Cognitive-behavioral art therapy (CBAT) is emerging as an intervention that builds upon the science of disrupting cognitive distortions while utilizing the creativity and narrative of the patient. This method could be particularly useful in working with youth from non-Western cultures, which tend to have a more expansive approach to self-expression and identity. This pilot study on CBAT for one of the world’s most vulnerable populations, refugee youth, intends to examine the intervention as an effective tool to decrease symptomology of generalized anxiety disorder.
Using a participant pool of youth from the world renown Children’s Hospital of Philadelphia’s Refugee Health Program, this pilot study delivers a ten-week CBAT intervention with concurrent evaluations using a variety of measures of anxiety. The results will demonstrate the feasibility of a longitudinal study of CBAT effectiveness as compared to other anxiety interventions.
Global crises, political tensions and unrest, natural disasters, and climate change have displaced more than 65 million people around the globe, according to estimates by the United Nations High Commission on Refugees.
The United Nations Convention Relating to the Status of Refugees (1951) defines a refugee as a one who is “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality and is unable…or unwilling to avail himself of the protection of that country (United Nations Commissioner for Refugees, 1951, Article 2). From October 2017-September 2018, Philadelphia, Pennsylvania welcomed 232 refugees from countries such as Bhutan, Democratic Republic of Congo, Afghanistan, Eritrea, Burma, and Ukraine.
By contrast, the county welcomed 643 refugees during in 2016-2017 (Refugees in Pa, 2019). Still, Philadelphia, with its globally diverse population, has been a welcoming location for refugee resettlement in the United States, supported by programs such as the Nationalities Service Center, Pennsylvania Refugee Resettlement Program (PRRP), HIAS Pennsylvania, and the Refugee Health Program of Children’s Hospital of Philadelphia. Both refugees and asylum seekers experience trauma and adverse events at higher rates than the general population (Kalt, Hossain, Kiss & Zimmerman, 2013). Acculturation, threat to identity, and adjustment of immigration status can also cause anxiety, depression, stress in refugees (Bogic, Njoku, Priebe, Fabrega, Parron, and Good, 2015; Burnett & Peel, 2001; Steel, Chey, Silove, Marnane, Bryant & van Ommeren, 2009).
Trauma and adverse events can increase the likelihood of anxiety disorders and other mental health illnesses, include depression disorders (Herringa et al., 2013; McGee, Wolfe, & Wilson, 1997; Moffit et al. 2007). In fact, anxiety not only impacts the traumatized child, but can evolve into more serious internalizing disorders as well as conduct disorder (Moffit et al., 2007). The DSM-5 operationally defines generalized anxiety disorder as “excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)” (2013). For children, there must be at least one of the following symptomologies: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, or sleep disturbances (APA, 2013). The distress must cause “significant impairment” in daily functioning and not be attributed to the use of substance or medical condition. For the purpose of this study, anxiety disorders will be measured by inventories including Generalized Anxiety Disorder-7 (GAD) screening, Screen for Child Related Anxiety Disorders (SCARED), Revised Children’s Anxiety and Depression Screening (RCADS). Other inventories, including the Personal Health Questionnaire and Traumatic Events Screening Inventory for Children (TESI-C) will build upon this measurement to give a holistic profile of well-being, symptomology for depression, and other mental health issues. Herringa and his team of colleagues found that treating child anxiety led to better outcomes as adults, so it is imperative that researchers determine early interventions for traumatized children experiencing anxiety (2013).
Cognitive behavioral art therapy made its first appearance in the 1970s by Ellen Rothe and Janie Rhyne. The benefit of art therapy as a means to address PTSD and anxiety is the use of visual processing to collect and interpret memories of trauma events (van der Kolk, 2002; Perry, 2008). Art therapies can also help overcome language and cultural barriers explicit in talk therapy, while allowing children to express their cultural identity (van Westrehen & Fritz, 2014). Additionally, non-verbal constructs associated with anxiety and trauma are aided by creative expression interventions (Kapitan, 2017). While cognitive-behavioral therapy is an evidence-based intervention for anxiety disorders, many adolescents from non-Western cultures might not respond as successfully to a talk-based intervention, particularly when it involves open, frank discussions about traumatic experiences (Kapitan, 2017). While they have proficiency in English, CBT may prove difficult as an intervention for communication and expressing thought patterns (Kapitan, 2017). The majority of research studies on the effectiveness of CBT predominantly include white participants from Western nations. When non-culturally adaptive CBT was used in studies for non-Western participants, including immigrants, adherence to treatment is relatively poor compared to Western participants (Antoniades, Mazza, & Brijnath, 2014). For example, researchers found that using CBT with autobiographical writing improved adherence to treatment and depression scores in Korean immigrants (Antoniades, Mazza, & Brijnath, 2014). Autobiography, as a written art form, allows self-expression and storytelling to become part of CBT practice as a culturally-competent approach for non-Western cultures (Antoniades, Mazza, & Brijnath, 2014).
While research on CBAT is nascent, the use of CBT for immigrants is well-documented for anxiety disorders and depression, similar to its effectiveness in non-immigrant groups (Antoniades, Mazza, & Brijnath, 2014; Shattell, Quinlan-Colwell, Villalba, Ivers, & Mails, 2010; Interian, Allen, Gara, & Escobar, 2018). For vulnerable immigrant populations living in rural locations, telephone-based CBT was seen as one effective treatment (Dwight-Johnson et al., 2011). Most of these studies have focused primarily on immigrant adults, but fewer studies have investigated the use of these therapies in immigrant children specifically for anxiety. The implication of this feasibility study is the use of CBAT as a preferential intervention for anxiety for this population, and the broadening use of evidence-based practice in hospital, education, and private practice settings.
Children’s Hospital of Philadelphia’s Refugee Health Center provides psychosocial assessments for children of refugees. Their services also include immunizations, preparations for adjustment of status, and screenings for infection diseases, developmental conditions, and adolescent risk behaviors. They also provide training for medical residents and students. The center, located in West Philadelphia, Pennsylvania, includes three primary doctors and a nurse practitioner.
This pilot study posits that cognitive behavioral art therapy will demonstrate a difference in anxiety levels that might warrant a deeper investigation into the use of arts-integrative interventions to existing evidence-based practice. This pilot study is unique in that it utilizes CBAT specifically with anxiety disorders in refugee adolescents, whereas most studies involved adolescent anxiety have used CBT or art therapy, rather than an integrated approach.
The researchers predict there will be a change in anxiety levels indicated by composite scores from the Generalized Anxiety Disorder-7 (GAD) screening, Screen for Child Related Anxiety Disorders (SCARED), Revised Children’s Anxiety and Depression Screening (RCADS), Personal Health Questionnaire (PHQ) and Traumatic Events Screening Inventory for Children (TESI-C) following a trial of cognitive-behavioral art therapy. If there is a reduction in anxiety levels, future research can look at the effectiveness of CBAT as compared to other interventions for anxiety, particularly CBT without arts interventions.
Participants in the program will include teenagers from thirteen to seventeen years of age. All participants will be primary care patients at the Children’s Hospital of Philadelphia Refugee Health Center. The Refugee Health Center serves families from around the world, so participants are expected to come from a variety of countries around the world. Philadelphia has large concentrations of refugees from Afghanistan, Ukraine, and Eritrea, Congo, Bhutan, and Pakistan. The study also expects to recruit a balanced gender spectrum. Primary care physicians will screen teenage patients using the physician health questionnaire (PHQ) and GAD-7 inventory for generalized anxiety disorder. Participants who receive between 10-21, indicating moderate to severe anxiety, will be eligible. Patients who indicate an affirmative respond to PHQ questions related to prior or future suicide attempt or ideation will be excluded. Prior history of severe mental illness will also exclude participants in the study. Conversational English language will be a requirement for inclusion for adolescent participants. The study is limited to thirty participants over a one-year period. Families who request intervention services will be put on a waitlist for future intervention studies of CBAT following the pilot period to ensure equitable access to services and ethical treatment to this vulnerable population.
It is important to adhere to ethical standards of working with vulnerable populations. Working with refugees in research requires an adherence to ethical practice. Refugees might fear revealing their immigration status or have apprehension about the jargon that is involved in the informed consent process, even when they are interested in the study (Birman, 2005). For example, Yu & Liue describe how potential Vietnamese participants were unwilling to sign an informed consent out of fear that a paper trail of their participation would result in retaliation from their government (1986). One participant was so concerned that she stopped the clinical interview, ripped up her informed consent document, and then suffered three sleepless nights (Yu & Liue, 1986). While this study’s adolescent pool will likely not be impacted by these particular concerns, it is still critical for the research team to be acutely aware of these concerns for refugee populations and to mitigate opportunities for potential harm and to increase the likelihood of nonmaleficience.
This study will involve considerable safeguards for the rights and dignity of this population, including adhere to anonymity and confidentiality, and an intervention that has demonstrated to cause no harm to participants. The study design protects the participants sense of beneficence, while providing access and equity to a treatment intervention with negligible risk of harm to participants in the study. The design also utilizes exclusion criterion of suicidal ideation or attempt and severe mental illness, as these areas would require escalation in service. Potential subjects who do endorse suicidal ideation or prior attempt on the Personal Health Questionnaire will receive a suicide risk assessment by research staff with the provision of either immediate emergency services or referral to an advanced level of care, including post-referral follow-up.
As a pilot program, this study will involve a quantitative, single-subject design. Potential participants will be notified by their primary care physician that they qualify for this pilot program for anxiety. Research staff will call potential participants to explain study, implications of potential care, and to receive informed consent from both teenagers and parents. Informed consent will be available in multiple languages for the parents.
Teen participants will receive $20 for baseline, mid-intervention, end of intervention, and six-month post intervention evaluations. Baseline evaluation will include the Generalized Anxiety Disorder-7 (GAD) screening, Screen for Child Related Anxiety Disorders (SCARED), Revised Children’s Anxiety and Depression Screening (RCADS), Personal Health Questionnaire (PHQ) and Traumatic Events Screening Inventory for Children (TESI-C). Following baseline intervention, adolescent participants will receive five, fifty-minute sessions of CBAT with a trained psychologist in the intervention. Following first five weeks of CBAT, the participant will complete the inventories during a mid-intervention evaluation, to be followed by five additional fifty-minute CBAT sessions. After the last session, adolescents will complete end of intervention evaluations. There will be a six-month follow up post-evaluation. Participants will receive similar CBAT treatments to include touchpoints with various forms of art, including written expression, painting, and collage. The treatment will be standardized by utilizing one trained psychologist for all subjects. The trained psychologist will not only have expertise in CBAT, but will have demonstrated successful prior interventions with similar populations. The trained psychologist will also be required to attend refresher professional developer courses on working with multicultural populations prior to the start of the intervention. Total length of participation for each participant is expected to be about one year from baseline evaluation to post-intervention evaluation.
Interventions will be preceded by a family session, which will include psychoeducation about generalized anxiety, cognitive behavioral art therapy, and questions or concerns from parent/guardian or adolescent participant. A translator provided by Children’s Hospital of Philadelphia will be available during the parent sessions, as English language for the adolescents is considered inclusion criteria for the study, but not for the parents. The family session will allow the psychologist to gain a better appreciation and understanding of the cultural context from which the participant adolescent is bringing into individual sessions.
The design of the intervention is supported by several studies using art integrated CBT (Morris, F., 2014; De Beurs, Chambless, & Goldstein, 1997; DeFrancisco, 1983; Perry, 2008; Rosal, 2001; Sandmire, Gorham, Rankin, & Grimm, 2012; van der Vennet & Serice, 2012). The use of writing as a form of healing was made popular by James Pennebaker (2004). Though the specific intervention will be dependent on participants’ individual needs, histories of trauma, and symptomology, there will be common intervention themes used by the psychologist in all sessions. The first session will be dedicated to psychoeducation, which include defining GAD, explaining symptoms, and understanding the link between thoughts, feelings, and behaviors. During psychoeducation, all participants will be asked to develop a visual representation of anxiety, using collage or color. The second and third sessions will focus on diaphragmatic breathing and identifying support systems and coping skills for the adolescent to utilize during higher levels of anxiety. Diaphragmatic breathing will involve the use of visualization and coloring of the images conjured by participants. Participants will use collage materials to develop a map of their support systems. Sessions four and five will consist of cognitive restructuring, in which participants will draw pictures of their distortions and the likelihood of their occurrence. Following the first initial sessions, a mid-intervention evaluation using the inventories will take place.
Sessions six through ten begin to introduce the use of exposures, typical of CBT for anxiety, panic, and phobia. Session six begins with a return to diaphragmatic breathing following the use of cognitive structuring. Session seven incorporates elements of imaginal exposure. Participants will rank their hierarchies of anxiety, and draw imagery related to each unlikely scenario. Session eight and nine incorporate in vivo exposures beginning with desensitization drawings followed by an exposure. Session ten will incorporate art into what is known as a “bridge drawing” for relapse prevention, creating a visual representation of progress. Session ten is followed by an end-of-intervention evaluation. All sessions will incorporate the use of an anxiety diary.
Scales of anxiety will be analyzed at baseline, mid-intervention, end of intervention, post-intervention for all participants using GAD-7, SCARED, RCADS, TESI-C, and PHQ. As a pilot program, the feasibility of an intervention study comparing CBAT, CBT, and art therapy will be devised.
The implications for this pilot study are timely given a geopolitical climate that has impacted some of the most vulnerable populations – children escaping violence. Many of these children have experienced prior trauma, from environmental conditions to family violence, which is compounded by migration, concerns for immigration status, and acculturation. If the finding supports CBAT as an effective treatment for anxiety, larger studies that compare CBAT with CBT or CBAT with psychoanalytic art therapy would be important for determining best treatment options for this vulnerable population. The findings might also continue to expand the traditional notion of CBT as a multitude of diverse approaches to disrupting thought patterns and reducing maladaptive behaviors.
The pilot study is not without its limitations to providing culturally competent care for the diversity in refugee populations. While the psychologist is required to undergo specific multicultural training in providing CBT and prior experience with CBAT, the psychologist will not necessarily hold the knowledge of every cultural background of the participant adolescents. As a pilot intervention, this study will require deeper research utilizing control groups and alternate interventions for comparison. This study does not include any financial conflict of interests and all funders have been reported appropriately.