CO-CREATING SAFE SPACES (CCSS) – THE DEVELOPMENT OF AN ART THERAPY CLINICAL PROTOCOL FOR REFUGEE AND ASYLUM-SEEKING CHILDREN AND THEIR PARENTS.
Principal Investigator: Nehama Grenimann Bauch
APPROVAL HAS BEEN GRANTED FOR THIS STUDY TO BE CARRIED OUT BETWEEN 17/05/2022 AND 30/12/2024
Background
The number of displaced people has been rapidly increasing since 2015 due to multiple civil conflicts, political violence, and persecution in the middle east, central Africa, and Central America, among others. Over a third of displaced people are children and adolescents below the age of 18. The process of displacement often includes events – in their country of origin as well as during their flight and upon arrival in their destination country – that may be experienced by many as overwhelming and traumatic (Anagnostopoulos et al., 2016). Children and adolescents are especially vulnerable, often experiencing long periods of separation from their primary and secondary caregivers (Baron et al., 2019). Not all refugee and asylum-seeking children will necessarily develop symptoms of traumatization due to these experiences. However, there will, most likely, be consequences to these experiences that affect their quality of life, as well as ongoing daily stressors as they adjust to the new host country. These include environmental and structural stressors, such as a lack of fulfillment of basic needs (appropriate housing, for example), and psychosocial stressors, including a loss of social networks, experiencing social isolation, and worrying about family members they had left behind. Therefore, rather than focus primarily on trauma-related symptoms (Malchiodi, 2020; van der Kolk, 2014), the focus of this research is on the development of interventions for children that prevent and “buffer the effects of early resettlement conditions on asylum-seeking children’s adjustment” (de Freitas Girardi et al., 2020, p. 484).
Consequently, there is a need for appropriate, evidence-based, therapeutic interventions that attend to the complex psychosocial and mental health needs of refugee and asylum-seeking children and their parents. Creative arts therapies, which employ the arts – such as visual art, movement, drama, and music – within psychotherapy, have often been used as part of such interventions due to their nonverbal and body-based qualities that help bridge communication barriers and encourage resilience (Bonz et al., 2020). As with any mental health intervention for children, it is imperative to involve refugee parents in their children’s therapeutic processes (Yaylaci, 2018) since the parent-child relationship has a significant effect on the child’s mental wellbeing (Allen et al., 2008). The impact of family-level processes has, however, not been researched enough within the context of interventions for refugee children (Fazel & Betancourt, 2018). To this avail, this research seeks to explore and develop guidelines for an art therapy intervention with refugee and asylum-seeking children and their parents, to assess their acceptability and their underlying mechanisms of change.
Aims and objectives
This research seeks to explore the perceived impact and change processes of art therapy interventions provided for refugee children and how parental engagement could be encouraged within this context. Through the exploration of practitioners’, parents’, and stakeholders’ perspectives, examining practice elements and significant events within them, and assessing their acceptability, this research aims to develop clinical guidelines for a cogent, evidence-informed art therapy intervention with refugee and asylum-seeking children and their parents. This forms an important step towards addressing the general need for more substantial evidence regarding the efficacy of art therapy interventions for refugees and asylum-seekers.
Research methodology
Using the Medical Research Council’s (MRC) complex intervention development process (Shahsavari et al., 2020), the research will focus on different perspectives and voices relevant to the development of an art therapy intervention with refugee and asylum-seeking children and parents. These will be explored through the MRC’s first phases of intervention development:
a) Theory development – based on a literature review, scoping review, clinical experiences, and professional exchanges with practitioners in the field.
b) Modelling – the development of a logic model and process evaluation through focus groups and parent-child workshops.
c) Operationalization (pre-piloting) – finalizing the components of a replicable intervention informed by the developed logic model.
Due to the complex nature of the proposed intervention, four different groups of participants will be recruited for the different stages of the research:
1. Creative arts therapists and relevant practitioners.
2. Refugee and asylum-seeking parents.
3. Refugee and asylum-seeking children (together with their parents).
4. Relevant stakeholders – NGO project managers, shelter, and school staff.
Creative arts therapists and relevant practitioners will be recruited through professional networks (such as creative arts therapist’s associations), NGOs working with the population, creative arts therapies training programs, and through other professional networks and social media platforms. Stakeholders will be approached through similar professional networks, as well as refugee and asylum-seeking shelters. Refugee and asylum-seeking parents and children will be recruited in collaboration with practitioners and stakeholders assisted by interpreters (mostly from migrant and refugee backgrounds themselves).
Procedures
Two focus groups will take place online and will be divided into two populations: a) Creative arts therapists working with refugee and asylum-seeking children and parents; and b) Refugee and asylum-seeking parents to children who have participated in an art therapy intervention (with a language interpreter). A minimum of three sessions are planned for each of these populations, structured around a Nominal Group Technique (NGT) that begins with participant’s individual (written) answers to specific questions about engaging parents in art therapy interventions and then narrowed down into themes through group discussions (Harvey & Holmes, 2012). If deemed necessary, additional group and individual sessions will be conducted until reaching data saturation. In addition to the written and verbal answers, each group will be invited to bring art materials to the session, to allow them to express themselves creatively, as well, thus evaluating the process in a culturally contextualized and sustainable manner (Huss et al., 2015).
Based on the findings in the first two phases, a logic model (developed parallel to the previous stages) will guide the structuring of three parent-child arts-based workshops. These workshops will form a pilot for a community-based method to engage parents as part of a larger art therapy intervention for refugee and asylum-seeking children. The workshops will be conducted online due to potential COVID-19 restrictions as well as the need to reach more geographically distant participants, according to the availability of partnering organizations. The interpreters who assisted in the focus groups will assist with the workshops (with the possibility of offering other focus group participants a role as co-facilitators). The core goal of the workshops will be to encourage parent-child artistic co-creation which, in turn, is meant to encourage relational engagement with the potential to enhance caregiver sensitivity and reflective functioning among parent and child (Taylor Buck & Hendry, 2017). The second goal of the workshops is to create a non-intimidating space in which to engage with parents in their mother tongue (with the help of the interpreters) thus creating a framework that encourages a relationship with the therapist and, consequently, additional parental engagement (in the form of individual meetings, for example). Each participant will receive art material for the workshops, either via post or through the partnering organizations. The following structure is planned for the workshops (this may be tweaked or changed based on focus-groups findings):
1. The first session will be for the parents without their children and will have a psychoeducational component and an artistic self-reflective component (using clay) focused on the parents thinking about their wish for their child.
2. The second session will be focused on co-creation, using the Joint Painting Procedure (JPP) developed by Gavron (2018). The JPP is a structured dyadic painting activity in which parent and child paint on the same paper following instructions by the therapist. It has been found to enable mutual regulation, mentalization, mutual recognition, pleasure, fun, and bidirectionality (Gavron & Mayseless, 2018). To keep the space safe, the discussion at the end of the activity will focus on creating a story about the painting and on their experiences creating together and not on more complex or negative aspects of the relationship.
3. The third session will invite parents and children to reflect on the topics of art therapy and safe spaces through drawing and discussion. Participants will be invited to share their overall feelings about the workshops and give space to summarize the experience and say goodbye to the therapist, interpreters, and participants.
One final session will describe the developed logic-model to stakeholders and received their feedback about it. All participants will be invited to continue their engagement in the research in a participatory manner if they wish to (receiving appropriate credit for their work and opportunities to continue their involvement, such as facilitating workshops, for example). They will also have the possibility of completing the acceptability survey and providing their insight about the developed logic model based on their experiences and observations.
Questionnaires
Practitioners and parents will each fill a brief survey before the first focus group session and a longer survey collecting demographic data after the last focus group session (for questions that make create bias among participants). These will include questions related to their backgrounds and specific clinical experiences (for practitioners) or user experiences (for parents) related to art therapy among refugee and asylum-seeking children and parents.
All participants will receive an information sheet and sign consent forms. Language interpreters will also sign confidentiality forms after participating in a short training session in preparation for the first focus group. They will be compensated for their time either through partnering organizations or funded by the researcher. Where necessary, all forms and documents will be translated into a few languages appropriate for the participants (such as Arabic, Persian and Tigrinya).
The Helpful Aspects of Therapy form (HAT; Elliott, 2011) will be adjusted and distributed to the parents, interpreters and facilitators after the third workshop with the goal of assessing events (specific moments or activities during the workshop) that were significant for the parents and might encourage engagement and participation. Acceptability will be measured through surveys that will be distributed (together with the developed logic model) to all adult participants (clinicians, parents, and stakeholders) using a 6-point Likert scale. All documents will be available both in print form as well as online (with a preference for them to fill the online version, if possible).
Outcome measures and expected impact
Through the MRC’s (Shahsavari et al., 2020) gradual and sensitive development process, findings are expected to provide a preliminary overview of the population’s needs and the intervention elements that may be used to address them, incorporating different viewpoints that provide a depth of knowledge into a pragmatic complex intervention protocol. Since this research is focused on the pre-trial stage, the main impact is expected further downstream, using the initial findings and protocol to conduct a larger-scale study that informs evidence-based art therapy interventions with refugees and asylum-seekers. Indirect impact on the population is expected through exchanges with NGOs and practitioners, in the form of practical guidelines, consultation, and training. These international exchanges are also expected to encourage a pervasive spread of knowledge, subsequently impacting the quality of interventions aimed at improving refugee and asylum-seeking children’s mental health and wellbeing. An ongoing cycle of on-the-ground pilots, evaluations, and feedback is expected to permeate policymaking and funding, encouraging evidence-informed planning of art therapy interventions for refugees and asylum-seekers.
Justification and the potential contribution of research
By focusing on the complex, multi-faceted, aspects of intervention development, this research seeks to set the ground for further research to move forward with the next three stages recommended by the MRC: feasibility/piloting, evaluation, and implementation. The fine tuning of much needed guidelines for engaging refugee and asylum-seeking parents in their children’s art therapy processes in host (western) countries is expected to benefit the art therapists working with this population, the NGOs employing them, and, most importantly, the refugee and asylum-seeking parents and children themselves. It is assumed that better planned multi-level interventions for this population will improve their adjustment into the new host society, encourage and emphasize resilience and coping mechanisms, and prevent future mental health difficulties. This research will thus contribute to both an improvement of clinical practice approaches as well as gaining a deeper understanding of the population’s needs and of ‘what works’ in art therapy with refugee and asylum-seeking parents and children, enriching a continual collection of qualitative and quantitative data to support organizational planning and policy making in this field.
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