Research Toolkit:
The Inter-cultural research toolkit has been developed to be used within the project framework. It consists of a Cultural Context questionnaire (Appendix A) and the Mental Health Practitioners Questionnaire (Appendix B) which aim to gather data on the local and ethnic culture, social and cultural use of art and artefacts, build a profile of indigenous psychologies and gain an overview of mental health service provision and approaches.

The research methodology, process, and evaluation will follow a standardised course as defined by appendix C, D, E & F of the toolkit (questionnaire & contact group arrangements).

Referral guidance, Information for the patient and the patient consent form Performa appear in Appendix G, H & I of the toolkit.
 
The collation of research data along with interpretative outcomes will be extrapolated using the criteria and presentation formats will be provided in a separate appendix.

Research Methodology:
The research format for this project is Qualitative (interpretative); based on engagement, observation, self-reflection and experiential feedback from the field research process. The data collated will be in the form of Narrative research and will be analysed through a pre-set evaluation criteria.

Theoretical Position:
As Art Therapists are aware we marry the explorative qualities of image making (short-hand: art) with a psychodynamic understanding of human development.  What shapes each practitioners notion of ‘psychodynamic’ will be a collection of theories which resonate the most.  For the purposes of this research we have identified some basic theoretical tenants that we will use to guide us through the project; not comparing like with like but working with assumption that there may be approximations/similarities.

Research disclaimer:

The narrative data will contain case examples and artefacts; images; pictures; models and stories which will be used in the inter-cultural evaluation of the project. Permission will need to be sought at the outset of the project to enable their use in professional forums, discussions and presentations and any subsequent publication of related materials.

The information gathered will provide a cultural context of the region within which the research project is taking place and will be divided into five categories:

Questionnaire framework

1. Cultural location:
To include profiles of local, regional and ethnic cultural groupings ie. Rural, urban, Tamilian, Keralan, Naxalite, Caste groupings: this will be gathered through literature research and historical data

2. The use of art and artefacts:
To help build a profile from a cultural perspective of how images and sculptures are used and understood within the local population. This data will establish social and cultural rules of art making specific to the local population and will consider the symbolic values attached to art and artefacts.
Data will be from observation and formal and informal discussion, literary research, contact with local artisans and observation of cultural rites, rituals, ceremonies and events.

3. Indigenous psychologies:
Cultural and psychological based data which will help build a profile of approaches used in understanding and working with mental health related phenomenon.
This information will be gathered by talking with local contacts both formal and informal, links with practitioners and access to psychological data, research and reports.

4. Mental health and treatment approaches:
This area of data collection will build on the previous section. The data gathered will be subjective from local, informal sources and will consider folklore and superstition as well as ethnic differences.
And objective; from formal, mainstream service providers (Appendix B). Combined this will aim to establish a profile of mental health issues, services and approaches from a regional, local and ethnic viewpoint.

5. Other areas of enquiry:
The research process may find other dominant cultural narratives which may have an impact on the study, the use of artefacts and the provision of mental health services such as: political ideologies; economic policy; health & education policy; equality of access; gender roles; social/class/caste structure; religious ideologies; family structure; parenting and attachment patterns.

Questionnaire

Brief description from the researcher: including location, background details, leaflets, subjective impressions and observations:

1. Name/position of interview:                                     Job Title:

    Date of Interview:                                                     Duration of Interview:

2. Background to the Institution:
      2.1 When was the service established?
      2.2 How was it set up initially?
      2.3 What is the background philosophy and beliefs?

3. How is the service founded:
      3.1 Does it belong to a larger health/social care service?
      3.2 Is it independent?

4. Who are the patient population:
      4.1 Who do you provide services to?
      4.2 What age and gender groups/limits?
      4.3 What is your capacity?

5. How do you provide services:
      5.1 Is it crisis intervention?
      5.2 In-patient; Out-patient; Residential; Outreach?
      5.3 Hours of operation?

6. Referral process:
      6.1 How do people come to you for care?
      6.2 How are they funded?
      6.3 How long do they stay?

7. Treatment approach:

      Allopathic                    Homeopathic            Ayurvedic              Therapeutic 

      Psychotherapeutic        Behavioural              Activity based        Social skills based

8. Tell me more about the approach(s) used:
      8.1 What do they hope to achieve?
      8.2 What are the success rates?
      8.3 What are the outcomes?

9. Describe the main treatment approach:
      9.1 How regular are these activities?
      9.2 How many people receive this approach?
      9.3 Is it for individuals or groups?
      9.4 How do you record the effectiveness of this approach?
      9.5 What are the underpinning theoretical perspectives of this approach?

10. Do you use art making in the treatment or recuperation process?
      10.1 If so how is it used?
      10.2 How is it seen as helpful?

11. Supplementary questions regarding the use of art as a treatment modality:
      11.1 How regular are these activities?
      11.2 How many people attend?
      11.3 Are they for group or individuals?
      11.4 Are they recorded?
      11.5 Do record notes/process notes contribute to the overall evaluation of the client/patient?
      11.6 What is the theoretical perspective on mental health and the use of art?
      11.7 What happens to the images and artefacts?

12. Supplementary questions regarding the use of psychotherapy as a treatment modality:
      12.1 How regular are these activities?
      12.2 How many people attend?
      12.3 Are they for group or individuals?
      12.4 What theoretical perspectives inform the psychotherapeutic approach?
      12.5 In the West there are a variety of Eurocentric approaches such as Jungian; Freudian;
              Object Relations; Kleinian; behavioural and cognitive (C.A.T.) are these referred to
              or applied in your approach?
      12.6 What are the main theories and approaches which are culturally specific to this setting?

13. Do you think that art as a therapy would be beneficial in this setting?

Thank you for your time and co-operation.                                    Interview end.

Define 3 groups for study - in 2 parts.               Questionnaire and groups to cover 3
                                                                              populations:
Part I: Questionnaire (10-20 samples).              A.  Hospital or similar facility in-patients.
Part II: Art Therapy groups (5-8 members).     B.  Recognised alternative to hospital.
             Use of MYMOP questionnaire.            C.  Out-patient or community based.

1. Family Background:

      1.1 Your age and gender
      1.2 What is the size of your family?
      1.3 What is your position in your family?
      1.4 Who was your primary carer as an infant?
      1.5 What links do you have with your family now?

2. Attachment relationships:

      2.1 Can you reflect on your childhood?
      2.2 Do you think your relationship with your parents affects the person you are now?
      2.3 Can you give an example of a way in which your parents’ treatment of you as a child
            has impacted on the person you are now?
      2.4 Do you think that the example you gave for question 3 can be changed?

3. Treatment:

      3.1 What does your illness mean to you?
      3.2 Can you describe your symptoms?
      3.3 What would you most like to change in your symptoms?
      3.4 Which treatment are you receiving?
      3.5 Which aspects of your treatment do you find most helpful?
      3.6 Can you say why?

4. Art:
Questions relating to cultural, personal and subjective understanding, use and meaning of art and artefacts:
3.1 What do you use art for?                                                              
3.2 Do you think that you can express you thoughts
      through art?
3.3 Do you think that you can express your feelings
      through art?
3.4 Please can you give examples for questions 2 & 3
3.5 Do you think that art could be healing for you?

A MYMOP questionnaire consists of six items, each scored by the patient on a seven-point scale. The first three scales are for the three symptoms that the patient feels are the most important. The fourth is an activity of daily living that is being disrupted or prevented by the illness, which is also specified by the patient. The fifth asks the patient to rate their general feeling of well-being. All ratings are for the previous 5 weeks.

On the fifth and final sessions, the wording of the initially chosen items remains unchanged, but there is an optional sixth item for a new symptom.

Name:			Date completed:
Please circle the number to show how severe your problem has been OVER THE LAST 5 WEEKS.  This should be your opinion and no-one else’s!
Symptom 1	…………………………… ……………………………	As good as it could be		.1  2  3  4  5  6  7	As bad as it could be
Symptom 2	…………………………… ……………………………	As good as it could be		.1  2  3  4  5  6  7	As bad as it could be
Symptom 3	…………………………… ……………………………	As good as it could be		1  2  3  4  5  6  7	As bad as it could be
Activity	I cannot ……………………. ……………………………...	Able to do it  normally		.1  2  3  4  5  6  7	Not able to do it normally
Wellbeing	How would you rate your general feeling of wellbeing?	As good as it could be		.1  2  3  4  5  6  7	As bad as it could be
If an important new symptom has appeared you may describe it and mark how bad it has been over the last 5 weeks. Otherwise do not use this line.
Symptom 4	…………………………….. ……………………………..	As good as it could be		.1  2  3  4  5  6  7	As bad as it could be

The following sheet of outcome measurements will be used in the form of a semi-structured questionnaire, and discussed with participants after their last treatment. Any patients who drop out of the project without warning will be sent the questionnaire and asked to complete it and return it to the researcher

1. Has there been an overall change in your mental health since you began Art Therapy?

YES / NO

2. If so would you describe it as:

• Much better
• Somewhat better
• About the same
• Somewhat worse
• Much worse

 (Please tick one answer)

3. Have you experienced change in relation to any of the following since you started Art Therapy?

	Improved	No Change	Worse
Interaction with others
Personal/family relationships
Self awareness
Confidence and self-esteem
Fears or phobias
Anxiety or nervous reaction
Stress and pressure
Tension and frustration
Levels of agitation
Worrying unnecessarily
Anger management
Sense of control
Communication
Outlook on life
Concentration
Sleep and relaxation

Please tick the box which applies most to each.

4. If you have left the project before completing the sessions please indicate why this was :

• I did not have time / I could not attend the group on the day
• I did not feel any benefit from the sessions
• I did not feel comfortable with the sessions (please give details)

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE

Semi-structured questionnaires:
These will be used for interviews with the doctor, psychologist, RMO, at the end of the project. This will aim to give insight into how they feel that the project has impacted on patient’s health, as well as any issues that have arisen frothe project itself.
Patient benefit (to be completed for each patient who received treatment)

a) Has there been any change in the patient’s medication during the period of treatment?

b) Has there been any change in the patient’s presenting symptoms?

c) Has there been any observable change in the mental or behavioural status of the patient?

d) Has the patient reported any feedback from the art therapy sessions?

e) Do you feel that the patient has benefited from the sessions?

f) Has the patient’s pattern or number of visits or reliance on the service changed since we began the project?

Practical issues

a) Has the participation in the project increased your workload? If so can you quantify this?

 

b) Do you feel there have been any positive benefits from the use of art therapy?

 

c) Do you feel there have been any negative results from the use of art therapy?

 

d) Do you have any recommendations for further studies, which would have the effect of:
 

                                1.Increasing positive benefits?

        2.Decreasing negative aspects?

Referral sheet

It is important that referral procedures are made clear due to the small scale of the study. Psychology staff are requested to refer patients, according to the following selection criteria:

Contra Indications to art therapy are as follows:

• Current drug or alcohol use or evident intoxication
• Catatonic states

Due to the nature of this project being conducted as a psychodynamic art therapy group the inclusion of individuals with a sociopathic or personality disorder will be assessed on the individual’s capacity to function in a group.

• It is important to assess any temperament or condition whereby a group situation may arouse extreme anxiety leading to physical disruption.

• Given the small scale of this study, subjects who are not able to give informed consent will be excluded. This includes patients under the age of 18 which might affect their ability to give informed consent.

Suitability for referral with any of the following conditions:

• Adults who experience difficulty in engaging in: verbal dialogue or verbal, reflexive psychological treatments.

• Art therapy is considered to be particularly effective for the following conditions:

           Schizophrenia
           Paranoid conditions
           Bi-polar disorder
           Depression
           Eating Disorders
           Phobia
           Anxiety

Doctors should assess the patients’ medical records, to ensure suitability for entrance into the project.  All records of treatments and research will be maintained at the clinic to ensure confidentiality. Any information taken from the clinic would use a patient reference number allocated within the study to retain anonymity.

A STUDY ON THE INTER-CULTRURAL SENSITIVITY OF ART THERAPY

We would like to invite you to take part in a research study. The purpose of this leaflet is to explain why the research is being carried out, and what it will involve. It is important that you understand this before you make your decision if you wish to take part. Please read this sheet carefully and discuss it with others if you wish. If there is anything which is not clear at this stage, or you require more information please ask. Take time to decide whether or not you wish to take part.

Thank-you for reading this.

What is the purpose of this study?
This research is being carried out as part of an independent study into the use of Art Therapy across cultures. The aim is to assess the benefits to patients of offering art therapy in addition to existing healthcare services. Art Therapy has been used alongside other health care practices in previous studies. This study will examine the usefulness and benefits of such a treatment.

What is Art Therapy?
Art therapy is based on the belief that the creative process involved in the making of art is healing and life-enhancing. Through creating art and talking about art and the process of art making with an Art Therapist, you can increase awareness of self, cope with symptoms, stress, and traumatic experiences, enhance cognitive abilities, and enjoy the life-affirming pleasures of artistic creativity. 

Why have I been chosen?
Your RMO has assessed your suitability for entrance to the study, as there are certain conditions for which Art Therapy is recommended. The treatment is being offered to patients who it is believed may benefit from art therapy, and not for any specific condition. 5-10 patients will be treated as part of this study.

Do I have to take part?
No, you do not have to take part in this study if you do not want to. If you decide to take part you may withdraw at any time without having to give a reason. Your decision whether to take part or not will not affect your care and management in any way. Art Therapy is being offered in addition to other healthcare that you may be receiving, and it is hoped that participants will find the sessions both enjoyable and beneficial.

What will happen to me if I take part?
If you chose to take part in the study you will be offered a series of one hour group sessions over a period of 10 weeks at your (name of setting). Prior to the first group there will be an initial individual/referral meeting which will take 20 minutes. The group sessions will take place in the day room at 2pm on Thursday afternoons and will run between January – March 2006.

What are the possible benefits of taking part?
Art Therapy is a treatment that is generally available in the West. Some studies have shown that Art Therapy can be beneficial to the treatment of many psychiatric conditions. Some of the research outcomes show that it can reduce feelings of stress, improve communication, increase self understanding and self-esteem as so lead to feelings of well-being. We hope that the sessions will help you. However, this cannot be guaranteed. 

What if something goes wrong?
If taking part in this research project harms you, there are no special compensation arrangements. If you are harmed due to someone’s negligence, then you may have grounds for a legal action but you may have to pay for it. Regardless of this, if you wish to complain, or have any concern about any aspect of the way you have been approached or treated during the course of the study the normal complaint mechanisms should be made available to you.

Will my taking part in the study be kept confidential?
YES. Confidentiality will be maintained for all participants. Documentation will be retained at the Health centre, and destroyed on completion of the study. Any information about you which leaves the setting will have your name and address removed so that you cannot be recognised from it. All records, written and verbal, will be processed and made available along with any images made and will be anonymised to protect your identity.

What will happen to the results of the research study?

The results of the study will be analysed as part of an International research program in the inter-cultural sensitivity of art therapy. These will be made available to participants on request from the researcher.

Who is organising and funding the research?

This research has been organised independently with part funding from the Art Therapy Trust (UK). The researcher is a qualified Art Therapist practitioner and will be offering his/her time on a voluntary basis in order to research the potential benefits to patients of including Art Therapy as part of your package of care and treatment.

Who has reviewed the study?
Your health service has reviewed and agreed to the research taking place. All proposals for research using human subjects are reviewed by an ethics committee before they can proceed. This proposal has been reviewed and approved by the Indian Medical Committee.

What do I have to do now?  
If you decide to take part in the project, your RMO will fill out a referral form, and the Art Therapist will contact you within the next week to discuss details of the sessions and arrange dates.  You do not have to decide at this point. If you are interested in the study inform your RMO and the Art Therapist will contact you to answer any further questions and discuss any concerns that you may have.

What will happen at my first appointment?
At your first appointment the Art Therapist will ask you to sign the attached consent form, and also to complete the pre-group questionnaire.

What will happen at the end of the course of treatment?
Following a series of 5 sessions you will be asked to complete a questionnaire on the effects of the treatment and again on completion of the 10 sessions. If you leave the project before completing 10 sessions you will also be asked to complete the questionnaire or it may be sent to your home address. You are in no way obligated to complete this questionnaire, but your opinion is of great value to us, and will aid in future research.
When the research study stops further art therapy sessions will not be available at your health care setting.

ALL PARTICPANTS WILL BE GIVEN A COPY OF THIS SHEET AND A SIGNED COPY OF THE CONSENT FORM TO KEEP

Patient Identification Number:

Title of Project:                The Inter-cultural Sensitivity of Art Therapy Research Project.

Name of Researcher:     

                To be completed by the patient                                                                     Delete as necessary

  1.         I have read the information sheet about this study                                                       YES/NO

  2.         I have had an opportunity to ask questions and discuss this study                                YES/NO

  3.         I have received satisfactory answers to all my questions                                              YES/NO

  4.         I have received sufficient information about this study                                                  YES/NO

  5.         I understand that information of medical history which my RMO                                  YES/NO
              believes to be relevant will be passed on to the Art Therapist
              I give permission for this to take place.

  6.         Which health professional have you spoken to about this study?

  7.          I give permission for the use of any of my pictures, images or stories                           YES/NO
               to be used for research, write up, presentation and publication        

  8.          I understand that my identity will be anonymised in any publication                              YES/NO

  9.         I understand that I am free to withdraw from this study:-

                           *at any time
                           *without giving a reason for withdrawing
                           *without affecting my future medical care                                                        YES/NO

  10.         Do you agree to take part in this study?                                                                     YES/NO

                             Signed.................................................................Date..................................

                                       Name in Block Letters         

                             Signature of  Researcher…………………………………………………

NOTE

The consent form must be signed by the actual investigator/s concerned with the project after having spoken to the subject to explain the project and after having answered his or her questions about the project