Lecture drs. Marius den Otter (BEd, BPSc, BA) Lecturor NHLStenden, University of Applied science, Leeuwarden, Netherlands Academy of Healthcare. Art-therapy in the Netherlands Art therapy is a way of treatment for people with a mental illness or psychosocial problems. The focus is more on doing and to experience then on talking (vaktherapie, 2021) Art-therapists work under the responsibility of a general practitioner, coordinating practitioner or as an independent person established art-therapist. Art-therapists can be deployed with colleagues from (other) Arttherapeutic disciplines and with colleagues from other treatment disciplines (interprofessional). There is flexibility in the care offer (open and reduced scale, evening/weekend). Arttherapy can be used in mental health care (including child and youth psychiatry, addiction care and forensic psychiatry); mental-disabled care; youth Services; special education; to recover; psychogeriatrics; nursing home care; assistance to asylum seekers/refugees; hospital care; welfare work and palliative care. In treatment institutions, several Art-therapeutic disciplines often work within a treatment team of care programmes. They can specialize in the treatment of specific target groups (e.g. addiction care, personality disorders, people with severe trauma) from within specific care programs based on the choice of specific methodologies. Art therapists working with people from all age groups (elderly, adults, youth and children). We differentiate art, music, dance, drama psycho-motoric and play-therapy as specialisation. 1) Professional Tasks Art-therapist (vaktherapie, 2021) client-oriented tasks The client-related professional tasks are directly related to or arise from the treatment contact with the clients, the client system and/or the client. 1. Reasons and operates on the basis of an evidence and/or consensus-based therapeutic method; 2. Connects and builds a working alliance with the client; 3. Carries out professional therapeutic application, observation, examination, indication and diagnostics; 4. Executes the professional therapeutic treatment plan and evaluates the effect; 5. Uses own professional discipline when treating clients. Organizational tasks Supporting processes have to do with working in an organization or network, arranging funding, creating spatial and material conditions and organizing innovation. 6. Collaborates and coordinates the professional therapeutic treatment with fellow professional therapists, other professionals, clients; 7. Aligns activities with governmental and/or organizational policy and contributes to innovation; 8. Manages preconditions regarding subject therapy. Profession-oriented tasks Professional tasks have to do with the development of the professional therapist himself and that of the professional group. The profession-oriented core tasks are: 9. Develops and maintains professional therapeutic competencies and professionalizes and profiles the practice of the profession; 10.Participates in practice-oriented (and scientific) research; 11.Transfers knowledge and experience to others. 2) Clinical process Art therapy Textové pole: (preliminary)diagnose general practitioner Vývojový diagram: rozhodnutí: Effort Art therapy Ar Textové pole: Joint decision-making Textové pole: Ending treatment Textové pole: Not feasible; looking for alternative Textové pole: Continuing treatment Vývojový diagram: rozhodnutí: Goals achieved? Textové pole: Monitoring / evaluation Textové pole: Treatment / interventions Textové pole: inventory expectations, intensity and duration; determine / adjust goals Textové pole: Treatment plan Textové pole: Proces of art therapeutic- - Observation - Diagnosis - (contra-)Indication 3) Working in the art (Smeijsters, 2003) When the substance is used without there being an explicit connection between processes in the art and psychological processes, we speak of 'working with the art'. When working in the art it is paramount that the process that takes place in the art is psychological in itself: the client shows in the art what he/she is like and how he/she changes. - Art – analogous: a client's process resembles that of an artist: (but… therapy is more than seeking solutions to problems that are comparable to solutions to artistic problems) - Analogous process: the psychological process takes place within the process in the means: The fictional context and the real feelings Balance between over- and under-distancing (Landy, 1983) Analogy of drama and psyche: reversal (targeted vs spontaneous; controlling vs sympathetic) Bv: the use of roles (Landy, 2009) 4) Art – therapeutic triangel (Smeijsters, 2009) T=Therapist C=client M=Middel / Resource / Zdroj 5) Acting for real; 5 phases (Emunah, 1994) Phase 1: Dramatic play There is a safe environment where clients can move and interact with each other. Goals are to acquire more spontaneity, increase self-confidence and develop the ego strength of the client. This phase serves to warm up and to get fun, the assignments are group-oriented and inviting. The improvisation exercises are very suitable to let people come into contact with each other and to have fun playing. Much attention is paid to gaining confidence in oneself, in the fellow player and in the therapist. The assignments are non-directive in nature and invite free association. The client is invited to reflect on what has been experienced in play and to establish relationships with feelings, cognitions and behavior. Phase 2: Scenework. By playing fictitious roles, the client can be different and allow emotions. Status games are useful in this phase. A fictitious role, not having to be yourself, pretending, gives the safety to try emotions or behavior that is often avoided within a role or staged game reality. The focus is now still on the outside, shaping feelings, recognizing them and being able to express them without avoiding behaviour. The assignments can evoke resistance, because what has been played is experienced as not real. A caveat to this for the therapist is that any new behavior does not feel real or strange. In this phase the connection is made between drama and therapy. Clients indicate themselves what they avoid and what they want to practice. The role of spectator slowly changes from assessment or admiration to giving feedback. In play there is attention for emotions and feelings, wich makes it clear in a playful way which cognitions have an inhibitory effect on the expression of these. The cognition is not challenged, but experiential working methods are sought in which a client, for example, dares to explore his anger, guilt or sadness. Phase 3: Role play Difficult situations from one's own life are played out. Reality is the starting point of the therapy. A shift is taking place from the imaginary and fictional game to reality and current events. Clients have their own input and ask for time to work individually in the group on certain themes and problems. The realism of the scenes increases. In this phase, clients practice challenging their automatic thoughts through behavioral experiments. In this phase we work towards playing out feelings, the 'inside' Phase 4: Culminating enactment Through psychodrama, among other things, the client experiences and processes repressed themes from the past. Game is autobiographical, aim is to discharge and control emotions surrounding painful events. Psychodrama shows scenes from the client's life that symbolize what has been lacking in the child-parent relationship. Psychodrama is not a goal within drama therapy, although psychodrama involves a technique that acts directly on the essential stimuli. Psychodrama provides the ability to make changes to the stimulus, it can affect fear and arousal, and aims to modify the avoidance response. Phase 5: Dramatic ritual. Closure and integration of the earlier phases. 6) Concepts and Principles of Assessments in Dramatherapy (Johnson, 2011) Goals assessments: General: “understand” clients and determine which interventions are appropriate in treatment A distinction is made here between character traits that are currently visible and changeable and character traits that show more permanent, 'persistent' and fixed patterns. Another distinction is who the findings are for: - Internal assessments: treatment within drama therapy; - External assessments: communication with other disciplines Research Measurement has become increasingly important in the development of science. A distinction is made here between 'objective observation of phenomena' and 'subjective observation'. Both are important because they both offer a "form of truth." Within drama therapy, an objective observation is difficult, as we are dealing with creativity, play, spontaneity, roles, stories, etc. Nevertheless, it is important to find out what has value in development and interventions and what has less. Quantitative measurement with numbers (such as a Likert scale) makes it possible to calculate how reliable and valid the results are. With qualitative measurement you focus on the experience and perception. Interviews are often held for this purpose. Within drama therapy it is important (also) to capture 'dramatic behaviour' in language. Question within drama assessments: What is important to pay attention to if I want to investigate whether an intervention is suitable for my client? Inside drama: Structure vs improvisation Therapist's position Embodiment Emotion – expression Proximity to the roll Outside drama: Emotional expression and intelligence Resistance Functioning in daily life traumas Neurology 7) Treatment, methods, interventions Art-therapists do not treat the disorder itself, but underlying, transdiagnostic factors, such as perception, loss and emotion regulation.Within art-therapy, the patient can work on various treatment goals, aimed at, among others: Strengthening autonomy Regulating emotions, impulses and/or aggression Regulating tension and learning to relax Assertivity Learning to feel, handle and determine boundaries Improving body experience Self confidence, self image Loss Processing social functioning The challenge . . . is to keep the discourse open and allow the richness of voices to be heard. (Landy, New Essays in Drama Therapy) Why should change happen in dramatherapy? It does so by identifying a number of different elements which combine in dramatherapy work. These elements, or core processes, describe the ways in which drama and theatre forms and processes can be therapeutic. The factors or elements do not consist of specific techniques or methods. They concern fundamental processes within all dramatherapy. The core processes (Jones, 2007) are: 1. Dramatic Projection: (in the drama therapy process) a client projects a certain aspect of his or her life, or experiences, into theatrical material. This aids the patient into being able to make a relationship between their inner thoughts and actions. They are lead to ask “why did you do that action the particular way that you did?” 2. Therapeutic Performance Process: the differing ways in which the end goal performance is reached within the frame work of drama therapy. 3. Dramatherapeutic Empathy and Distancing: It is imperative to have both elements within a session. A patient cannot be fully empathetic or completely distanced. Empathy is created through making a relationship with the audience. Distancing comes more from Brecht in which the actor does not become fully immersed in the character or environment. 4. Personification and Impersonation: These are both ways in which the client can work to devise their own work. They can become a representation of something using personification or completely transform to someone else or and imaginary character through impersonation. 5. interactive Audience and Witnessing: audience refers to the particular role while witness in the action prompted by the audience. The two must work together to create harmony and motivation 6. Embodiment: This works with the aforementioned process in that the characterization must also pull out and match with the audience and witness. In drama therapy it is important because the actor will learn through their body, what they are comfortable with, something they did not realize they could do, or different ways of communicating. 7. Playing: This is where the bulk of the work is created. This process is meant for adults and children alike using games and warm ups. 8. Life-Drama Connection: We must establish a connection between the real life and the work the patient has created. If not there will be no change and all previous processes will be for not. If this connection is not there it would be impossible for them to bring information into the space to work on. 9. Transformation: Theatre is meant to change the way we think about the things around us, and that is exactly why drama therapy is a thing. In order for all the previous work to be valid, the client must have made some sort of shift in their daily life. 8) Dramaskills of a dramatherapist A wide range of dramaskills and –knowledge are required to practice dramatherapy, but always in favour of the client. At NHLStenden university we use the following learning-outcomes for students in dramatherapy: • The student is able to move freely in drama. • The student is able to independently research and analyze his or her own work and develop customization for flow. • The student is able to reflect on his own and others' drama processes/products and their meaning. In the drama exam, the following parts are tested with regard to drama: - Craft, artistic and technical skills belonging to the own discipline - Ability to produce, analyze and reproduce within their own field - Being able to use specific characteristics and qualities of a field in a targeted manner - Basic attitude: expressiveness, individuality, flexibility, interest, openness - Sensitive to movement, design, style and development of others Recommended literature Emunah, R. (1994). Acting for real; Drama Therapy Process, Technique and performance. Part II New York (NY): Brunner Routledge. Johnson, D.R. & Emunah, R. (2009). Current approaches in drama therapy, 2^nd Edition. Springfield: Charles C Thomas Pub Ltd. Johnson, D.R. Pendzik, S. Snow, S. (2011) Assessment in dramatherapy. Springfield: Charles C Thomas Pub Ltd. Jones, P. (2007). Drama as therapy. London: Taylor & Francis Landy, R. J. (1983). The use of distancing in drama therapy. The Arts in Psychotherapy, 10(3), 175–185. Landy, R.J. (2009). Role theory and the role method of drama therapy. In D. R. Johnson & R. Emunah (Eds.), Current approaches in drama therapy (pp. 65-88). Springfield, IL: Charles C. Thomas. Smeijsters H. (2009). Handboek creatieve therapie. Bussum: Coutinho. (only in Dutch) www.vaktherapie.nl consulted on 5-12-2021 (only in Dutch)