Thesis Thursday, a weekly series of consecutive sections from my master’s thesis, Art Therapy with Type 1 Diabetic Adolescents, Non-Adherent to Treatment: A Literature Based Study, will be coming to a close next week. Last week, I presented Clinical Applications from Chapter 5: Discussion. The follow-up and final section of Chapter 5 includes Implications for Future Research and Proposal for a Small-Scale Study.
Implications for Future Research
It is proposed that research into the use of art therapy with type 1 diabetic adolescents be implemented, as a new means of addressing a persistent problem that is the source of frustration for clinicians who work with this population, and who are frequently left scratching their heads in search of an effective approach.
Because art therapy with diabetic adolescents has not been researched, small-scale studies exploring the relationships between this treatment modality, the self-management behaviors of this population, and health outcomes could be developed and implemented. The results of such studies could then be examined for trends and larger scale studies could be developed. Both quantitative and qualitative methods have potential application. The synthesis of the results of multiple studies would allow researchers and clinicians to develop and implement effective treatment strategies using art therapy with non-adherent type 1 diabetic adolescents.
Proposal for a Small-Scale Study
A qualitative multiple case study is proposed to assess the general response to the method of treatment, art therapy, from both the adolescents’ and the art therapist’s perspective. One reason for choosing this type of research format is that “evidence from multiple cases is often considered more compelling” (Yin, 1994, p. 45) than a single case study format. Verhoef, Casebeer and Hilsden (2002) identify purposes for using qualitative research methods: (1) “gaining an understanding of an intervention by identifying the meaning of the intervention for the participants” (p. 276); (2) “understanding the particular (natural) context within which the participants act, and the influence that this context has on their actions”, an important part of which is “identifying the role of the patient-provider interaction in the intervention” (p. 276); (3) “understanding the process by which events and actions take place” (p. 276); and (4) “assessing how perspectives of reality of different stakeholders (patients, practitioners, and researchers) on interventions differ” (p. 277).
While the benefits of a group therapy format have been reviewed, because there have been no studies on the application of art therapy with diabetic adolescents, it is recommended that the preliminary study be conducted individually. The reasoning is that it is important to garner a more thorough comprehension of the variety of issues each individual might have. To construct a potentially effective group art therapy protocol, there should be an understanding of the type of individuals and the range of issues each might contribute to a group. It is thought that an adolescent might be more disclosing on an individual basis once a therapeutic alliance begins to take form. With the knowledge of the more personal aspects, fears and concerns that a diabetic adolescent might be experiencing, an art therapist conducting group art therapy can more effectively present tasks and negotiate the dynamics of a group.
Four to six adolescents, who have been identified by their healthcare providers as non-adherent to self-management tasks, would be recruited from a larger urban medical center offering specialized multi-disciplinary pediatric endocrinologic services. It is suggested that a short treatment course of ten individual sessions be implemented. Ten sessions would provide more time for the adolescent and therapist to establish a therapeutic alliance, essential if the adolescent is to trust the therapist and feel comfortable with self-disclosure. Additionally, the number of sessions would allow the therapist and adolescent the opportunity to execute and process as many art therapy tasks. The number of sessions would be limited to ten because the lengthier the study, the higher the risk of drop-out by the participants. Each session would involve the presentation and completion of a task that addresses some aspect of diabetes or has a diabetes-related theme. A selection of materials would be offered for most sessions in order to give the adolescent choice and an increased feeling of control. Tasks for inclusion are:
Session One: Draw what it feels like to have diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. The purpose of the task is to gain some understanding of how the adolescent feels about his diabetes. The artwork serves as a vehicle for verbalizing these feelings as well as an outlet for expressing these feelings in a non-verbal format. The therapist has the opportunity to begin to establish a therapeutic alliance by being accepting of the artwork and the associated feelings, and empathizing with the adolescent. Session Two: Draw yourself managing your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. In addition to further establishing a therapeutic alliance by showing an interest in and an understanding of the work involved with managing diabetes, the therapist gains insight into the adolescent’s investment in and understanding of self-management. The artwork can serve as a springboard for discussing the particular aspects of self-management that the adolescent finds most troublesome. Session Three: Draw yourself and your family doing something related to your diabetes management. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. The therapist gains insight into the relationship between the adolescent and her family, both in a general sense, and also how diabetes plays a role in the relationship. The adolescent has the opportunity to consider and discuss the role her family plays in the management of her diabetes. Session Four: Draw how your diabetes affects your social life. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. The adolescent can consider and discuss the impact diabetes has on social relationships and activities, and express associated feelings, as well as identify solutions to perceived problems. The therapist gains insight into how the adolescent sees himself in a social context, and how diabetes relates to this, and she can assist the adolescent in identifying conflicts and possible solutions. Session Five: Draw any fears or concerns you have about your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. Now that the adolescent and therapist have a more established therapeutic alliance, this more sensitive topic can be explored. Fears associated with diabetes and both the present and the future can be examined together. The therapist can validate the fears, then assist the adolescent in reality-testing those fears and concerns. Methods for coping with those fears can be considered. Session Six: Using clay, represent yourself in relation to your diabetes. Using a concrete material to represent an abstraction, the adolescent can create a sculpture, which will allow him to objectify this relationship. The therapist can help the adolescent to identify unconscious feelings that might ultimately be interfering in his ability to have a ‘healthy relationship’ with his diabetes. Session Seven: Create a collage of life with diabetes and life without diabetes as you recall it or as you imagine it. Materials provided would be magazines about diabetes with advertisements for diabetes-related products, and magazines of interest to adolescents, scissors, glue-stick, and a selection of more structured drawing materials (pencil, colored pencils, markers) to offer the adolescent the option of adding their own personal content to augment the magazine images. This task can serve as an expression of loss for the life the adolescent no longer has or cannot have without diabetes. The therapist can help the participant process feelings of sadness and anger associated with this loss. Magazine collage allows the adolescent to project onto the imagery, and the highly structured materials are conducive to maintaining defenses when dealing with potentially sensitive ideas and feelings. Session Eight: Draw the pros and cons of mismanaging your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. This task lets the adolescent visually weigh the advantages and disadvantages of mismanagement. Objectifying the consequences of mismanagement can make the risks seem more personally relevant, and thus worth more in depth consideration. The therapist can assist the adolescent in processing feelings about the pros and cons, and in identifying solutions. Session Nine: Draw the pros and cons of managing your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. Similar to session eight, the goal is to look at the adolescent’s management behaviors, but from a more positive, solution and future-oriented angle. Also, the therapist can help the adolescent focus on positive possibilities that can serve as motivating factors to properly managing diabetes. Session Ten: Draw a positive experience you have had that was a result of your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. The final session is intended to end the therapeutic relationship on a positive future-oriented note. The adolescent must re-frame his experience with diabetes in order to find the benefits it has brought him. The therapist can assist the adolescent in using this art experience as a model for living with diabetes with a more positive state of mind. This task also allows the opportunity to look back on the therapy sessions, identify how it has been a positive experience associated with diabetes, and bring closure to the therapeutic experience.
Following completion of the task, the client and therapist would process the artwork. After the therapeutic portion of a session, the adolescent could be asked to complete a structured feedback form, and write a more impressionistic response to the session. Once the course of treatment is complete, the adolescent would again be asked to complete a structured form and write a free response, accounting her overall response to the therapy, whether or not she found it helpful, and identifying insight gained, if any. Each adolescent participant would be asked to evaluate the tasks proposed for inclusion in the study for their perceived effectiveness and relevance, and they would be asked to identify the factors of treatment which were most helpful. Additionally, the adolescents would be asked if there was anything that should have been different about the therapy protocol which might have made it more effective or helpful.
The therapist would also need to record her impressions of the sessions and her perceived evaluation of the adolescent’s receptiveness and response to tasks and feedback, both within and across sessions. Working within a multi-disciplinary pediatric endocrinologic clinical setting, the therapist would have the opportunity to discuss cases with other care providers, including the participant’s endocrinologist, diabetes nurse educator and dietician. Information gathered from the art therapy sessions could be used to make recommendations on how best to approach a patient about their treatment regimen and self-management behaviors. Realistic diabetes-related treatment goals could be more clearly negotiated and delineated with the adolescent. With a clearer understanding of underlying issues contributing to non-adherent behavior, those issues can be taken into account and their resolution integrated with medical treatment goals.
The qualitative information gathered from this process would include:
1. Structured feedback form completed by the adolescent at the conclusion of each session.
2. Impressionistic response written by the adolescent at the conclusion of each session.
3. Structured feedback form completed by the adolescent at the end of the treatment protocol.
4. Impressionistic response written by the adolescent at the end of the treatment protocol.
5. Written response of the therapist completed at the conclusion of each session.
6. Written response of the therapist completed at the end of the treatment protocol.
7. The artwork completed by the adolescent.
The data would be analyzed for trends in the content and nature of both the adolescent and therapist’s responses to the therapeutic process, the tasks, the therapeutic alliance, and any suggested changes in protocol. The collected data could then be used to more clearly outline a treatment protocol which could be tested on a larger scale, the ultimate goal of which would be to determine whether or not art therapy might be beneficial in the treatment of non-adherent diabetic adolescents.
Since all of the people I know who have been reading aren’t art therapists, I’m definitely interested in your thoughts and impressions. Next week I’ll tie everything into a neat package by posting the Summary and Conclusions. Thanks for reading!