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Expressive Art to Facilitate the Development of the Occupational Profile: A Scoping Review.

Art has a broad and rich history in occupational therapy. Since the inception of the profession, art has been instrumental in occupational therapy evaluation and intervention (Bathje, 2012; Reed, 1986). Various forms of art were first used in occupational therapy for clients with mental illnesses or physical disabilities, where the inherent therapeutic value of engagement in creative activities as an occupation was recognized and appreciated (Bing, 1981; Meyer, 1922). Historically, moral treatment movement perspectives regarding the use of purposeful occupations to prevent idleness laid the foundation for the use of creative and personally appealing activities (Bing, 1981). Arts and crafts were considered essential for well-being, as the individualized activities promoted pleasure, productivity, development of functional skills, and feelings of meaning and purpose in clients' lives (Bing, 1981; Meyer, 1922).

Art was initially used in occupational therapy as both a means and an end in the context of service delivery. Intervention focused on the process of creating art for the curative experiential component and diversional aspects, as well as the potential for generating vocational opportunities by crafting a useful or desired product (Fisher, 1998; Levine, 1987; Reed, 1986; Trombly, 1995; Yerxa, 1967). During the 1930s and 1940s, around the time of the Great Depression, intraprofessional shifts occurred that divided practitioners and steered many away from the use of arts and crafts (Bathje, 2012; Levine, 1987). Occupational therapists began to embrace the medical model of practice, which emphasized a reductionistic approach to improve individual clients' function (Bing, 1981; Levine 1987). At that time, arts and crafts lacked scientific research regarding the perceived benefits of increased self-expression, development of skills, occupational participation, and organization of daily routines (Fidler & Fidler, 1978; Peloquin, 1996; Reed, 1986). This ultimately diminished the foundational value of arts and crafts and established the profession's emphasis on and value of the scientific method.

Throughout the next several decades, arts and crafts interventions were increasingly categorized as leisure activities as the medical model became more integrated and inherent in occupational therapy practice (Reed, 1986; Reilly, 1962). In contemporary practice, there has been a revitalization of arts and crafts interventions due to renewed emphasis on occupations that are meaningful to individual clients (Mouradian, DeGrace, & Thompson, 2013; Perruzza & Kinsella, 2010; Reed, 1986). In turn, this recovery of arts and crafts interventions has led to an increased interest in the evidentiary base for the inclusion of expressive art in occupational therapy practice. For the purpose of this study, the term expressive art encompasses any medium that evokes creative processes in the person engaged (Gunnarsson & Eklund, 2009; Perruzza & Kinsella, 2010). In occupational therapy, art mediums can include, but are not limited to, crafts, jewelry making, woodworking, leatherwork, book binding, textile arts, needlework, drawing, painting, scrapbooking, collaging, pottery, music, poetry, and creative writing exercises (Fidler, 1982; Levine, 1987; Perruzza & Kinsella, 2010; Reed, 1986; Symons, Clark, Williams, Hansen, & Orpin, 2011).

There is a subset of art, which incorporates some of the modalities mentioned above, called projective techniques. Projective techniques are used when the clinician is concerned with bringing unconscious conflicts to consciousness through analyzing the process and content of a creative activity (Lambert, Fleming-Castaldy, & Romeo, 2014b; Veltman & Browne, 2002). Historically, occupational therapy practitioners received inconsistent training in the use of projective techniques, leading to confusion in assessment interpretations. Therefore, projective techniques are viewed by mental health practitioners as a type of assessment requiring specialized training to ensure the accuracy of interpretation. It is worth noting that a variety of projective techniques have been used in practice, including the House-Tree-Person Test, the Draw-a-Person (DAP) Test, the DAP: Screening procedure for emotional disturbance, the Draw-a-Man Test, the Draw-a-Tree Test, the Human Figure Drawing Test, the Kinetic Family Drawing Test, favorite kind of day drawings; family drawings; and self-portraits (Lambert et al., 2014b; Veltman & Browne, 2002). These techniques have not been studied extensively in recent years in relation to occupational therapy, and thus research to determine if these techniques may be appropriate and beneficial in contemporary practice is warranted. At the time, Veltman and Browne (2002) found these techniques to promote discussion, allow for more free communication, and establish initial rapport between the clinician and client by incorporating nonverbal interactive alternatives. Though projective techniques have a role in occupational therapy, the current investigation focuses on alternative expressive art techniques that can be used by generalist clinicians.

This newfound focus on the therapeutic benefits of expressive art has mainly been studied in mental health, pediatric, and occasionally geriatric settings for clients living with chronic illness or who are survivors of abuse (Cardinale, Malacari, Broggi, Savignano, & Fisher, 2014; Gross, Hayne, & Drury, 2009; Gunnarsson & Eklund, 2009; Kato & Morita, 2010; Katz & Hershkowitz, 2010; Lev-Wiesel & Liraz, 2007; Patterson & Hayne, 2011; Perruzza & Kinsella, 2010; Symons et al., 2011; Veltman & Browne, 2002; Wesson & Salmon, 2001; Woolford, Patterson, Macleod, Hobbs, & Hayne, 2015). An interesting theory involves the idea that art employs visual thinking or imagery, thus engaging the client on a deeper symbolic level, which facilitates verbal expression (Christiansen, 1999; Gunnarsson & Eklund, 2009; Lev-Wiesel & Liraz, 2007). Life experiences, both positive and negative, may be more easily communicated through art, as it is believed to reduce the social demands of an interview while making the client an active participant in the process (Gunnarsson & Eklund, 2009; Lev-Wiesel & Liraz, 2007; Wesson & Salmon, 2001). This can have important implications for the profession in the ever-changing contemporary health care environment.

The occupational profile is a long-standing concept in occupational therapy that practitioners incorporate into evaluation to gather information about clients. An early and well-known example includes Fidler's Activity Laboratory (Fidler, 1982). The Activity Laboratory was designed to discover key details about diverse clients and was rooted in the concept that art is both therapeutic and a foundation for establishing nonverbal communication (Fidler, 1982). This type of communication is valuable in gaining information that may not have been obtained through verbal communication. Fidler's contributions to assessment are directly related to the contemporary occupational profile, which specifically summarizes a client's occupational history and experiences; patterns of daily living; and engagement in occupations, interests, values, and needs (American Occupational Therapy Association [AOTA], 2014). According to the American Occupational Therapy Association (AOTA) (2014), practitioners employ a client-centered approach to determine what is meaningful to the client while considering past experiences and interests (Hinojosa, Kramer, & Crist, 2014). Information for the occupational profile is usually collected at the beginning of treatment to guide intervention and outcome planning, and the profile may be modified as the occupational therapist gathers more information once treatment sessions commence (AOTA, 2014; Hinojosa et al., 2014).

The occupational profile has been recognized as a vital aspect of service delivery because this interactive communication initiates the practitioner-client relationship and sets the foundation for the evaluation and intervention that follows (AOTA, 2014; Hinojosa et al., 2014). The AOTA and the American Medical Association have recognized the importance of the occupational profile, reflected in changes to CPT billing codes that took effect January 1, 2017 (AOTA, 2016b). In the new codes set forth by the AOTA (2016b), all evaluations must consist of an occupational profile, a medical and therapy history, an assessment of occupational performance, the clinical decision making, and the development of a plan of care. The occupational profile must be completed or modified at every evaluation and re-evaluation session. In addition, the evaluation is now categorized into three levels of complexity: low, moderate, and high. The complexity of the occupational profile is determined by the client's presenting problem, the reason for referral, and the client's goals. The occupational profile is part of the profile and history component of the larger evaluation process, of which the complexity is determined by the sum of its parts. The profile and history complexities are determined as follows: low complexity is a brief history of medical records relating to the presenting problem; moderate complexity is an expanded review that considers physical, cognitive, or psychosocial factors in relation to functional performance; and high complexity is an extensive review of the aforementioned factors' influence on functional performance (AOTA, 2016b).

A consideration of these upcoming changes in evaluation requirements and the implications for the occupational profile makes this a paramount concern in current practice. As the occupational profile becomes mandatory for Medicare reimbursement, other third-party reimbursement systems (i.e., Medicaid, private insurance) will follow by developing individual policies to reflect these code changes (AOTA, 2016b). Practitioners may need to consider alternative methods to generate information for clients with emotional or speech disturbances who may have difficulty communicating verbally. For example, this may pertain to clients who have changes in mood (fearful, angry, anxious, elated, or depressed), emotionally lability, disturbances of affect, disturbances in speech (e.g., poverty of speech or content, nonspontaneous speech, perseveration), disturbances in language output (e.g., aphasia), or disturbances in recent past or episodic history (Lambert et al., 2014a). This makes the benefits of expressive art even more relevant to consider in contemporary occupational therapy practice as a way to gather information from clients and establish rapport (Gunnarsson & Eklund, 2009; Lev-Wiesel & Liraz, 2007). Expressive art may help practitioners glean deeper psychosocial information from clients, thus increasing the complexity of the occupational profile and potentially the evaluation process.

Method

The researchers chose a scoping review method to address the evidence supporting the effectiveness of expressive art techniques as intervention tools to enhance the occupational profile for clients with the aforementioned communication deficits. Scoping reviews are appropriate when researchers seek to organize existing evidence for the purpose of discovering and addressing gaps in the literature (Armstrong, Hall, Doyle, & Waters, 2011). In the current investigation, this gap is in regard to a re-emerging area of practice. Art has recently become a renewed focus of the profession, as it returns to occupation-based roots, despite earlier tendencies to use art less frequently in practice for its lack of "sophistication" (Fidler & Fidler, 1978, p. 305) and strong supporting evidence. Thus, current research on the role of expressive art in contemporary occupational therapy is warranted. A scoping review was chosen over a systematic review to allow a broad research question and exclusion criteria to be refined over time as the study progressed through analysis of the evidence (Armstrong et al., 2011). The research team followed Arksey and O'Malley's (2005) recommended steps to conduct a scoping review:

1. Identify and refine the research question.

2. Identify relevant studies by following a structured search strategy.

3. Select studies and refine exclusion criteria using a multi-stage iterative team process.

4. Obtain results by charting and categorizing the data through critical appraisal and analysis using a matrix to elicit themes.

5. Synthesize and summarize findings as they relate to occupational therapy practice.

The initial research focus was to determine the effectiveness of drawing as a tool to improve meaningful treatment outcomes for occupational therapy clients who demonstrate reluctance or difficulty communicating during the goal-setting process. The resulting research question for the current study emerged as follows: Does expressive art enhance verbal communication and develop the therapeutic relationship to inform the occupational profile when evaluating clients for occupational therapy services?

The research team began this study with a search of 11 interdisciplinary databases available through the University of Scranton Library, including CINAHL, COCHRANE Library, ERIC (EBSCO), JAMA Network, JSTOR, PEDro, PubMed Central, Sage Premier, Taylor & Francis Online, Wiley Online Library, and Google Scholar. The team used the following key words: art in therapy, art in occupational therapy, self-expression, use of art for self-expression, expressive art, expressive art and cancer, expressive art with veterans, expressive therapy, projective assessments, nonverbal communication, art as nonverbal communication, Fidler and activity laboratory, Gunnarsson's tree theme method, kinetic family drawing, house-tree-person, painting and therapy, art and children in therapy, art and adults in therapy, expressive art and non-verbal clients, expressive art and mood disorder, expressive art and depression, expressive art and dementia, expressive art and memory deficits, expressive art and speech deficits, expressive art and poverty of speech, and expressive art and communication deficits. The following inclusion criteria guided the initial search of the databases listed above: Studies had to be peer-reviewed research, written in the English language, and involve expressive art used in any therapeutic discipline. The initial inclusion criteria yielded 347 peer-reviewed articles to be considered in this study.

After the initial yield of articles, the research team followed a multi-stage iterative group process to critically appraise topics and systematically develop rounds of exclusion criteria as the study progressed. The first round of exclusion criteria eliminated articles involving music therapy, art therapy, play therapy, and other articles irrelevant to expressive art. This resulted in 62 articles for consideration. Next, studies solely based on projective art with an exclusively interpretive focus were eliminated, leaving 47 articles. At this point, all 47 articles that remained were analyzed using a matrix. The matrix format followed a structure previously used by Eschenfelder and Gavalas (2017) by considering individual articles on the basis of study design; level of evidence, when applicable; number of subjects and demographics; interventions; measured outcomes and assessments used; and findings and results. The third and final round of exclusion in this study was the most selective, as articles were excluded for further analysis if they (a) were published prior to the year 2000, (b) were purely informative articles, (c) studied interpretation of art in any way, (d) included fewer than three participants, or (e) used art modalities not feasible to use during an initial evaluation to construct an occupational profile. This final round of article elimination retained a final item pool of 12 articles to be considered in the current study (see Figure 1).

It is worth discussing the research team's specific decisions regarding article elimination in the current study. This investigation focuses solely on the efficacy of using expressive art to enhance communication in order to inform and deepen the richness of a client's occupational profile. It is meant to be informative for all occupational therapy practitioners. Therefore, articles focusing on projective assessments or interpretation of art were excluded, as these modalities may require supplemental specialized training on the part of the clinician (Veltman & Browne, 2002). Furthermore, as mentioned above, studies incorporating art modalities not feasible for use during an initial evaluation session were excluded. Specifically, studies incorporating photography, scrapbooking, song writing, poetry, pottery, and textiles were excluded. Though these modalities qualify as expressive art, too much time must be dedicated to instruction or completing the activity for it to be practical during an initial evaluation or reevaluation session, especially when other required assessments may need to be performed. In the current study, traditional art modalities that can be readily incorporated into practice, such as drawing, coloring, painting, and collaging, were retained for analysis.

Results

The investigators created a subsequent matrix for the purpose of charting the data based on the 12 studies that were retained after application of the refined exclusion criteria. The articles included in the current study were of various design: There were five quantitative studies (Gross et al., 2009; Gunnarsson & Eklund, 2009; Kato & Morita, 2010; Lev-Wiesel & Liraz, 2007; Patterson & Hayne, 2011), one qualitative study (Symons et al., 2011), four mixed-method studies (Cardinale et al., 2014; Katz & Hershkowitz, 2010; Wesson & Salmon, 2001; Woolford et al., 2015), and two systematic reviews (Perruzza & Kinsella, 2010; Veltman & Browne, 2002). There has been a regeneration of research on the use of expressive art in recent years, and recognition of the value and role of art in occupational therapy interventions will likely lead to more research in the future. However, it is worth noting that there are gaps in the literature and relatively few rigorous research studies addressing the area of focus in the current study. Populations

A majority of the research published on the use of expressive art has been conducted on children and young adults under 20 years of age (Gross et al., 2009; Kato & Morita, 2010; Katz & Hershkowitz, 2010; Lev-Wiesel & Liraz, 2007; Patterson & Hayne, 2011; Veltman & Browne, 2002; Wesson & Salmon, 2001; Woolford et al., 2015). Most studies focus on clients who have experienced abuse or trauma or who are living with mental illness (Cardinale et al., 2014; Gunnarsson & Eklund, 2009; Katz & Hershkowitz, 2010; Lev-Wiesel & Liraz, 2007; Veltman & Browne, 2002; Woolford et al., 2015). Other populations studied include typically developing children (Gross et al., 2009; Kato & Morita, 2010; Patterson & Hayne, 2011; Wesson & Salmon, 2001) and occasionally adults living with physical disabilities (Symons et al., 2011). See Figure 2 for a diagram depicting the interrelationship of client factors that may assist clinicians in determining appropriate candidates who may benefit from expressive art interventions.

As depicted below, expressive art interventions have been studied with clients of various ages and with a wide range of diagnoses. Some clients who may benefit from these intervention techniques may have verbal communication abilities; however, it may be difficult to develop an occupational profile if they are reluctant to engage in the process or possess disorganized memories that make it challenging to communicate coherently. In the current study, art is being considered as an alternative method for promoting verbal communication, rather than as a substitute.

Assessments and Expressive Art Modalities

Expressive art studies have incorporated established art assessments or unstructured art modalities designed to allow clients to express themselves and be creative. Below, some common expressive art assessments and modalities are explored that may enhance the depth and complexity of the occupational profile during the evaluation and re-evaluation processes (AOTA, 2016b).

Gunnarsson's Tree Theme Method. Recently, Gunnarsson's Tree Theme Method (TTM) has been used as an expressive art intervention that has yielded significant positive results (Cardinale et al., 2014; Gunnarsson & Eklund, 2009). Gunnarsson's TTM involves the occupational therapist introducing themes in five stages. Clients are asked to paint a tree with roots, a trunk, and a crown, which symbolize their personality, interests, and relationships in:

(a) the present situation, (b) childhood, (c) adolescence, (d) adulthood, and (e) the future (Gunnarsson & Eklund, 2009). This process promotes occupational storytelling related to the clients' perceptions of their abilities and limitations at each stage of their lives, and occupational story-making that can be useful when developing client-centered goals and an intervention plan (Cardinale et al., 2014; Gunnarsson & Eklund, 2009).

Gunnarsson's TTM has been introduced and studied as a process that develops over multiple sessions. However, the ideas and methods used in the TTM may be adapted to be used during initial evaluation sessions. If not, the TTM may be incorporated throughout the intervention process to help inform necessary revisions or additions to the occupational profile at subsequent re-evaluation sessions.

Free drawing, painting, and collages. Several studies included in the current investigation used expressive art in some form of free drawing, painting, or collaging that was not structured in the form of an established assessment (Gross et al., 2009; Kato & Morita, 2010; Katz & Hershkowitz, 2010; Lev-Wiesel & Liraz, 2007; Patterson & Hayne, 2011; Symons et al., 2011; Wesson & Salmon, 2001; Woolford et al., 2015). When free drawing is used as an expressive art technique, a variety of factors should be considered on an individualized client basis during evaluation sessions. Oftentimes, unstructured drawing was used in conjunction with interview techniques to elicit information from participants (Gross et al., 2009; Katz & Hershkowitz, 2010; Lev-Wiesel & Liraz, 2007; Patterson & Hayne, 2011; Symons et al., 2011; Wesson & Salmon, 2001; Woolford et al., 2015). Researchers provided different materials, allotted certain amounts of time for drawing, and used a variety of verbal prompts and questioning styles. See Table 1 for a summary of expressive art techniques that are categorized by different investigators.

Many of the studies included in this investigation that used free drawings or unstructured expressive art techniques did not specify the duration of time allotted for the intervention. Through analysis, a theme emerged in the pattern of interviewing: several studies began with establishing rapport and had investigators prompt children to narrate while drawing (Gross et al., 2009; Patterson & Hayne, 2011; Wesson & Salmon, 2001; Woolford et al., 2015). Benefits of Expressive Art

The matrix was collaboratively reviewed by the research team to elucidate themes related to potential benefits of expressive art techniques. Critical appraisal of topics and analysis using a matrix revealed that several studies found positive results regarding expressive art's effect on the quantity of verbal communication, the client's therapeutic reflection, the accuracy of information, the clinician's use of prompting during interviews, the clinician-client therapeutic relationship, and the client's engagement and attention during the session.

Quantity of verbal communication. A common finding across studies is that the use of expressive art techniques increases the amount of verbal communication from clients (Cardinale et al., 2014; Gross et al., 2009; Gunnarsson & Eklund, 2009; Katz & Hershkowitz, 2010; Lev-Wiesel & Liraz, 2007; Patterson & Hayne, 2011; Perruzza & Kinsella, 2010; Veltman & Browne, 2002; Wesson & Salmon, 2001; Woolford et al., 2015). Some studies specified that expressive art interventions (e.g., drawing) yielded nearly twice as much verbal information compared to clients in 'tell' only conditions (Gross et al., 2009; Wesson & Salmon, 2001; Woolford et al., 2015). Expressive art interventions have been found to elicit new information not obtained from open-ended interview questions, possibly because art enables participants to consider new perspectives on life experiences (Cardinale et al., 2014; Katz & Hershkowitz, 2010). Another theory proposed by Lev-Wiesel and Liraz (2007) and Veltman and Browne (2002) is that drawing may be less threatening than a purely verbal interview, thus yielding additional or more in-depth verbal information. Furthermore, Symons et al. (2011) reported that visual art interventions increased the participants' socialization and ability to meet new people, thus encouraging verbal communication and developing critical social interaction skills.

Client therapeutic reflection. Cardinale et al. (2014) reported positive findings related to the use of Gunnarsson's TTM to increase participants' reflection on their past, present, and future life experiences. This therapeutic reflection was enabled by the TTM's multi-perspective focus on various aspects of clients' lives. In addition to enhancing detail and depth of verbal communication, clients' reflection assisted them in taking ownership of their life experiences and promoted occupational storytelling. This reflection served to promote open and free client expression that can have positive implications for the therapeutic relationship (Cardinale et al., 2014).

Accuracy of information reported. The reported benefits of expressive art on the quantity of verbal communication makes it important to consider implications on the accuracy of clients' report. There is inconclusive and contradicting evidence regarding expressive art's effect on the accuracy of information reported in 'draw' conditions: Gross et al. (2009) reported that accuracy is not compromised with open-ended questions, but may be severely compromised with suggestive or closed-ended questions; however, Patterson and Hayne (2011) found that drawing conditions may have slightly decreased the accuracy of verbal information reported. Determining the accuracy of reported information becomes a paramount concern when considering the context of developing an occupational profile to inform practice.

Clinicians' interview style. Several investigators have reported important findings regarding expressive art's impact on various interview styles and techniques that may strengthen the information gathering process during evaluation sessions (Katz & Hershkowitz, 2010; Patterson & Hayne, 2011; Wesson & Salmon, 2001; Woolford et al., 2015). Katz and Hershkowitz (2010) found that clinicians' use of specific prompts increased the quantity of additional details provided by children. However, other investigators have reported that when clients are drawing, interviewers tend to use more open-ended questions and non-specific prompts and encourage minimal responses, all of which support a client-centered interview style (Patterson & Hayne, 2011; Wesson & Salmon, 2001; Woolford et al., 2015). Evidence suggests that children provide the most verbal information when clinicians used minimal responses (Patterson & Hayne, 2011; Woolford et al., 2015). Of interest is that clinicians tend to provide fewer prompts per minute in drawing conditions rather than solely verbal conditions, leading the investigators to believe that clients in the drawing condition required less verbal cueing (Wesson & Salmon, 2001). However, the drawing condition was found to have the longest interview duration with a mean of approximately 25 min (Wesson & Salmon, 2001).

The therapeutic relationship. The quality of the therapeutic relationship is a critical concern for occupational therapy clinicians. Multiple studies indicate that expressive art interventions may facilitate establishment of rapport and strengthen the quality of the therapeutic relationship (Gunnarsson & Eklund, 2009; Perruzza & Kinsella, 2010; Veltman & Browne, 2002). This is a noteworthy finding, as high ratings of the therapeutic alliance may promote clients' perceptions of their needs being met as well as increase satisfaction with the therapy process and outcomes (Gunnarsson & Eklund, 2009). Establishment of rapport is initiated upon the first encounter with a client, and ideally continues to develop throughout the service delivery process to promote core values of occupational therapy while practicing individualized, client-centered care.

Client engagement and attention. Expressive art interventions may be useful for promoting client engagement by making clients active participants throughout the session and by maintaining clients' attention (Gross et al., 2009; Gunnarsson & Eklund, 2009; Katz & Hershkowitz, 2010; Symons et al., 2011). Katz and Hershkowitz (2010) propose that this may be due in part to the contribution of art in organizing information retrieval processes, reducing anxiety, and empowering children to become more active in the retrieval process. In addition, Gunnarsson and Eklund (2009) offer a differing opinion that certain expressive art techniques, specifically the TTM, stimulate the client to promote engagement and increase coherence of occupational storytelling. Methodological Strengths and Limitations

Several studies featured methodological strengths, contributing to the rigor of the results and the quality of the findings in the current investigation. Of the 11 studies that were quantitative, mixed methods, or systematic reviews, all of them were Level III evidence or higher according to the AOTA's evidence guidelines (AOTA, 2012). Six of these 11 studies were Level I randomized controlled trials (RCT) or systematic reviews (Gross et al., 2009; Lev-Wiesel & Liraz, 2007; Perruzza & Kinsella, 2010; Veltman & Browne, 2002; Wesson & Salmon, 2001; Woodford et al., 2015) and one study was a nonRCT (Katz & Hershkowitz, 2010). Seven studies featured large sample sizes of at least 30 participants (Gross et al., 2009; Gunnarsson & Eklund, 2009; Katz & Hershkowitz, 2010; Lev-Wiesel & Liraz, 2007; Wesson & Salmon, 2001; Woolford et al., 2015), with one study involving as many as 125 participants (Katz & Hershkowitz, 2010). These high levels of evidence and large sample sizes may increase the generalizability of findings in various clinical settings.

Despite significant methodological strengths, there are some limitations in the studies included in this analysis. Although there is evidence that the use of expressive art can be beneficial for clients across the lifespan, the authors acknowledge that a high number of studies (Gross et al., 2009; Katz & Hershkowitz, 2010; Lev-Wiesel & Liraz, 2007; Patterson & Hayne, 2011; Veltman & Browne, 2002; Wesson & Salmon, 2001; Woolford et al., 2015) are focused on children, which may limit the generalizability of findings from the current study to adult populations. Three of the 12 studies had a relatively small sample size of 10 or fewer participants (Cardinale et al., 2014; Kato & Morita, 2010; Symons et al., 2011), which is a common feature of clinical research that may make results difficult to generalize to all practice settings. As previously stated, eight of the 12 studies did not include formal, well-established assessments, and instead incorporated free drawing or other expressive art techniques. This may make it difficult to replicate or simulate similar techniques in the future. Gunnarsson and Eklund (2009) mention one specific limitation that undermines some of the findings reported in their study for the purposes of the current investigation. They explain that the study did not specifically aim to investigate the effects of the TTM, and thus did not include a control group. Rather, their investigation used the TTM to study process aspects, such as therapeutic alliance, client satisfaction, and changes in everyday occupations. Therefore, findings from this study cannot specifically be linked to use of the TTM alone (Gunnarsson & Eklund, 2009).

Discussion

In synthesizing the findings of this scoping review, a number of studies indicate that expressive art interventions may be an effective way to increase the quantity and quality of verbal communication from clients, establish rapport by enhancing the therapeutic relationship, and promote client engagement and attention throughout the session. The far-reaching benefits of art interventions have important implications for clinicians attempting to connect with clients and comply with changing reimbursement regulations. Expressive art interventions may be used to create a deeper and more informative occupational profile, which may increase the complexity of the evaluation and re-evaluation processes as per the new CPT codes (AOTA, 2016b).

Expressive art can be a useful intervention tool in practice if a client expresses interest in related activities. In addition, these creative intervention techniques may benefit a wide variety of clients. Clients who have verbal abilities, but who may be reluctant to speak or difficult to engage, might have an easier time communicating with the clinician via visual imagery. Creative expressive art interventions may help clients organize their thoughts and memory retrieval processes, come to terms with their experiences, or make them feel more comfortable communicating with the occupational therapist. Although these interventions have been primarily researched in people living with mental illness or those who have experienced trauma, similar results have been found in typically developing children. Thus, these benefits for enhancing verbal communication may generalize to different populations. Expressive art interventions should be considered as viable tools to integrate into practice on an individual basis considering the low risk, low cost, and positive benefits associated with these creative techniques.

The clinician's interview style plays an important role in the evaluation and information-gathering process. Oftentimes, clinicians employ a variety of techniques throughout interviews, including open-ended questions, closed-ended questions, encouraging phrases, and summaries (Drench, Noonan, Sharby, & Ventura, 2012). Clinicians used these techniques based on the nature of the information being discussed and what fit best with the client's personality. Open-ended questions are highly regarded in the profession as a way to promote collaborative client-centered discussion (Drench et al., 2012). Findings in the current study suggest that expressive art techniques are correlated with use of more open-ended and non-suggestive questions, which can facilitate the development of a more comprehensive and client-centered occupational profile during evaluations (Patterson & Hayne, 2011; Wesson & Salmon, 2001; Woolford et al., 2015).

Therapeutic use of self and the quality of the therapeutic relationship are widely recognized as paramount concerns in occupational therapy, as they are considered influential and critical for outcome achievement. Therapeutic use of self involves any conscious, intentional, or planned effort to connect with a client in verbal and non-verbal interactions as a way to optimize the therapeutic process (Drench et al., 2012). Engaging the client through the use of meaningful activities, such as expressive art, can be an effective way to connect and interact with clients to deepen the therapeutic relationship. These benefits facilitate individualized, meaningful client goals that promote increased quality of life and wellbeing. A strong alliance becomes clearly evident in all interactions with the client, as it contributes to smooth and natural intervention progression. Expressive art interventions ultimately may assist clinicians with establishing rapport and creating an overall positive service delivery process.

The AOTA identifies four guideposts to communicate and recognize the organization's Vision 2025 statement (AOTA, 2016a). Two of these guideposts include the profession being "collaborative" and "effective" (AOTA, 2016a, para. 5), which emphasizes the profession's individualized and client-centered nature. Expressive art interventions may enable the client to become an active participant in evaluation and intervention sessions. Furthermore, art can help the clinician elucidate clients' occupational history, skills, interests, and meaningful activities to meet the demands of changing CPT codes, which place increasing emphasis on the occupational profile (AOTA, 2016b). In practice, clinicians strive to incorporate meaningful occupations throughout service delivery, but it might not always be clear which activities are the most motivating to clients. A consideration of all of the information that can be yielded from expressive art interventions may help inform the client's occupational profile and assist the clinician in maintaining individualized, meaningful service delivery throughout the process.

Case Study

Below, a case study is provided from the perspective of an occupational therapist that relates and applies the aforementioned benefits to clinical practice in a skilled nursing facility. The name provided in this case study is an alias.

Case Study: Priscilla

In a skilled nursing facility, I primarily worked with a client named Priscilla, who was diagnosed with cancer and severe anxiety. During the evaluation, I found myself struggling to keep her calm enough to answer my questions. She was distracted by worrisome thoughts, so I attempted to redirect the focus of the evaluation to her interests. Priscilla answered with one word: painting. I told her to wait a few minutes and that I would be right back; then, I ran to the occupational therapy clinic. I quickly gathered painting supplies from the therapy closet, and when I returned I prompted her to paint whatever she wanted while we talked. Her eyes lit up and she immediately began arranging the supplies and started painting. She was more open and willing to elaborate on her life experiences, express concerns for the future regarding her health, and voice her expectations and desired outcomes for therapy. While she painted, she became completely engaged in the activity, and I was able to ask her simple questions to complete a thorough evaluation. A copy of a replicated image, which is similar but not identical to Priscilla's painting, is provided below as a sample guide (see Figure 3).

Art proved to be a great diversional and motivational activity to detract from negative thoughts and promote verbal communication. Without art, this evaluation would have been more difficult and less informative. The use of art yielded more in-depth verbal information, elucidated an activity of interest, and strengthened our relationship. I allowed Priscilla to keep her painting and the supplies during her stay, as this activity proved to be therapeutic and useful when working with her. Throughout the service delivery process, art helped Priscilla remain engaged and meet the goals she set for therapy. Conclusion

A scoping review approach was adopted as the design for the current investigation in order to examine the appropriateness of using expressive art interventions to inform the occupational profile during evaluation and re-evaluation sessions, as required by new CPT codes (AOTA, 2016b). The investigators envision the use of expressive art interventions for clients who may be difficult to engage in the information gathering process through solely verbal techniques. An analysis of the literature reveals that expressive art interventions have several benefits for verbal communication and the therapeutic relationship, both of which are important aspects of developing an occupational profile (AOTA, 2016b). Although there has been an increase in research in more recent years, a majority of evidence focuses on individuals living with mental illness or who have survived trauma, resulting in a gap in the literature when considering all clients who are receiving occupational therapy services. A revitalization of the profession's core values and emphasis on meaningful occupation will likely increase the use of expressive art techniques in practice. Changing requirements for reimbursement, such as the requirement of a complete or modified occupational profile at each evaluation or re-evaluation session, will likely lead clinicians to seek alternate ways to promote clients' active engagement in the information gathering process. Expressive art techniques offer promising effects to inform the occupational profile and optimize occupational therapy service delivery, and should not be overlooked by occupational therapists during evaluations and interventions.

DOI: 10.15453/2168-6408.1360

Verna G. Eschenfelder, PhD, OTR/L, Assistant Professor of Occupational Therapy, The University of Scranton, Scranton, PA

Christina M. Gavalas, Graduate Student of Occupational Therapy, The University of Scranton, Scranton, PA

Taylor M. Pendergast, Graduate Student of Occupational Therapy, The University of Scranton, Scranton, PA

Colleen A. Gorman, Occupational Therapy Student, The University of Scranton, Scranton, PA

References

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Verna G. Eschenfelder

The University of Scranton, verna.eschenfelder@scranton.edu

Christina M. Gavalas

The University of Scranton, christina.gavalas@scranton.edu

Figure: Figure 2. Venn Diagram depicting interrelating client factors in expressive art as per included studies.

Figure: Figure 3. Priscilla's painting of a tree during an evaluation session.
Table 1

Unstructured Expressive Art Techniques Used by Investigators

Citation         Expressive Art and Interview Techniques

Gross et         * Structured interviews in three phases: free
  al. (2009)       recall with open-ended questions; direct
                   recall with specific, direct questions; and a
                   comprehension test
                 * Children were verbally prompted if they did
                   not spontaneously narrate or
                   describe their image while drawing
Katz &           * National Institute of Child Health
  Hershkowitz      and Human Development interview
  (2010)           protocol to promote open-ended questions
                   and reduce leading/suggesting questions
                 * Children in the drawing group were
                   provided with a blank sheet of paper
                   and allotted seven to 10 min to draw
                   with limited verbal interaction from
                   the interviewers
Lev-Wiesel &     * Each child was asked to draw "your life
  Liraz (2007)     in the shadow of your father's addiction
                   to drugs" (p. 68) followed by 'telling'
                   with the same prompt
                 * No specifics were provided regarding the
                   amount of time allotted for
                   drawing or subsequent prompts
Patterson &      * The interview began with establishing rapport
  Hayne (2011)   * If the child did not spontaneously narrate
                   while drawing, the child was prompted
                 * Children were asked how they felt about
                   drawing
                 * Each interviewer was coded on his or her use
                   of open-ended questions, closed questions,
                   leading questions, or minimal responses
                   (i.e., a non-question prompt that encouraged
                   the child to keep talking, such as 'uh huh'
                   or 'wow')
Symons et        * Semi-structured interviews lasting 30 to 60
  al. (2011)       min with leading questions regarding the
                   client's background, expectations, art
                   experience, and outcomes related to the
                   art program
                 * Adult clients were verbally prompted
                   throughout each topic
                 * Sessions consisted of visual art activities,
                   such as painting, and styles/techniques were
                   implemented on an individual basis
Wesson &         * The interview began with establishing
  Salmon           rapport, and for children in the
  (2001)           drawing group the mean interview time was
                   approximately 25 min
                 * Children were asked to narrate times when
                   they felt happy, sad, or scared according
                   to three stages
                 * Then, children were asked to draw according
                   to the same prompt, while seated at a table
                 * If children did not spontaneously narrate
                   while drawing, they were prompted. In
                   addition, non-directive prompts were
                   incorporated throughout to encourage
                   further recall
Woolford et      * Children were supplied with 12 colored felt
  al. (2015)       pens and blank paper and were
                   provided a general prompt to
                   draw and tell everything they could about
                   the presenting problem
                 * Encouragers, reflections, and prompts
                   continued until there was no further
                   information to report
                 * Interviewers were coded based on use of
                   open-ended questions, closed questions,
                   leading questions, or minimal responses

Figure 1. Visual representation of articles and
modalities retained after each stage of exclusion.

347 Articles

* All therapy disciplines (occupational therapy, music therapy,
art therapy, play therapy)

* Any publication year and any number of participants

* Creative art activities

* Projective assessments

* Empirical research and informative articles

62 Articles

* Narrowed discipline focus

* Any publication year and any number of participants

* Creative art activities to facilitate expression

* Projective assessments

* Empirical research and informative articles

47 Articles

* Any publication year and any number of participants

* Creative art activities to facilitate verbal communication

* Empirical research and informative articles

12 Articles

* Creative art activities to facilitate verbal communication with
no clincian interpretation of art

* Articles published after the year 2000 with at least three
participants

* Empirical research and systematic reviews
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Author:Eschenfelder, Verna G.; Gavalas, Christina M.
Publication:Open Journal of Occupational Therapy
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2018
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