client is seeking an outlet where they are contained and safe o Client is already engaged in a wellness recovery action plan 8. Convey the above referral criteria and link back into evidence generating and profiling of clients benefitting from the therapy. This will strengthen confidence in their reliability over time and/or inform their refinement as appropriate.

9. Strengthen the research mechanism within the project to explore and expand our understanding of readiness for therapy of this type. The evidence from this research shows that referrers are discerning who best to refer in. They are using a range of criteria and intuitive signs to aid this decision making process.

10. Place a spot light on the three scales intended to track client mental well-being and

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resilience. It is important that the utility of these measures is maximised as standard tools to notice, track and gauge progression and positive change. At this point it seems best to proceed with all three and notice patterns if any in individual and cross referenced results.

Strengthen the utility and gravitas attached to these scales as indicators of evidence. Step up the briefing and training in the use of these. For example, the Warwick-Edinburgh Mental Well Being Scale (WEMWBS) has a user guide that will guide its best use for the Centre for Creative Therapies.

11. Explore ways to share the learning from analysis of the results from the scales over time in collegial and inspirational ways (e.g. with other similar projects in Ireland and elsewhere) whilst honouring client confidentiality. There is scope for a more academic exercise in this regard that could usefully inform the greater body of research work on their use and application with the target group and beyond.

12. Draw attention to the project’s commitment to careful endings and communicate this element of practice within the community of organisations charged with minding this client group. This will serve to build confidence in the service and reassure external stakeholders that clients are safe within the therapeutic space. It will also draw attention to the transition points for clients and alert us to careful management of same.

13. Begin to build up a strong sense of targets, realistic numbers, through put and exit strategies. Overtime, with good research, it will become clearer as to the optimal number and sequence of sessions that work well in terms of meeting client needs. Such evidence/ data will empower the project to offer guidance around typical numbers of sessions, ceilings, timing, etc. The results signal that a case load of 30 clients at any one time is workable for the two therapists. This is based on an average total of 15 sessions per week.

The results also show that time is a determinant of positive outcome(s). This relates to numbers of sessions offered to any one client. The process is necessarily slow and depth of engagement and attendance are good signs of client progression. The average number of sessions for any one client is 25. This suggests that more rather than less sessions are necessary and desirable, up to a point.

14. Continue to brief the surrounding organisations about the art psychotherapy. Raise awareness and nurture the possibility of incorporating art psychotherapy, into the suite of integrated interventions for the target group, as appropriate. Set the art psychotherapy usefully alongside other therapies, such as CBT, motivational interviewing, relaxation therapies, etc.

15. Strengthen collaboration and collegiality by deepening connections with referring organisations and in particular the mental health teams and critical key workers. Consider sharing evidence generating studies, meta- analysis of results, results of agreed scales and standardised tracking measures such as the Warwick-Edinburg Mental Well Being Scale.

16. Implement a system to track progression and augment the rigour around outcomes.

Build the continuum of outcomes commencing with electing to participate (what prompts this eager to please and/or eager to engage in art work and/or therapeutic work or both).

Communicate the continuum of outcomes and map client results onto this continuum over time. Celebrate the enjoyment, movement and relief experienced by many clients as they engage with art psychotherapy. Track attendance, engagement and disengagement patterns and ascertain, over time, how these affect outcomes.

17.

Continue the regular external supervision and support of the art psychotherapists.

Maintain the commitment to reflective practice and learning within the project. This includes regular attendance at external supervision and internal team meetings.

This will strengthen capacity and inform continuous improvement in response to the needs of the target group.

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In my early years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his/her own personal growth?

Carl Rogers

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Bibliography The following articles and research documents were considered: • The Use of Art Work in Art Psychotherapy with People who are Prone to Psychotic States – An Evidence-based Clinical Practice Guide. OXLEAS NHS Foundation and Goldsmiths, University of London.

• Homelessness and mental health: adding clinical mental health interventions to existing social ones can greatly enhance positive outcomes. Peter Cockersell. Journal of Public Mental Health. Vol. 10 No. 2 2011, pp 88 – 98.

• Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP).

Savneet Talwar, MA, ATR-BC, LPC. The Arts in Psychotherapy 34 (2007) 22-35.

• Reflect Interview using audio-image recording; Development and Feasibility Study. Neil Springham and Julie Brooker. International Journal of Art Therapy: Formerly Inscape. (13 May 2013) • A Systematic Review and Economic Modelling of the Clinical Effectiveness and cost effectiveness of Art Therapy among people with non-psychotic mental health disorders.

Uttley, L., Scope, A., Sevenson, M., Rawdin, A, Taylor Buck E. Sutton, A., Stevens, J. Kaltenthaler, E., Dent-Brown, K., Wood, C. Journal of Health Technology Assessment.

Volume 19. Issue: 18. March 2015.

• Handbook of Art Therapy. Edited by Cathy Malchiodi. Guildford Press, London. 2003.

• The Invisible Wound: Veteran’s Art Therapy. Internal Journal of Art Therapy, 2014. Volume 19.

• The MATISSE Study: A randomised trial of group art therapy for people with schizophrenia.

Crawford, M.j., Killaspy, H., Kalaitsaki, E., Barrett, B., Byford, S., Patterson, S., Soteriou, T., O’ Neill F., Clayton, K., Maratos, A., Barnes, T., Osbor, D., Johnson, J., King Michael, Tyrer, P., Waller, D., BMC Psychiatry 2010.

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First Fortnight - Centre for Creative Therapies Homeless Mental Health Pilot External Evaluation 2015

Appendix One Centre for Creative Therapies – Homeless Mental Health Pilot External Evaluation Structured Interviews with Referring Organisations - September 2015 • Awareness of CCT and Art Psychotherapy • Understanding of CCT and Art Psychotherapy • Fit of Art Psychotherapy within the suite of services and supports for the target group, i.e. adults with mental health difficulties and dual or multiple diagnoses who are also experiencing homelessness or at risk of this?

• Nature of current role?

• Length of time in current role?

• Number of clients they have on their case load • Number that they have considered referring to CCT Art Psychotherapy (and under what criteria)?

• Numbers that they have actually referred to CCT Art Psychotherapy?

• Aspects of their client’s situation or profile that help determine whether they refer?

• Experience of the referral process and procedure?

• Use of the referral forms? o Ease of completion o Use, e.g. in the case management of supports for client o Refer back to? o Storage of?

Administration/appreciation of the measures o Connor Davidson Resilience Scale o Warwick- Edinburg – Mental Health Well Being Scale o Rosenberg Self Esteem Scale Practice • Post referral practice?

• Reflective practices?

• Sense of CCT and Art Psychotherapy - what it does and how it does it and how it fits within the wider suite of service provision and support for those who are experiencing or at risk of homelessness?

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• What is their sense of the power of the psychotherapeutic intervention, e.g. does it reduce sense of exclusion, enhance sense of well being, resilience, etc?

• What difference has Art Psychotherapy made to date?

• What difference do they believe Art Psychotherapy may make in the coming months/years?

What else do they wish to share in the interest of strengthening the CCT Art Psychotherapy as a response to those with mental health difficulties who are experiencing or at risk of homelessness?

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Appendix Two

Meeting with Service Users September 2015

Proposed Points of Observation and Topics for Discussion (in harmony with Client’s wishes and capacity)

Introduce and the process (gentle and confidential) Profile/Demeanour Sense of how the art therapy has served to support them in their lives Growth, change, difference noticed since starting the art therapy.

What are you enjoying about Art Therapy?

What do like about coming here?

What do you like about being with E or L? How many times do you come?

What is it that draws you to return?

What was it that you like doing the sessions?

How did you feel during?

How did you feel afterwards?

Could you say a few words to describe how you were when you started AT? Could you say a few words about how you are today (after your sessions of AT)?

Have you had any other forms of therapy?

How was AT different from that therapy?

How hopeful are you?

How strong are you?

How confident?

How calm are you?

What do you do during the session?

What would I see you doing if I was watching a session?

Does it work for you?

How does it work?

How are you feeling since you started the Art Therapy?

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What have you learnt about yourself?

What do you call the therapy, e.g. art therapy, meetings with L or E, etc.?

How are you feeling now about the therapy?

What are your wishes for the future in terms of the therapy?

How long would you like it to continue?

How will you know when it is complete, when to stop coming?

Extend the benefit of the therapy beyond the therapy itself

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