Depression and Trauma: How Art Therapy can be combined with Play and Talking Therapies  

Intimate Partner Violence (IPV), physical or sexual abuse by a romantic partner, has been shown to affect around 30% of women globally (Garcia-Moreno et al., 2006). A multitude of studies have shown IPV has harmful social, psychological and health consequences for both women and their children (Woollett et al., 2020). Often, living in a household with IPV can increase internalising and externalising problems along with mental health struggles. Children who reside in these households may also experience maltreatment, especially in low- and middle-income countries (LMIC) (Patel et al., 2007). These statistics suggest that mental health support is needed for both the mother and the child.  

The domestic violence shelter system provides support for mother-child dyads, but a larger focus needs to be placed on mental health interventions for the mother-child relationship. Typically, an example of support given comes in the form of Trauma Focused Cognitive Behavioural Therapy (TF-CBT), an effective talking therapy targeted at PTSD and complex trauma in children and young people (Foa et al., 2008). However, there are occasions where 30% of patients have not benefitted from TF-CBT, but limited studies have attempted to qualitatively understand and improve the delivery of TF-CBT (Bradley et al., 2005). 

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Summary of Woollett et al., (2020) - Trauma-informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa 

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To address this, Woollett et al. (2020) combined TF-CBT with both art therapy and play therapy as an intervention for mother-child group therapy (Woollett et al., 2020). Art therapy utilizes the creative process by allowing the child to produce a piece of artwork capturing the therapeutic process and communication between child, artwork and therapist. While play therapy has frequently been used for establishing interpersonal processes to ‘help clients prevent or resolve psychosocial difficulties’ (Association for Play Therapy, 2019). Woollett et al. were interested in how TF-CBT could be integrated with art therapy and play therapy, and the efficacy of intervention implementation across high-income and low-income countries (Wollett et al., 2020). 

Woollet et al., (2020) presented a pilot group intervention combining TF-CBT with art therapy and play therapy and its efficacy in both high income (New York City) and low-middle income countries (Johannesburg). A mixed methods approach was taken to quantify child mental health alongside qualitative responses from the child and the mother, before and after the intervention.  

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Method 

School-aged participants (5-14 years) and their mothers attended the combined TF-CBT sessions at shelters in Brooklyn and Johannesburg, for 1-2 hours each week for 12 weeks. The sessions alternated between client-led and the use of a predetermined structure due to the combination of art and play therapy with TF-CBT. TF-CBT involved improving the acronym of PRACTICE to develop skills around: ‘Psychoeducation and Parenting, Relaxation, Affective regulation, Cognitive coping, Trauma narratives and cognitive processing of trauma, In vivo mastery of trauma reminders, Child-parent sessions and Enhancing safety and developmental trajectories (Cohen & Mannarino, 2008). The art component involved visual art materials (markers crayons, fingerpaint...) offered according to children’s preferences. Play therapy involved toys that had symbolically meaning, such as a dollhouse, other firemen and other professional dolls, puppets, phones... for children to engage with to explore individual trauma narratives. Time was spent exploring own and other’s feelings, with each session ending with mindful-ness based practices. Mothers were also facilitated in the same therapy groups to engage with their child in exploring the trauma they experienced. They were also supported to explore their own childhood trauma and how that affects their child.  

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Results 

37 participants (21 children, 16 mothers) completed well-being measures of Post-Traumatic Stress Disorder Reaction Index (PTSD-RI), while 21 children completed the Children’s Depression Inventory (CDI) prior to the intervention. Overall, quantitative findings show that mother’s assessments of PTSD symptoms in their children were significantly lower than what their children indicated through self-report. Only 11 participants from the US (n=5) and South Africa (n=6) completed both the pre- and post- assessment data. Regarding pre- and post- intervention scores, both US and South African populations had a decrease in PTSD scores, although this was not significant. Similarly, the South African group had non-significant decreases in depression scores, while the US group’s scores were significant.  

Qualitative data indicated that children (n=11) found the intervention helpful for expressing and managing overwhelming feelings, helping achieve relaxation and fun, recognising changes in behaviour in self and others and discovered a desire for emotional communication with mothers along with a validation of self. Specifically, children expressed that the artistic aspects of the intervention helped by feeling seen through their art products and drawing as a bridge to communicate difficult emotions.  

‘It helped me with being scared (Ayanda, 8 yr female, Johannesburg)’  

‘How to get out anger and our sadness, especially in the drawings (Laquasia, 12 yr female, Brooklyn)’ 

Although the quotes used in the qualitative analysis referred to the children’s thoughts, mothers (n=8) were also interviewed post intervention.  

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Discussion and Future Implications 

Wollett et al. (2020)’s modified trauma-informed intervention with art and play therapy showed similar outcomes for domestic violence shelters in both the US and South Africa. These results show that when physical and emotional safety are achieved, interventions can benefit mental health needs in different contexts. Positive qualitative themes from the research have shown promising avenues for future research surrounding the benefits of art therapy and producing art products in a therapeutic setting. However, qualitative themes were not able to reach saturation. Quantitative data also did not show consistent significant differences pre- and post-intervention, potentially due to the small sample size and the inability to run t-tests for differences between the two groups. Likewise, qualitative quotes were only reported in the paper, although both children and their mothers were interviewed. A replication of this pilot study in a larger sample size, potentially with shorter interventions, would aid research on trauma-informed art and play therapy and its impact on mental health. Additionally, this paper carried the assumption that the parent who experienced IPV is the mother, although the same could occur to all caregivers.  

A key implication for clinical practice to consider when working with vulnerable groups of caregiver-child dyads who experienced IPV is the consideration for children’s voice. Quantitative findings in this paper show that mothers tend to under report children’s violence exposure and mental health, and it may be difficult to find out from children directly due to their language limitations. Overall, it is important for children to express their fearful or sad feelings to their caregivers and for their caregivers to support and engage with them, potentially through verbal or non-verbal methods, such as art or play therapy. 

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References

 

American Art Therapy Association (2019, October 21). Retrieved from https://arttherapy.org/about-art-therapy/. 

Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multi-dimensional meta-analysis of psychotherapy for PTSD. The American Journal of Psychiatry, 162(2), 214–227.https://doi.org/10.1176/appi.ajp.162.2.214. 

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Cohen, J. A., & Mannarino, A. P. (2008). Trauma‐focused cognitive behavioural therapy for children and parents. Child and Adolescent Mental Health, 13(4), 158–162. https://doi.org/10.1111/j.1475-3588.2008.00502.x. 

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Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (2008). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. Guilford Press ISBN 9781609181499. 

 

Garcia-Moreno, C., Jansen, H., Ellsberg, M., Heise, L., & Watts, C. (2006). Prevalence of intimate partner violence: Findings from the WHO multi-country study on women’s health and domestic violence. Lancet, 368(9543), 1260–1269. https://doi.org/10.1016/S0140-6736(06)69523-8. 

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Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: A global public-health challenge. Lancet, 369(9569), 1302–1313. https://doi.org/10.1016/S0140-6736(07)60368-7. 

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Woollett, N., Bandeira, M., & Hatcher, A. (2020). Trauma-informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa. Child abuse & neglect, 107, 104564.