Revisiting art therapy: a counseling intervention for pupils

This work is licensed under a Creative Commons Attribution 4.0 International License. Revisiting art therapy: a counseling intervention for pupils Jocelyn G. Capacio Faculty, College of Arts and Sciences University of Perpetual Help System Laguna, Philippines Abstact: The purpose of this qualitative research was to (a) investigate how counseling intervention through art therapy influenced the psycho-emotional, social, physical, and spiritual selfdevelopment of school children who have conflicts and problems with their families and other institutions; and (b) to consider the practical implications of the findings for the future use of art therapy in school settings. A phenomenological research design was implemented, because the researcher was concerned with collecting qualitative data to describe the lived experiences of the people who participated in the research. Forty (40) participants were sampled from Grade IV pupils of Pedro H. Escueta Memorial School for the Academic Year 2015-2016 based on their attendance during the researcher’s visits and their willingness to participate in the study.


Introduction
This study focused on the use of art therapy as a counseling intervention to help the psycho-emotional, social, physical, spiritual, self-development of school children who have conflicts and problems with their families and other institutions. The background to this study is considered from five perspectives, based on a review of the literature: (a) what is art therapy? (b) history of art therapy; (c) art therapy counseling (d) art therapy counseling in schools; and (d) effectiveness of art therapy counseling.
Art therapy is a therapeutic intervention to aid in the reconciliation of emotional conflicts, increase self-esteem, foster self-awareness, and increase reality orientation, develop social skills and reduce anxiety (American Art Therapy Association, 2004). Art therapy uses images, art media, and the creative process to reflect personal development, abilities, personality, interests, concerns, and conflicts. Malchiodi (2012) states that "art therapy is the application of the visual arts and the creative process within a therapeutic relationship, to support, maintain, and improve the psychosocial, physical, cognitive and spiritual health of individuals of all ages. It is based on current and emerging research that the creation of art is a health-enhancing practice that positively impacts the quality of life".
Art as therapy embodies the idea that creating art is therapeutic and that the creative process is a growth-producing experience. Art is a powerful medicine. It can work towards the healing of our deepest fears and concerns. Self-exploration through art can be for many, a way of coping with situations too difficult to assimilate. Art therapy allows for a place with no judgment where we can "view art with wide eyes, when often elsewhere this act may be forbidden" (Rubin, 2005).
The human need to express emotions through art has existed since the dawn of human history. "From cave man through the Sunday painter, normal people in ordinary settings have been using art for personally helpful purposes" (Rubin, 2005). We each have a need to express our emotions in some manner as a process in the release of taming of our fear and frustration. Art therapy began with clinical interest in children's drawings, which has a long documented history in Europe. As early as 1885 in England, an article by Ebeneezer Cooke described developmental stages in children's drawings. Since then, the psychological and personality dynamics of children have commonly been evaluated through art, such as the Draw a Person (DAP) test and the House-Tree-Person (HTP) test (Weiner & Green, 2008). Rogers (1993) argued that art therapy is a process of personal discovery and development that comes from a profound emotional depth. It leads individuals directly into their unconscious, revealing unknown facets of their personalities, bringing to light new information and awareness, and cloaking perceptions of stress as harmless elements, by censoring stress as harmless in the eye of the consciousness.
Art therapy counseling combines the therapeutic uses of art therapy, with the skills of a professional counselor to provide multiple levels of communication within a therapeutic relationship. Art therapy counseling developed in the 1980s following clinical interest in the interpretation of children's drawings. In his book The Arts and Psychotherapy, McNiff (1981) states that art therapy counselling introduces action to psychotherapy and that "action within therapy and life is rarely limited to a specific mode of expression". Whilst talk therapy continues to be the primary mode of communication among psychotherapists, art therapy counselers are more aware of the fact that people have different styles of expression. Some clients prefer to use visual channels for communicating. When therapists are able to include various modes of expression in their work with clients, they can enhance each client's ability to communicate in a more individualized manner.
Art therapy counselors are credentialed professionals who purposively use specific artbased approaches with children, adults, groups and families to support, maintain, and improve overall health, physical, emotional and cognitive functioning, interpersonal skills, personal development, and quality of life. Art therapy counseling is helpful for people who experience illness, trauma, mental health issues, challenges in living, as well as for those who seek personal insight and change (Southern Illinois University Edwardsville, 2016).
Art therapy counseling can be used in schools as a means for pupils and therapists to visualize the unconscious and to eventually recognize it on a conscious level. When pupils cannot articulate through words, emotions, and feelings about their true state of mind, the use of art can help to identify and reconcile internal conflictes. In the realm of art teaching, art therapy is a close match to many other non-therapeutic approaches. For example, art education with children with disabilities, community art programs for groups, shelters or neighborhoods with economic or social challenges, and art studios for people with mental illness have similar goals and objectives and are difficult to differentiate from art therapy (Malchiodi, 2014).
Art therapy counseling can be used in a school for pupils with special needs. These special needs may range from learning disabilities to behavioral, emotional or medical problems. Bush (1997) highlighted that art therapy counseling is, in effect, a catalyst that takes students with varying special needs and, through art, helps them to improve their outlook on life, referring to special needs children and their right to an education. Shostak (1985) suggested that "The pressing needs of these youngsters call for unique educational and related services applications". One of these is the interdisciplinary model which promotes collaboration between professionals. Art therapy for children with special needs does not only involve the art therapist alone, but also teaching and counseling from experts, supported by the child's parents and family members. Bloomgarden and Schwartz (1997) suggested that in order for art therapy to work for students with special needs, teachers, counselors, and art therapists need to collaborate.
Several studies have been conducted using art therapy counseling for children with a variety of special needs. Kearns (2004) found art therapy to be a useful intervention with children with ADD/ADHD and Asperger"s syndrome. Darrell and Wheeler (1984) used art therapy counseling to help underachieving seventh grade junior high school students. Pleasant-Metcalf & Rosal (1997) used art therapy counseling to improve academic performance.
There is a relative lack of research based evidence regarding the effectiveness of the outcomes of art therapy for children. Only a limited number of rigorously designed experimental studies have been conducted. Eaton, Doherty, & Widrick (2007) published a review of 26 articles reporting the results of qualitative and quantitative research to determine if art therapy was an effective treatment for traumatized children (e.g., to reduce symptoms of anxiety, depression, phobias, and post-traumatic stress). The conclusion of this review was that art therapy appeared to be an effective method to relieve the negative psychosocial consequences of childhood trauma. Furthermore, art therapy was shown to facilitate the development of a strong client-therapist relationship, and this was one of the most important predictor of a successful client outcome. Most of the reviewed studies, however, did not use experimental methods that involved the random assignment of the participants into a control group and an experimental group. Eaton et al. (2007) raised the issue that randomly assigning traumatized children to a control group was an ethical dilemma that could not be resolved. Furthermore, the researchers emphasized the difficulties they encountered in reviewing art therapy studies, because many authors did not provide detailed information regarding exactly what modality of the art therapy was chosen, the degree of its formal or informal structure, and the duration of the therapy.
The limited experimental evidence to support the efficacy of art therapy may due to the disinclination of art therapists toward quantitative research (Deaver, 2002). Furthermore, the complexities of art therapy may not be so easily regulated by the rigid standards used in clinical research (e.g., using a randomized controlled trial to test the efficacy of a physical therapy or a pharmacological treatment). The nature of art therapy is often unstructured and unconstrained, in order to allow temporal and physical freedom for each individual to unfold, to self-actualize, and to grow both emotionally and spiritually (Rogers, 1993). The manifestation and duration of these processes varies from one individual to another, and so the measurements of the outcomes of art therapy are not easily forced into a clean, controlled, time-constrained experimental design, such as that needed to conduct a formal randomized controlled trial in a clinical setting (Kaplan, 2005).

Theoretical framework
The use of counseling intervention through art therapy is underpinned by psychodynamic theory, rooted in the classical philosophies of Freud, Jung, and Bion. Psychodynamic theory supports the use of short-term, dynamically oriented, individual psychotherapy, supportive psychotherapy; hypnotherapy, relaxation techniques and cognitive therapy (Horne, Sowa, & Isenman, 2000). The psychodynamic theory posits that (a) the personal growth of an individual takes place in a safe, supportive environment; (b) a safe, supportive environment is created by therapists who are genuine, warm, empathic, open, honest, congruent, and caring; (c) personal growth is also influenced by creative processes that help individuals find their inner essence or source; (d) when individuals find their inner essence or source, they tap into the universal energy source, otherwise known as the collective unconscious, or the transcendental experience, which is the essential source of all types of mind-body intervention; and (e) the collective unconsciousness derived from elements derived from within the mental structure of each individual includes nonthreatening well-disguised images.

Statement of the purpose
In the light of the foregoing background, the purpose of the current research was to address the following two research questions: 1. How does counseling intervention through art therapy influence the psycho-emotional, social, physical, and spiritual self-development of school children who have conflicts and problems with their families and other institutions? 2. What are the practical implications of the findings of this study for the future use of art therapy in school settings?
The purpose of this study complied with the mission statement, philosophy and objectives of the University of Perpetual Help System Laguna, in line with, and supportive to, the national development goals of the country and the policies, thrusts and objectives of higher education. The efforts of the University are focused on instituting community outreach services to the people in the communities and acting as an agent.

Research Design
The majority of the arguments supporting the efficacy of art therapy come from qualitative research (Eaton et al., 2007). Holttum (2013) highlighted that quantitative research (e.g., a randomized controlled trial, involving the collection and statistical analysis of numerical data) is not necessarily the best way to determine the effectiveness of art therapy, and suggested that qualitative research provides deeper insights into the possible helpful impacts of art therapy. Accordingly, a phenomenological research design was implemented to address the stated research questions, because the researcher was concerned with collecting qualitative data to describe the lived experiences of the people who participated in the research. Phenomenology meant that the researcher wanted to understand a social and psychological phenomenon from the perspectives of the people involved, and to describe the essence of the phenomenon as accurately as possible (Merriam, 2009). The phenomenological design also meant that the researcher's approach was not entirely neutral, but could potentially be influenced by her personal background, values, beliefs, and points of view (Denzin & Lincoln, 2008).

Participants
The participants in this study consisted of forty (40) A). The school has 10 instructional rooms and 2 noninstructional rooms, which are all powered by a power grid. With 515 students, class size is around 60 students" The choice of the pupils for this study was based on their attendance during the visits of the researcher and their willingness to participate in the study. The participants represented a purposive sample, because they were chosen specifically to help the researcher to improve understanding of the phenomenon of the research, specifically the use of art therapy as a counseling intervention to help the psycho-emotional, social, physical, and spiritual self-development of school children who have conflicts and problems with their families and other institutions.

Ethical Considerations
The stages of communication for this study were considered by sending letters of request to the concerned authorities and receiving approval.The confidentiality and anoymity of the participants' identity and art works were strictly maintained. Consent from guardians and parents were secured and all participants were informed that the data they provided will be used for research purposes only. The children were not exposed to any mental, physical, or environmental risk, and no unethical techniques were used. No children were forced to participate against their will, and no students were excluded on the basis of their gender, age, race, or socio-economic status.

Instrumentation
Three instruments were used in this study. The first instrument was the Psychological Needs Assessment Tool, administered to conduct the Needs Assessment Survey. This is similar to the tool recommended by the World Health Organization (2012) for assessing psychosocial needs. It consists of a form with thirty (30) items, classified into six (6) dimensions of needs, as follows. A: Self development; B: Family relationship; C: Psychological-emotional; D: Physical; E: Spiritual, and F: Social, with six (6) items in each group. The dimensions of the Needs Assessment Survey are defined in Table 1. The pupils were asked to "Kindly indicate your response to each item as it presently applies to you". The higher the scores, the more the pupils agreed with the items, expressing higher psychological needs.

A: Self development
Trends and variations in physical attributes because of puberty, motor development, and perspectives regarding health and illnesses. B: Family relationship Pyschosocial development that involves the quality of parentchild relationships, the effects of work on families, the changing nature of modern families, separated parents, and its effects on children.

C: Psychologicalemotional
Psycho-emotional aspects that build the emotional make-up of children, as well as the component of experiences in the surrounding environment.

D: Physical
Bodily activities that children are inclined to do.

E: Spiritual
Relationship to our creator and behavior that relates to religious beliefs.

F: Social
Social relationships that affect children, including the functions of friends, influences of peer group membership, gender role stereotyping, popularity, social acceptance, rejection, and conformity to peers.
The second and third instruments were the Draw a Person (DAP) and House-Tree -Person (HTP) tests for the evaluation of personality traits and cognitive function from a psychological perspective For the DAP test, the pupils were asked to draw a man, a woman, and themselves. The DAP test was originally designed by Florence Goodenough, a child psychologist, in 1926 (Weiner & Green, 2008). For the HTP test the pupils were asked to draw a house, a tree, and the figure of a person (Buck & Warren, 1992). No further instructions were given and the children were free to make the drawings in whichever way they liked. When finished, the pupils were asked to describe the pictures they had drawn.
The DAP and HTP tests are subjective and open to interpretation by the evaluators of the drawings, to make inferences regarding the personality traits and cognitive functions of the creators of the drawings. The subjective nature of these tests, as with other qualitative tests, has little empirical evidence to support their reliability or validity (Weiner & Green, 2008).

Data Collection The researcher presented a letter addressed to the Dean of College of Arts and Sciences and the Community Outreach Program Director of University of Perpetual Help System
Laguna as well as the principal of Pedro H. Escueta Memorial School to obtain permission to conduct the study. The researcher also explained the importance of the study to the participants.
A Pre-evaluation of the pupil's personality and cognitive functioning was conducted on August 16, 2015 using the Needs Assessment Survey, a series of six (6) sessions of art therapy counseling interventions were then conducted. Individually each student were asked to describe the pictures that they had drawn using the Draw a Person (DAP) and House-Tree-Person (HTP) tests. Counseling followed immediately after. A Postevaluation was conducted on January 20, 2016 using the Needs Assessment Survey to ascertain whether there had been improvements in the pupils' personality and cognitive functioning after the art therapy counseling interventions.

Data Analysis
The researcher coordinated with an expert in the field of psychology to: (a) compare the negative and positive findings in the pre-evaluation and post-evaluation Needs Assessment Survey; and (b) interpret and analyze the data procured from the participants using the interpretation tools for the DAP test (Scott, 1981) and the HTP test (Buck & Warren, 1992).

Results and discussion
The ranked list of items in Table 2 show that the thirty-one (31) negative findings in the Pre-evaluation Psychological Needs Survey, conducted before art therapy as a counseling intervention, exceeded the eight (8) positive findings. The results of the pre-evaluation survey indicated that the Grade IV pupils of Pedro H. Escueta Memorial School, at the beginning of this study, faced many problems with their psycho-emotional, family, physical, social, spiritual, and self-development needs. They found to be mentally and emotionally healthy. The clients were vulnerable.
Family Passive and submissive They were being positively reinforced by their loving parents. They showed extreme emotional and psychological stress

Physical and Social
Their social and emotional skill were undeveloped They enjoyed simple things in life They had restless personality with uncertainty They had good manners They were Indecisive, disdain Self-Development Their behavior were fidgeting They boosted self-confidence through activities They still have positive attitude

Negative Positive Family
They experience difficulty in dealing with their family.
They showed great potentials to be a leader They were not in favor of being away from family Their self-efficacy were high They lack love and acceptance They lack deeper communication with his family They lack strategy in dealing with family problems Physical and Social

They don't know their boundaries and limitation
They lack self-confidence They have inferiority complex They were uncertain to relate well with others, They lack pleasant personality, quiet,childish and immature behavior They were not comfortable disclosing personal life They had low self-confidence They were much physically disturbed They were physically abused They fear of interacting with others They lack vigor and energy

Self-Development
They have poor academic performance They don't have the guts to do the things They have the needs to be more vocal They lack motivation and self-esteem They are not courteous and considerate

Spiritual
They lack some guidance in morality They have poor relationship to God In the psycho-emotional dimension, many participants exhibited extreme emotional and psychological distress, and they expressed it through their artwork. They also exhibited fidgeting, passive, indecisive and disdain behavior when they could not express their emotions to other people. When trying to confront them, they demonstrated nervous affect and anxious mode. The results showed that the emotional skills of the pupils were undeveloped and they were vulnerable to adopt certain behavior within their surroundings.
In the Family dimension, the pupils revealed that they lacked love and acceptance from their family. Deeper communication with family members was not present that is why they felt that they were unable to cope with problems in their family.
In the Physical and Social dimensions, the pupils disclosed that they lacked a pleasant personality, leading them to become anxious and lose their self-confidence. They seemed to lack healthy nutrition with resulted in lack of vigor and energy. Some of the pupils were physically abused by their family. This abuse influenced their behavior of interacting with other people. They had lost their trust in other people and were not comfortable disclosing details of their personal life. An inferiority complex had developed, associated with the lack of support from ther family.
In the Spiritual dimension, most of the respondents had poor relationship with God and lacked guidance on morality. Lastly, in the Self-Development dimension, some of the pupils reported they had a poor academic performance because of lack of motivation and self-esteem. It appeared that the inculcation of cultural values was neglected by the institution responsible for developing it.
Despite the plethora of negative findings, some positive findings were noted. In the psycho-emotional dimension, most of the pupils were mentally and emotionally healthy. This meant that they were able to absorb the counseling they received. The Self-Development dimension was also positive, reflecting an optimistic attitude.
The ranked list of items in Table 3 showed that the eighteen (18) positive findings in the post-evaluation of Psychological Needs Survey exceeded the nine (8) positive findings of pre-evaluation. The results of the post-evaluation indicated that the Grade IV pupils of Pedro H. Escueta Memorial School faced fewer problems with their psycho-emotional, family, physical, social, spiritual, and self-development needs after art therapy as a counseling intervention.

Negative
Positive Psycho-emotional Psycho-emotional They could not express more of their thoughts and emotions deeply They were no extreme emotional and physical problems to their personal aspect They were suffered depression They were able to give trust to others Family Family Their family problems interfered with their behavioral and emotional functioning They were happy with their family They needed more attention from their family They are coping up with the problems from their family and education

Social and Physical
They have a good family relationship, selfless and full of dreams They found hard to trust other They wanted to use their ability and remember their family doing the activity They were worried and frightened to be bullied by their classmates The positive findings indicated many improvements in several different aspects of life of the participants. In the Psycho-emotional dimension, none of the pupils reported any extreme emotional problems. There were also developments in the Family dimension. Pupils who had a good relationship with their siblings had the advantage to cope with their problems, enabling them to become happier and contented individuals. Improvements in the Self-Development dimension were also noted. Most of the children felt stable and had a dream looking positively about their future. They showed maturity and willing to work hard for everything that they wanted to achieve. Lastly, in the Social and Physical dimension, they had developed a good personality even if they were facing some problems. They become friendly, cheerful and smart.

Social and Physical
The results of this study provided an answer to the first research question: How does counseling intervention through art therapy influence the psycho-emotional, social, physical, and spiritual self-development of school children who have conflicts and problems with their families and other institutions? The results of the current study indicated that after six sessions of art therapy counseling, there was an improvement in the psycho-emotional, social and physical, spiritual and self-development needs of Grade IV pupils at Pedro H. Escueta Memorial School. The counseling intervention through art therapy appeared to lessen the pupils emotional and psychological problems. Furthermore, strong family relationships were found to improve the emotional and psychological development of the children.
The findings were consistent with the suggestion that art therapy counseling can be used in a school to help pupils with emotional problems (Bush, 1997). Art therapy counseling provides a means for pupils and therapists to visualize unconscious thoughts and to recognize them on a conscious level (Malchiodi, 2014). The results also supported the conclusion of Eaton et al. (2007) that art therapy appears to be an effective method to relieve the negative psychosocial consequences of childhood trauma.
The results of this study also facilitated an answer to the second research question: What are the practical implications of the findings of this study for the future use of art therapy in school settings? The use of arts as therapy can be very helpful in school setting as it improve the pupils' emotional and social well-being. And it is supported by findings of Shemps (2008) in her thesis entitled "The Need for Art Therapy in Middle Schools", that "(The arts) enable persons to develop in ways that are personally and socially challenging" (Gladding, 1998, Preface). Art therapy can facilitate appropriate social behavior and promote healthy affective development so students can become more receptive to learning and, in turn, realizing their social and academic potential (Stepney, 2001).
The limitation of his study is that the data were collected using only one purposive sample at one school during one short period of time. Consequently, the results may have little or no external validity, meaning that it is not possible to generalize the conclusions from the sample to the population of all Grade IV pupils at other schools at other times.

Conclusion
The overall conclusion of this qualitative study, based on a phenomenological design, is that the psycho-emotional, social, physical, and spiritual self-development of forty (40) Grade IV school children at Pedro H. Escueta Memorial Elementary School appeared to be improved through the counseling intervention of experts experienced in the use of art therapy. The main recommendation based on this conclusion is that the teachers along with other school officials are encouraged to implement art therapy as a counseling intervention. Future research, at other schools, at other times, is necessary to determine if these findings have external validity.

Recomendations
1. The main recommendation for action is that teachers of Grade IV pupils at Pedro H. Escueta Memorial School along with other school officials are encouraged to implement art therapy as a counseling intervention. Furthermore, the school should welcome other agencies to conduct different programs to help address the needs of the pupils. Professionals in the practice of psychology should have a chance to share their time, effort, and expertise in helping to implement art therapy as a counseling intervention for pupils with psycho-emotional, social, physical, and spiritual problems.
2. The quality of teaching should ideally be improved to catch the attention of the pupils, so they will become more dedicated to study their lessons. In particular, teachers could provide more time and patience in guiding the academic performance of pupils with emotional problems.