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Treatment of mood disorder in an at-risk sample of high school adolescents: a randomized trial of art… Hucul, D. Michele 1998

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Treatment of Mood Disorder in an At-Risk Sample of High School Adolescents: A Randomized Trial of Art Therapy Intervention by D. M I C H E L E H U C U L B.A., University of Victoria, 1992 THESIS SUBMITTED IN P A R T I A L F U L F I L M E N T O F T H E R E Q U I R E M E N T F O R T H E D E G R E E O F M A S T E R O F A R T S in T H E F A C U L T Y O F G R A D U A T E STUDIES Department of Counseling Psychology We accept this thesis paper as conforming to the required standard T H E UNIVERSITY OF BRITISH COLUMBIA December, 1998 © D. MicheleHucul 1998 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of G - n ^ s p L U n e IS^cKo<U> The University of British Columbia Vancouver, Canada Date ~Q<Lc^ Hp/*tg>-DE-6 (2/88) 11 Abstract Although a vast scope of literature has investigated the efficacy of other treatments of depression there remains a gap in the research of creative arts modalities as treatment for depression. The following research study will address this oversight providing new information on the efficacy of short-term art therapy as treatment for depression in the adolescent population. In the following study high school counselors and other helping professionals identified high school adolescents at risk for future depressive disorder by virtue of having elevated depressive symptomology. The study then compared two randomly assigned individual or group art therapy treatment groups to a wait-list control group. The Children's Depression Inventory, Stony Brook Child Psychiatric Checklist, and the Children's Behavior Inventory assessments were administered pre- and post-treatment for all three groups. Quantitative statistical analysis was used to determine the effectiveness of individual or group art therapy intervention vs. the non-intervention control group. Results seem to show that the individual art therapy treatment group when compared to themselves after treatment displayed a significant decrease in depressive symptoms according to the Children's Depression Inventory [t(df=3)=2.87, p=0.03] and the Child Behavior Checklist [t(df=3)=3.33, p-0.02]. Those receiving group art therapy treatment seemed to show significant improvement according to the Children's Depression Inventory [t(df=4)=2.39, I l l p=0.04] when compared to themselves after treatment. The Control Group results indicate there was no significant difference in the scores on any of the three psychological measures. Between group analysis indicates the individual treatment group showed a decrease in psychiatric symptoms (p=.04) compared to the control group. In light of the many between group differences it is the researcher contention that a larger sample size may result in stronger effects. The post-treatment comparison of the combined treatment groups to the control group indicates significantly fewer parent-reported behavior problems and social incompetencies (p=01) as well as psychiatric symptoms (p=.02). Based on these results it is concluded that individual and group art therapy are effective in relieving symptoms of depression in youth compared to no treatment, with individual art therapy appearing to be more effective than group art therapy. iv Table of Contents Abstract i' Table of Contents iv List of Tables viii List of Figures ix Acknowledgments x CHAPTER I. Introduction 1 Purpose 3 Hypothesis Statement 4 Research Hypothesis 4 Assumptions 6 Definition of Terms 6 CHAPTER II. Review of the Literature 8 Theories of Depression 8 Cognitive Theories 9 Behavioral Theories 9 Developmental Theories 10 Biological Theories 10 Learned Helplessness Theory 11 Theories of Art Therapy 11 Group Therapy Treatment Research 13 Art Therapy Treatment Research 16 CHAPTER IB. Method 19 Sample 19 Inclusion Criteria 21 Exclusion Criteria 22 Sample Procedure 22 Sample Procedure for Intervention Groups 22 Sample Procedure for Control Group 23 Setting 24 Kitsilano Mental Health Centre 24 Surrey Central Mental Health Centre 25 Delimitations 25 Data Collection Instruments 26 Demographic Data Sheet 26 Children's Depression Inventory 26 Stonybrook Psychiatric Checklist 27 Child Behavior Checklist 28 House-Tree-Person 29 Design 29 Procedures: Individual Intervention 30 Pre-Test 30 Art Therapy Intervention 30 Post-Test 47 Procedures: Group Intervention 38 Pre-Test 39 Art Therapy Intervention 39 Post-Test.. 47 Procedures: Control Group 47 Pre-Test 47 Waiting Period 48 Post-Test 48 Procedure for Quantitative Analysis of Data 48 Procedure for Qualitative Analysis of Data 49 CHAPTER IV. Results 50 Description of Means and Standard Deviations 50 Pre-Test Analysis of Variance 52 vi Post-Test Analysis of Variance 52 Scheffe Post-Hoc Tests 52 Before and After Outcome Measures Within Treatment Groups 53 Independent Sample T-Test 54 Qualitative Analysis of House-Tree-Person 54 Individual Art Therapy 55 Group Art Therapy 59 Control Group 63 CHAPTER V. Discussion 69 Hypothesis #1 69 Hypothesis #2 70 Hypothesis #3 71 Hypothesis #4 72 Hypothesis #5 74 Hypothesis #6 75 Hypothesis #7 76 Hypothesis #8 77 Hypothesis #9 77 Hypothesis #10 78 Summary of Quantitative Research Findings 78 Summary of Qualitative Research Findings 82 Implications for Future Research 85 References 86 Appendix A Letter of Contact Regarding Research Project 123 Appendix B Letter to Prospective Client 124 Appendix C Letter to Parent of Prospective Client 126 Appendix D Demographic Data Sheet 127 V l l Appendix E Children's Depression Inventory 128 Appendix F Stonybrook Psychiatric Checklist .131 Appendix G Child Behavior Checklist 135 Appendix H House-Tree-Person Assessment 139 Appendix I Circle of Strength Guided Imagery Activity 141 V l l l List of Tables Table Page 1 Demographic Data for all Groups 96 2 Descriptive Statistics for Pre and Post Tests 97 3 Analysis of Variance for Pre and Post Tests 98 4 Scheffe Post-Hoc Comparisons of Groups 99 5 Before and After Outcome Measures Within Treatment Groups... 100 6 Independent Samples T-Test 101 ix List of Figures Figure Page 1.1 Pre- and Post-Test Means for Children's Depression Inventory 102 1.2 Pre- and Post-Test Means for Child Behavior Checklist 103 1.3 Pre-and Post-Test Means for Stonybrook Psychiatric Checklist 104 1.4 House Picture Before Individual Art Therapy Treatment 105 1.5 House Picture After Individual Art Therapy Treatment 106 1.6 Tree Picture Before Individual Art Therapy Treatment 107 1.7 Tree Picture After Individual Art Therapy Treatment 108 1.8 Person Picture Before Individual Art Therapy Treatment 109 1.9 Person Picture After Individual Art Therapy Treatment 110 2.0 House Picture Before Group Art Therapy Treatment I l l 2.1 House Picture After Group Art Therapy Treatment 112 2.2 Tree Picture Before Group Art Therapy Treatment 113 2.3 Tree Picture After Group Art Therapy Treatment 114 2.4 Person Picture Before Group Art Therapy Treatment 115 2.5 Person Picture After Group Art Therapy Treatment 116 2.6 House Picture Before 8 Week Control Period 117 2.7 House Picture After 8 Week Control Period 118 2.8 Tree Picture Before 8 Week Control Period 119 2.9 Tree Picture After 8 Week Control Period 120 3.0 Person Picture Before 8 Week Control Period 121 3.1 Person Picture After 8 Week Control Period 122 Acknowledgments I wish to express my deepest appreciation to the chairman of my committee, Dr. J. Allan for his support and encouragement. I would also like to thank Dr. Jane Garland for her guidance and support of the research project. A special thanks to Ron Peters of GVMHS for his undying patience and attention to the statistical aspects of the research project. I also wish to express gratitude to the many adolescents and their families that participated in the research project. It is their willingness to share their deepest and private emotions and experiences that made this study possible. I thank my husband and family for their encouragement. Finally, thank-you to my Dad who inspires me daily. 1 Chapter I Introduction Adolescence is a time of immense growth and developmental change, a process that for many is both exciting and frightening at the same time. Many cultures have rituals or rites of passage that define and honor this stage of transition from childhood into adulthood. Allan (1992) writes that an effective young adolescent rites de passage not only helps the child with inner and outer identity issues but also provides a sense of change and renewal for significant others in the culture surrounding the child. However, North American culture fails to provide its youth with a process that supports and provides the tools for them to navigate through this developmental task of identity formation and individuation from the core family. Psychological theories like that of Carl Jung (1964) provide further insight into this process of development and the nature of the adolescent's struggle. According to Jung (1964) the human psyche is in a constant process of evolution and change much like a death and rebirth with accelerated and then diminishing growth. During adolescence this process is particularly strong as it is a time of individuation the most central drive in the human psyche (Jung, 1964). The individuation process involves a struggle of opposites that is resolved through the rhythm of chaos, struggle, and resolution. It is when the adolescent is unable to resolve or'becomes immobilized within this struggle that emotional and psychological difficulties ensue. Adolescent depression is one example of an inability to resolve the inner conflict that is part of the individuation process. Depression can also be seen as part of the death rebirth process: a psychological death before the rebirth of the newly evolved self. Nevertheless, it is clear from the 2 immense increase in the prevalence of depression that we must look closer at ways in which to support our youth through this critical time. Since the early 1980s, the study of depression in children and adolescents has emerged as a major research domain in the field of child and adolescent psychopathology (Reynolds, 1991). This attention is undoubtedly warranted given the many years of misconceptions and even denial of depression as a disorder in children and adolescents (Cantwell, 1983; Poznanski, 1984). There is no argument that the impact of depression on adolescents can be debilitating and pose a serious cost developmentally, impairing interpersonal skills and causing relationship deficits in all areas of their life (Puig-Antich, Davies, Goetz, Brennan-Quattrock & Todak, 1985). Further research on depression must consider these costs and address the need for effective treatment methods. Professionals differ vastly in their estimates of the prevalence of depression and this is likely due to the fact that their symptoms can easily be confused with other disorders. Recent prevalence rates of adolescent depression have been reported from 0.4% to 12.0% (Whitaker, Johnson, Shafer, Rapoport, Kalikow, Walsh, Davies, Braiman & Dolinsky, 1990; Fleming & Offord, 1990). This is particularly concerning due to the fact that epidemiological data indicate that while rates of depression are increasing throughout adolescent populations, the age of onset is decreasing (Klerman, Lavori, Rice, Reich, Edicott, Andreassen, Deller & Harschfeld, 1985). Research for depression has focused primarily on cognitive-behavioral (Reynolds & Coats, 1986), social skills training or therapeutic support groups (Fine, Gilbert, Hayley, Maxwell & Forth, 1989) in a group context. Although some studies indicate a therapeutic benefit to group therapy, research regarding their application to individual treatment is rare. Furthermore, 3 antidepressant medication has been ineffective for adolescents with placebo-controlled, double blind studies failing to demonstrate any benefit (Weiler & Weiler, 1990). Given the prevalence and seriousness of depression in adolescents, there still exists a tremendous need for the further development of effective prevention and treatment strategies. It is for these reasons that further research must investigate preventative as well as curative treatment options such as art therapy. Given the recent attention to art as a therapeutic modality and its recognition as an effective intervention for emotional difficulties, its application in the treatment of depression seems obvious (Crandall, 1984). According to Jung (1964) it is the act of doing, making, or symbolizing inner impulses that facilitates the individuation process and all of which take place within the art therapy process. Researchers also explain that art therapy allows individuals who are emotionally hurting to experience catharsis, growth, and change (Kramer, 1971). Furthermore, it is an effective way in which to provide treatment to the adolescent population in a non-threatening way; it acts as an inscape to the adolescents psyche, facilitates communication, fosters cooperation and allows easy establishment of rapport. Despite the obvious benefits of the use of art therapy as treatment, there exists sparse literature on its effectiveness in the treatment of adolescents who are suffering from psychiatric difficulties. Although a vast scope of literature has investigated the efficacy of other treatments of depression there remains a gap in the research of creative arts modalities as treatment for depression. The following research study will address this oversight providing new information on the efficacy of short-term art therapy as treatment for depression in the adolescent population. More specifically, this study 4 addressed these issues by examining the effects of individual and group art therapy treatment for adolescents suffering from symptoms of depression versus a no-treatment control group. Purpose The purpose of this study was to investigate the efficacy of individual and group art therapy intervention for adolescents presenting with symptoms of depression compared with a control group. Levels of subjective symptoms of depression were inferred from the Children's Depression Inventory, behavior and social adjustment were inferred from the Child Behavior Checklist and levels of psychiatric symptomology was inferred by the Stonybrook Psychiatric Checklist. Hypothesis Statement Depressed adolescents that receive individual or group art therapy treatment will have fewer symptoms of depression after treatment compared to a control group. Research Hypotheses 1. Adolescents that receive individual art therapy treatment will have fewer subjective symptoms of depression according to the Children's Depression Inventory compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 1 = mean 3. 2. Adolescents that receive individual art therapy treatment will have fewer behavioral problems and social incompetencies according to the Child Behavior Checklist compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 1 = mean 3. 5 3. Adolescents that receive individual art therapy treatment will have fewer symptoms of psychiatric difficulty according to the Stonybrook Psychiatric Checklist compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 1 = mean 3. 4. Adolescents that receive group art therapy treatment will have fewer subjective symptoms of depression according to the Children's Depression Inventory compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 2 = mean 3. 5. Adolescents that receive group art therapy treatment will have fewer behavioral problems and social incompetencies according to the Child Behavior Checklist compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 2 = mean 3. 6. Adolescents that receive group art therapy treatment will have fewer symptoms of psychiatric difficulty according to the Stonybrook Psychiatric Checklist compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 2 = mean 3. 7. Adolescents that do not receive any treatment will not show any change in subjective levels of depression, behavioral problems or social incompetencies or psychiatric problems according to the three measures (p>.05). The null hypothesis is as follows: mean 3 does not = mean 3. 8. Adolescents that receive individual or group art therapy will have fewer subjective symptoms of depression according to the Children's Depression Inventory 6 compared to a control group (p<05). The null hypothesis is as follows: mean 1 and mean 2 = mean 3. 9. Adolescents that receive individual or group art therapy treatment will have fewer behavioral problems and social incompetencies according to the Child Behavior Checklist compared to a control group (p<05). The null hypothesis is as follows: mean 1 and mean 2 = mean 3. 10. Adolescents that receive individual or group art therapy treatment will have fewer symptoms of psychiatric difficulty according to the Stonybrook Psychiatric Checklist compared to a control group (p<05). The null hypothesis is as follows: mean 1 and mean 2 = mean 3. Assumptions This study assumes that: (a) art therapy intervention for adolescents that are suffering from symptoms of depression is an effective treatment for alleviating symptomology; (b) adolescence is an important period of life and mental illness during that period may have long-lasting effects on the patterns of development of the individual, as well as on the patterns of interaction between the adolescent and his / her family and community; (c) the adolescent is capable of self reflection regarding their feelings and behaviors so that self report is an accurate measure of levels of depression; (d) the adolescent's guardian is capable of objective observation regarding the adolescent's behaviors so that parent report is an accurate measure of level of depression. Definition of Terms Art Therapy. The use of art mediums and the process of creating art products for the purpose of psychological wellness. Ethinicity. A family's genealogical race or common ancestry. Family. Consists of at least one child and one parent or guardian. Greater Vancouver Mental Health Service Society (GVMHSS). A non-profit organization with nine community outpatient mental health centers servicing Vancouver, British Columbia, a large metropolitan city with a population base of approximately 475,000 people. Group Therapy. Two or more individuals entering into counseling process for the purpose of psychological wellness. Guardian. Primary adult caregivers legally deemed as such. Parents. Natural or foster, the primary adult caregivers. Primary Therapist. Professional Counseling Therapist assigned by the mental health child and youth team who is required to provide counseling treatment and case management to referred clients as deemed appropriate. SES. The yearly family gross income per year according to the following income categories: low (under $ 25,000.00 per year), middle ($25,000.00-45,000.00 per year), high (over $ 45,000.00 per year). 8 Chapter II Review of the Literature The literature relevant to this study is presented in two formats. The first, "Theories of Depression", explores the theoretical issues relevant to the study of depression. Second, "Theories of Art Therapy" will look at the development of art therapy and theoretical underpinnings that have provided the foundation for the use of art therapy in the treatment of mental illness. Third, "Group Therapy Treatment", presents the most significant group therapy treatment research to date. Lastly, "Art Therapy Research" will present studies that have explored the impact of Art Therapy intervention as a treatment modality. Theories of Depression Many theories and models of depression have been developed throughout the early 1970's; however, they have been developed in reference to adult depression rather than depression in children. This poses a large problem given the lack of consideration to developmental differences and the unique characteristics of children and adolescents. Nevertheless, most current clinical research and opinion maintain that depression in children and adolescents consist of many of the same symptoms as in adults (American Psychological Association, 1980, 1987). Some people experience depression despite the fact that no obvious stressor has occurred. Others may experience loss, trauma, relationship difficulties or a variety of other stressors yet they do not become depressed. Most researchers now believe that depression is typically the result of a combination of biological and psychological vulnerabilities and stressful life events. Various theories go further to identify the 9 specific variables that relate to depression. The following outlines these theories to date, including some of the more contemporary theories of depression that take into consideration the different qualitative make-up of youth: Cognitive Theories. Cognitive Theories of depression hypothesize that depressed individuals experience thought processes in which they view others and themselves more negatively than non-depressed individuals. For example, attributional research claims that a depressogenic attributional style exists in which negative events are attributed to stable, internal, and global cause (Abramson, Metalsky & Alloy, 1989). Aaron Beck and colleagues (Beck, Ward, Mendelson, Mock & Erbaugh, 1961) proposed that depressed people tend to view themselves, their environment and their future in a negative light. These negative views result from errors in thinking such as focusing on negative facts, misinterpreting situations, and blaming themselves for misfortune. Mayer and colleagues (Mayer, Gaaschke, Braverman, Evans, 1992) researched these ideas further and found that mood congruent judgments may influence an individual so that a depressed person is more likely to make depressed attributions, recall depressed events, and evaluate outcomes as negative. Behavioral Theories. While cognitive theories focus on depressive thought processes, behavioral theories focus on the improvement of social skills (Hersen, Bellack & Himmelhoch, 1980), increasing pleasant activities and time management skills (Lewinsohn, 1978) and general problem solving skills (McLean & Hakistian, 1979). Social learning theory proposes that depression is due to a decrease in response-contingent positive reinforcement (Lewinsohn & Arconad, 1981). Therefore, treatment 10 studies using this approach focus on increasing pleasant activities, and decreasing negative activities. Developmental Theories. Developmental models of psycholopathology focus on the role of attachment as a common denominator in individuals who suffer from depression. For example, Spitz and Wolf (1946) in their study of infant attachment, proposed that mother separation is a necessary, but not a sufficient factor in the development of anaclytic depression. Bowlby (1988) discusses the role of socioemotional bonds, examining attachment and its relationship to loss, separation, bereavement, and depression in children. Erickson further suggests that identity crisis may be a natural and signigicant developmental task of the adolescent years (1986). Subsequently, researchers propose that difficulty working through and resolving the identity crisis may contribute to adolescent depression (Garrison, 1989; Smith & Crawford, 1986). Biological Theories. Biological models have been vastly researched ranging from genetic (Reich, Rice & Mullaney, 1986) to neuroendocrine (Burke & Pieg-Antich, 1990) basis for depression. Neuroendicrine research focuses on the role of neurotransmitters, such as catecholamines, and indolamines, and their mechanism in the neurochemistry in the brain (Reynolds, 1992). Neurotransmitters play an important role in regulating moods and emotions. Research suggests that individuals suffering from depression have lower levels of these transmitters in their brain and this is supported by the effectiveness of antidepressant medication relieving depression in some patients (Reynolds, 1992). In the research of depression specific to children and adolescents there has been a focus on psychological factors such as growth hormone secretion (Pieg-Antich, et al., 11 1985). Other hormone research finds that many depressed people have higher levels of hydrocortisone which is secreted by the adrenal gland as a reaction to stress (Reynolds, 1992). Learned Helplessness Theory. Seligman and Peterson (1986) proposed that individuals that are depressed experience "learned helplessness" which is a result of beliefs including two dynamics: (a) that negative outcomes will occur; (b) the expectation that the event or outcome is beyond the individual's control. According to their view, prolonged exposure to an uncontrollable and inescapable event result in apathy, pessimism, and loss of motivation, which are all characteristics of depression. Research on learned helplessness focuses on changing these cognitive beliefs so that the depressed individual will feel a stronger sense of self-control. Lynn Abramson takes this theory further by proposing that depression results not only from helplessness but from hopelessness as well (Reynolds, 1992). Hopelessness theory attributes a negative thinking pattern to depression in which people blame themselves for negative experiences, they believe the causes of negative events are permanent and they overgeneralize specific weaknesses as the cause of problems in many realms of life. Theories of Art Therapy Art therapists use art in a therapeutic way by using the images and narratives in an attempt to help clients become more aware of their inner selves. Art therapists then help clients to integrate their new insights regarding their inner self with their outer realities in the hope that generalizations to the every day interpersonal behaviors can occur (Oster & Gould, 1987). 12 Art therapy's foundation lies within the psychoanalytic movement where it was used initially to facilitate verbalization and the symbolic content was subject of interpretation by the analysand. Margaret Naumberg is a pioneer in Art therapy who trained in the climate of Psychoanalysis. Naumberg (1966) believed that when a person expresses their fears, wishes, and fantasies on paper or in clay, they are expressing the unconscious inner world in the symbolic language of images. This consequently expresses that which cannot be said in words and allows self-insight, healing and growth. Naumberg also discovered that spontaneous art expression, as a symbolic form of speech, is basic to all education and to psychotherapeutic treatment. Naumberg's predecessor was Edith Kramer who saw the art therapy process as one in which the role of the therapist was to encourage creative production and provide technical assistance and support without diverting into play or fantasy (Oster & Gould, 1987; Kramer, 1971). Kramer developed a program in 1950 called the Wittwick School for Boys where most importantly she began to describe using art as a healing act in itself (Packard, 1980). It is here that she also began to see that art therapy assists in the transformation of raw aggression into constructive energy (Kramer, 1971). Many proponents of art therapy now agree that the process of creating art in itself has a therapeutic benefit. Allan (1978) adds that art therapy is a way of establishing contact with and expressing one's inner world of feelings, and symbols in order for growth to occur in both the conscious and unconscious realm. Art therapy facilitates the release of strong emotions from within the individual, which allows the catharsis, self-disclosure, insight, and resolution of inner conflicts leading to changes in behavior and attitude (Crandall, 1984). It is through art that immobilized and difficult to reach 13 individuals such as those suffering from depression may build upon ego strengths and deal with painful and frightening feelings and experiences. Recently, family therapists have been incorporating art therapy in the treatment of families. Kwiatkowska (1978) suggests that art therapy that includes all family members improves family relations and strengthens certain components of the family. Family art products are also thought to reveal diagnostic information regarding the alliances between family members as well as providing information about individual roles and status. According to Oster and Gould the humanistic movement has accomplished much in increasing the visibility of art therapy in counseling therapy. Therapists influenced by humanistic theories believe that by focusing on the creative product itself self-insight and healing will be fostered. For example, one therapist used art therapy in experiential growth groups and found that it allowed for expansion of self-expression, self perception, and group interaction (Rhyne, 1973). Because of the efforts of all of these pioneers in art therapy it is now recognized as a very important profession with much to offer towards the plight for human wellness. Today art therapy is found in drug abuse agencies, mental health agencies, in programs for the special education of our youth, psychiatric hospitals, and residential programs for the elderly, and many other social programs within (North American) society. Group Therapy Treatment Research Many research reports have indicated that group psychotherapy is an effective form of intervention with adolescents with depression (Corder, Whiteside & Haizlip, 1981; Fine, Gilbert, Hayley, Maxwell & Forth, 1989; Hayley, 1991; Fine, et al., 1991). However, most group therapy treatment focuses on cognitive-behavioral, therapeutic 14 support groups or social skills training. The following section outlines research literature attesting to the treatment of depression utilizing these various forms of group therapy intervention. The first published group treatment study for depression in adolescents compared a cognitive-behavioral treatment, a relaxation training group, and a waiting list control group over 10 one-hour sessions in a 55-week period (Reynolds & Coats, 1986). In this study cognitive-behavioral therapy included self-control procedures, cognitive restructuring, and the increase of involvement in pleasant activities and the relaxation treatment group received progressive relaxation skills training. Results showed that there were significant decreases in depression of adolescents who participated in both the cognitive-behavioral and relaxation treatment groups compared to wait list controls. Reynolds & Coats (1986) showed that by utilizing a short term treatment approach with a small group format, a positive therapeutic response was evident within ten sessions. Primarily, group intervention for adolescents with depression has focused on cognitive-behavioral approaches such as the study above. In another such study an effort was made to assess two commonly used group interventions. Fine and colleagues (1991) used a therapeutic support group (TSG) and social-skills group (SSG) training paradigm in the treatment of clinically depressed adolescents. The TSG treatment provided an unstructured therapeutic environment in which adolescents provided support to each other, explored common concerns and shared experiences with the facilitation of the group therapist. The SSG, on the other hand, provided a more structured environment in which concrete social skills were taught, such as recognition of feeling in self and others, 15 assertiveness, conversational skills, giving and receiving of negative feedback, social problem solving, and negotiation skills to resolve social conflicts. Treatment outcome was based on self-report and semi-structured interviews for depression, measures of self-concept, and cognitive distortions (Fine, et al., 1991). It was found that adolescents in the therapeutic support groups showed reductions in clinical depression and increases in self-concept compared with the social skills training group. However, these differences no longer existed after nine months and each group maintained improvements. One study by Brown and Lewinsohn (1979) more rigorously defined its group procedures for adults suffering from depression. These researchers developed a manual for group therapy protocol utilizing a psychoeducational approach with cognitive-behavioral and social learning techniques. The 8-week, 12-session course is intended to teach skills that generate a self-change plan, increase pleasant activities, think constructively and decrease negative thoughts, improve social skills, and plan the maintenance of treatment gains. Outcome studies report that out of 75 participants all improved markedly (Steinmetz, Lewinsohn & Antonuccio, 1983). Clarke and Lewinsohn (1984) have also created and adolescent version of the course designed for 14 to 17 year olds with depression. The adolescent version also includes instruction on basic communication, negotiation, and conflict resolution. Efficacy studies indicate a significant post-treatment decrease in the Beck Depression Inventory scores for adolescents post-treatment (Clarke, 1985). 16 Art Therapy Treatment Research There exists a significant gap in the literature on the use of group art therapy and other alternative therapeutic approaches to depression. However, a growing body of research indicates that the use of art therapy, even on a short-term basis, can result in significant clinical change in children who are experiencing emotional difficulties (Tibbetts & Stone, 1990; Walsh, 1993). A recent study by Walsh (1993) used an art future-image intervention designed to increase self-esteem, improve future time perspective, and decrease symptoms of depression in hospitalized suicidal adolescents. Walsh used a pretest-posttest repeated-measures design with 39 hospitalized suicidal adolescents. Each participant was tested on three occasions using the Coopersmith (1987) Self-Esteem Inventory, the Heimberg (1963) Future Time Perspective Inventory, and the Beck Depression Inventory (Beck, Ward, Mendelsohn, Mock & Erbaugh). Results indicate that the experimental group showed greater positive changes than the placebo group. The author notes that experimental participant enthusiasm, shorter hospitalization, and the positivity of comments at follow-up warrant continued testing refinement and testing of art therapy techniques such as the future image intervention. Recently, art therapy methods were used to assist the victims of the 1992 Los Angeles riots. Adolescents drew pictures in art therapy groups of the memories of the rebellion and the feelings they experienced. It was found that the non-judgmental aspect of art therapy aided adolescents in creating and externalizing their painful experiences (Pynoos&Eth, 1986). 17 Another study by Riley (1994) discussed the validity of traditional art therapy with adolescents and noted a dramatic shift in the responses of this age group to art therapy treatment. Riley explains that although clinical art therapy has been a preferred method for the individual and group treatment of adolescents within mental health treatment centers throughout the past twenty years, changes within society have contributed to a decrease in the effectiveness of this therapeutic modality. She argues through case vignettes that despite societal changes and differences in the speed of maturation there remain many fundamental aspects to art therapy that leave it valid and effective. Most importantly, Riley (1997) proposes that art therapy treatment that considers the differences in socioeconomic, family, peer influences, and that which follows the child in ways that meet them in the world that they live will be most successful. In another study by White and Richard (1971) an eight-week art-counseling group for pre-adolescent boys was effective in building self-image. Apparently the gains were maintained over a 14-month follow up period. Similar evidence seems to suggest that short-term art therapy treatment can reduce emotional problems (Wolf, 1973), hyperactivity and aggression (Virshup (1975) and the severity of trauma and loss in children (Eth, Arroyo, & Silverstein, 1985). Art therapy programs that are designed with a particular problem in mind are increasingly undergoing development. For example, a study of CODA, a creative therapy program for children in families affected by abuse of alcohol or other drugs, has done much in support of prevention programs using art and play (Springer, Phillips, Phillips, Cannady, & Kerst-Harris). This study evaluated the CODA program and found 18 it to be successful in recruiting and maintaining participation by both parents and youth of chemically dependent families. Most interesting is the fact that pre-post comparison of the Achenbach Child Behavior Checklist showed that adolescents in the 12-week program had significant gains in competencies and reductions in behavior problems. 19 Chapter HI Method A pre-test post-test study was conducted using two treatment groups as well as a control group. The following chapter outlines the research methodology that was used including the following: sample, sample procedure, setting, instruments and procedure. Sample The following presents the results of demographic information and provides further insight as to the cross section of subjects included in the study and subsequent generalizability of results. Description of the adolescents will be in terms of the following variables: age, sex, ethnicity, family structure, socioeconomic status, and location of mental health service. The sample consisted of adolescents currently living in the Greater Vancouver area and was referred to their local outpatient mental health facility, for treatment of symptoms congruent with a diagnosis of depression. Others were referred in response to the research study information sheet sent out to referral sources recruiting participants experiencing suffering from symptoms of depression. Table 1 shows that the average age of the twenty adolescents (nl=5; n2=5; n3=10) that participated in the study was 14.25 years with a range of 13 years 2 months to 15 years 9 months. Of the 20 subjects that participated 18 were females and 2 were males: individual art therapy included 5 females, group art therapy included 5 females, and the control group included 8 females and 2 males. Implications regarding the low female to male ratio will be addressed in the discussion section. Eighteen participants 20 were Caucasian with only one Asian participant (group treatment) and one Caucasian-African American participant (control group). [Insert Table 1] Information on family structure indicates that all participants in the individual treatment group were from single or divorced households and living with their biological mother. This group had the least variability on this factor. Of the group treatment group 2 participants (40%) were from single or divorced households and living with their biological mother, while 2 (40%) wereliving with both biological parents. One of the participants was living within a stepfamily. The control group had the greatest variability in family structure: 2 (20%) lived with both biological parents, 3 (30%) lived in single or divorced households with their biological mother and 1 (10%) lived with their father, 2 (20%) lived within a stepfamily and 2 (20%) lived within foster family structure. Data on the participants' family socioeconomic status included the entire yearly family income and was divided into categories of low (under $25,000), medium ($25,000-$45,000), and high (over $45,000). Participants in the individual treatment group were from either middle (n=3 [60%]) or high (n=2 [40%]) socioeconomic status. The group treatment group participants had variable socioeconomic status: 1 (20%) was low, 2 (40%) were middle and 2 (40%) were high. The control group also had variable socioeconomic status: 2 (20%) were low, 6 (60%) were middle and 2 (20%) were high. The participants were referred to one of two mental health centers: Kitsilano Mental Health Team or Surrey Central Mental Health Team. All Participants in the individual and group treatment groups were referred to the Kitsilano Mental Health 21 Team. Of the control group 6 (60%) were referred to Surrey Central Mental Health Team, while 4 (40%) were referred to Kitsilano Mental Health. Inclusion Criteria. The criteria for selection includes that the subject had to have been referred to the mental health team due to symptoms of depression. The subjects had to have displayed three of the following ten symptoms (American Psychiatric Association, 1994): (a) depressed mood or irritable mood most of the day, nearly every day (subjective or objective observation by others); (b) diminished interest or pleasure in all, or almost all activities of the day nearly every day; (c) significant weight loss when not dieting or weight gain, or a decrease or increase in appetite; (d) insomnia or hypersomnia nearly every day; (e) psychomotor agitation or retardation nearly every day; (f) Fatigue or loss of energy nearly every day; (g) feelings of worthlessness or excessive of inappropriate guilt nearly every day; (h) diminished ability to think or concentrate, or indecisiveness, nearly every day; (i) recurrent thoughts of death, recurrent suicidal ideation without a specific plan or suicide attempts; and (j) symptoms must have been present during the same two week period. Additional criteria for subject selection includes that individual or group therapy were indicated as helpful and appropriate for the subject. As well, both the adolescent and their guardian were in agreement to participate during all phases of treatment. For participants in the two intervention groups, the time commitment was ten hours per child: eight 1-hour art therapy sessions and two 1-hour pre- and post-test assessment sessions. Participants in the control group required a commitment of two hours for two 1-hour pre-and post-test assessment sessions. All guardians were required to commit two hours for two 1-hour pre- and post-test assessment sessions only. 2 2 Finally, all participants had to have been willing to sign a release of all photographs of their art products and the descriptions given regarding the therapeutic art process. Exclusion Criteria. Exclusion criteria included subjects that were suffering from an Axis II Psychiatric Disorder, a mental handicap, and that were currently suicidal or had attempted suicide within the past two months previous to the study. Currently suicidal clients were referred to an emergency response team at the local hospital Sample Procedure Sample Procedure for Intervention Groups. High School Counselors and GVMHS therapists received a letter of initial contact from the researcher describing the research study information, which included the study's purpose and requirements for participation (see appendix A). The referring parties were also provided with a letter to the prospective subject (see appendix B) as well as to the parent (see appendix C) outlining the studies purpose and the requirements for intervention. The referring party then approached prospective participants to explain the nature of the study, the treatment offered and the reasons why they believed that the participant might benefit. Once both the youth and their guardian gave permission to the referring party to do so, the referring party contacted the researcher with the names and telephone numbers of prospective subjects. The researcher then contacted the youth and their guardian via telephone to provide them with further information about the study, answer any questions, and confirm interest in service. If both the youth and their guardian were interested in receiving service an intake meeting was arranged. 23 At the intake meeting the researcher provided the youth and guardian(s) with information regarding GVMHSS, the procedures of the research study and its purpose, the participation requirements, and the implications of participation. The subjects then decided whether or not they wished to participate. Those subjects that did not wish to participate then explored other possibilities for treatment and subsequently received the appropriate intervention as decided upon by the primary therapist assigned and the individual themselves. Subjects were also informed that the decision of whether or not to participate would not affect the quality and timeliness of intervention provided. The subjects and guardians that agreed to participate then signed a release form that provided permission for the publication of any art products that they created throughout the Art Therapy Study. Once all of the intake meetings had occurred the subjects were randomly assigned into an intervention group; individual art therapy or group art therapy by simply drawing a ticket randomly out of a hat indicating either "I" (Individual Art Therapy) or "G" (Group Art Therapy). Sample Procedure for Control Group. The researcher contacted the directors of various Mental Health teams of GVMHS and Surrey Mental Health to provide them with a verbal description of the research study and a request that they refer those clients on their wait lists to the control group. The subjects within the control group included those individuals that had been previously referred to another GVMHS team or another Mental Health team independently of the research study. In these cases, the subject had already been assigned a primary therapist and had been on the therapist's waitlist. The Mental Health teams contacted potential control group participants and their guardians via telephone and informed them of the research study, its purpose and the implications of 24 participation. The subject and guardian were also informed that if their assigned therapist were able to see them before the end of the two-month period they would immediately begin treatment and no longer be included within the control group. Setting The study was conducted in two settings: (a) Kitsilano Mental Health Centre, and (b) Surrey Central Mental Health Centre. Each setting will be described separately. Kitsilano Mental Health Centre. This centre is one of nine community outpatient mental health centers servicing Vancouver, British Columbia. Vancouver is a large metropolitan city with a population base of approximately 475,000 people. The Kitsilano Mental Health Centre serves as a major referral centre for children, youths and adults experiencing mental health problems. This includes approximately 70 child and youth clients at any one time. The clients that participated in the study came from within an approximate 5-kilometer radius of the mental health centre. The setting was used for both individual and group art therapy treatment. As well, four of the ten control group subjects and their guardians participated at this setting. The specific setting for the study included a waiting area which can accommodate 10-15 people, a large conference room which includes a large conference table and chairs, two restrooms, several counseling offices with a desk and comfortable seating (approximately 18 offices), and a spacious (325 square foot) art therapy group room with painting easels, floor cushions, and two large supply tables. The small counseling offices were used to conduct the pre- and post-test measures for all three groups. The subject and their guardian completed the tests in separate offices to ensure privacy. The small counseling offices were also used for subjects receiving 25 individual art therapy treatment (a painting easel and art supplies were provided in the room). The art therapy group room was used for the group art therapy procedures. Surrey Central Mental Health Center. The Surrey Central Mental Health Center is one of two community outpatient mental health center's servicing Surrey, British Columbia. Surrey is a city within the Greater Vancouver area and is a suburb approximately 55 kilometers from Vancouver. Surrey has a population base of approximately 300,000 people. The Surrey Central Mental Health Center services approximately 170 children and youth experiencing mental health problems at any one time. The clients that participated in the study came from within an approximate 12-kilometer radius of the mental health center. The setting was used for six of the ten control group subjects and their guardians. The specific setting for the study included a waiting area which can accommodate 8-10 people, four restrooms, a small family room which contains a couch and several chairs, and twenty small counseling offices with a desk and several comfortable chairs. The small counseling offices were used to conduct the pre- and post-test measures for the control group and the subject and their guardian completed the tests in separate offices to ensure privacy. Delimitations The scope of this study is restricted to the Greater Vancouver Area. Therefore, its findings may only be generalized to this particular population group or groups with similar characteristics. As well, the study may only be generalized to female populations as 90% of participants were female. 26 Data Collection Instruments Data required for the study were collected through the use of the following instruments: (a) a demographic data sheet, (b) Child Behavior Checklist for ages 4-16 (CBCL), (c) Child Behavior Checklist-Parents Report Form (CBCL), and (d) Stonybrook Psychiatric Checklist (SBPCL). Each of the instruments will be described. Demographic Data Sheet. The researcher designed the Demographic Data Sheet to compile key information about the subjects and their family (see appendix D). The Data Sheet contained 9 questions including 4 fill in the blank questions and 5 checklist questions and takes approximately 5 minutes to complete. The fill in the blank questions included information about the adolescent's name, guardian's name, and current date and child's date of birth. The checklist items included information about the adolescent's ethnic background, the family environment structure (e.g., married vs. divorced household), the family's socioeconomic status, and the location of their mental health service provider. Children's Depression Inventory (CPI). The CDI, developed by Kovacs in 1982, is a 27-item self-report scale that measures symptoms of depression in children ages 8 to 17 (see appendix E). The scale was designed after the Beck Depression Inventory for adults, but has grade one readability and is targeted for school-age children and adolescents provided they are of average intelligence (Kovacs, 1983). The instrument quantifies depressive symptoms into the following commonly held symptom sub-categories: Negative Mood, Interpersonal Problems. Ineffectiveness. Anhedonia, and Negative Self-Esteem. The CDI consists of 27 multiple choice items allowing for three 27 choices in the 5 sub-categories. The individual may choose the item that best describes him or her for the past two weeks and each statement is graded from zero (absent) to 2 (severe). The total score of the CDI ranges from 0 to 54 with a higher score indicating greater severity. A total score of 9 is the average score in non-psychiatric samples (Kovacs, 1983). The internal consistency of the CDI has been reported from 0.70 in pediatric medical outpatients to 0.82 (Kovacs, 1985). Test-retest reliability has been shown to be from 0.38 to 0.87 (Finch, Saylor, Edwards & Mcintosh, 1987). Concurrent validity of the CDI against the Revised Children's Manifest Anxiety Scale (Reynolds & Stark, 1986) is reported to be significant (r = 0.65, p< 0.0001). Additionally, concurrent validity against the Coopersmith Self-Esteem Inventory (Coopersmith, 1967) has been found to also be correlated to the CDI (r = 0.59, p < 0.0001). Kovacs notes that the CDI serves as an index for severity of depression as well as a measure of change making it appropriate measurement tool in this particular study. The CDI appears to be the instrument of choice in the measurement of child and adolescent depression as indicated by its widespread use and evidence of its psychometric properties (Kazdin, 1981; Hepperlin, Stewart, 1990; Reinyherz, Frost & Pakiz, 1991; Goldberg, 1989; Crowly, Worchel, 1993). Stony Brook Child Psychiatric Checklist. The Stony Brook Child Psychiatric Checklist is a parent completed rating scale based on the DSMIII-R (see appendix F). The psychiatric checklist is designed to obtain information that would be expressed in a structured psychiatric interview. It addresses a variety of psychiatric diagnoses including: attention deficit hyperactivity disorder, conduct disorder, opposition defiant 28 disorder, overanxious and separation anxiety disorders, major depression, mania, psychosis , pervasive developmental disorder, enuresis, and encopresis ( G r a y s o n & C a r l s o n , 1991). T h e authors in establ ishing the threshold criteria for depression found it to be sensitive i n measuring dysthymia , m i n o r and major depression. Concurrent v a l i d i t y against the K - S A D S - E ( G r a y s o n & C a r l s o n , 1991) has been s h o w n to be h i g h for C D (0.93), O D D (0.903), overanxious disorder (0.86), as w e l l as for depression (0.90). C h i l d B e h a v i o r Check l i s t . T h e C h i l d B e h a v i o r C h e c k l i s t is a w e l l researched instrument that was developed by A c h e n b a c h and E d e l b r o c k i n 1981 ( A c h e n b a c h & E d e l b r o c k , 1983) and has been found to rel iably gain i n f o r m a t i o n about mult ip le s y m p t o m domains ( H e p p e r l i n , Stewart & R e y , 1989). T h e C h i l d B e h a v i o r C h e c k l i s t assesses behaviora l problems and social competencies o f ch i ldren, ages 4 to 16 years, as measured by parent report (see A p p e n d i x G ) . O n e o f the benefits o f the C B C L is it is s imple to administer and c o m p l e t i o n t ime is o n l y 20 minutes. T h e C B C L includes 20 items designed to measure social competency based o n social interaction, activities and school performance, and 118 items describes the c h i l d ' s behavior. T h e parent scores each i tem between 0 and 2 (0-not true; 1-sometimes true; and 2-often true). T h e C B C L includes a B e h a v i o r P r o b l e m Scale, w i t h broadband ( internal iz ing / external iz ing) and narrow-band (e.g. depression, anxiety, aggression, etc.) w h i c h varies according to the age and sex o f the c h i l d . A d d i t i o n a l l y , the C B C L contains a S o c i a l Competence Scale that pertains to activities, social and school . Research shows m i n i m a l correspondence between the C B C L parents, teachers and c h i l d self-reports (Pette, 1978; W o l f e et al. 1987); however, the C B C L is established 29 in the literature as an effective measure of child psychopathology with established test-retest reliabilities (Achenbach & Edelbrock, 1983). House-Tree-Person (H-T-P). The H-T-P is a projective technique in which the individual's inner world is expressed including their emotions, personality and inner conflicts (see appendix H). The H-T-P was designed as a technique to assist the clinician in gathering information regarding an individual's degree of personality integration, maturity and efficiency (Buck, 1948). The individual is asked to draw the following three picture's using standard 8.5" by 11" paper: a house, a tree, and a person (Allan, 1988). The individual may include anything in the picture that they wish in addition to the requested object. The individual is then asked a standard series of questions relevant to the images they created. Design A pre-test, post-test design with a nonequivalent control group was used in which treatment groups were randomly assigned to treatment and the control group was selected from a wait list population. The independent variable treatment group was selected from referrals from the community. The independent variable treatment group included a trial of either of the following: (a) individual art therapy intervention; (b) group art therapy intervention. A pre-test including Children's Depression Inventory, Stonybrook Psychiatric Checklist and Child Behavior Checklist, and House-Tree-Person Assessment was administered during the initial intake as well as post-intervention. Pre- and post-tests were administered at the beginning and end of eight week time period for group subjects. 30 Procedures: Individual Intervention Subjects receiving individual art therapy experienced three research stages: pre-test, intervention and post-test. The following details the procedures for each stage. Pre-Test. The subjects and their guardians met with the primary therapist in order to discuss any further questions or concerns regarding the adolescent's mental health or the art treatment itself. The time allotted for discussion was fifteen minutes. The guardian was then led to a separate private counseling office and given instructions for the self-administrating of the Stonybrook Psychiatric Checklist and the Chi ld Behavior Checklist. The guardian was given one hour to complete the tasks. Meanwhile, the researcher met with the adolescent, provided instructions for the administering of the Children's Depression Inventory and remained present while the test was completed. Since the C D I only takes approximately 15 minutes to complete the researcher engaged the adolescent in an art therapy activity to build rapport and trust. The art therapy activity is called the House-Tree-Person and has been described in the instrument section. After all tests were completed the guardian was reunited with the adolescent and both were asked to contact the researcher i f any concerns arose during the treatment stage (e.g. worsening of symptoms, suicidal thoughts or plans, etc.) Art Therapy Intervention . Session #1. Opening Activity. The therapist introduced herself and welcomed the participant. The therapist and participant then engaged in an activity to become acquainted with one another through conversation by collecting as much information as possible. A three-minute time limit was imposed to stimulate rapid two-way communication and motivate 31 interest in the other person. The therapist suggested the following as possible areas of discussion: name, personal history, school background, strengths or soft spots (qualities they wished to develop). This introductory exercise was used to promote reaffirmation of self-concept by hearing it from the therapist as well as the elimination of feelings of awkwardness from discussing oneself in front of the therapist. The therapist expressed the purpose of art therapy as the following: to explore and express the person's inner world, feelings, and experiences as it is believed that the process of creative expression is healing in and of itself. It was explained that the art therapy activities were designed to help the participant understand themselves, their feelings and the nature o f their depression more fully. The issue of confidentiality was discussed and the participant was assured that the content of their sessions would not be shared with anyone else with the exception of their art products being included in the study. A s well , it was explained that i f it was determined someone was abusing the participant in any way the Ministry for Children and Families or proper authorities would be informed. If the individual became concerned regarding safety concerns of any kind (e.g. suicidal thoughts, physical harm, etc.) they were informed that they could arrange an additional meeting with the therapist. Therapeutic Activity. The participant explored various art mediums by experimenting with technique on paper. Second, an 18" by 24" piece of paper and oil and chalk pastels of various colors were provided. The participant and therapist simply took turns making a shape, movement or object on the page using the pastels as a medium. The participant and therapist engaged in this process for five minutes. The participant then decided on one particular feeling that they wished to focus on and began a new 32 picture with the therapist whereby they again made a shape movement or object on the page while stating that which makes them feel that particular feeling state. For example, "Failing my exam makes me angry". The participant and therapist continued the exercise for ten minutes time. The participant then chose an opposite feeling to focus on and continued the activity for ten minutes time creating a picture on a separate piece of paper. Lastly, the participant compared the qualities of the two separate art products and reflected on their experience. Closing Activity. The participant was asked to share any comments that they wished to make regarding their therapeutic experience. Session #2: Opening Activity. The participant discussed any thoughts, feelings or unfinished business since or from the last session. The participant then expressed himself or herself through metaphor by answering the question, "If you were a rainbow where would you land?" Therapeutic Activity. The therapist guided the participant through a relaxation and guided imagery activity (see appendix I). The imagery exercise was intended to build relaxation skills and help them to create a healing and strengthening image for themselves. After the imagery activity the participant was supplied with pastels and an 18" by 24" piece of paper and they were invited to create a picture of themselves surrounded by the circle of strength that they imagined during their therapeutic experience. Closing Activity. First, the participant was invited to tell a story of what might be happening in their image. Then, the participant was asked to share any comments that 33 they wished to make regarding their therapeutic experience. For example, whether it was difficult or easy to relax, the feelings evoked by the images, which parts of the exercise were difficult to follow and/or to describe the art image created. Session #3: Opening Activity. The participant discussed any thoughts, feelings or unfinished business since or from the last session. The participant then expressed himself or herself through a metaphor by imagining themselves as an animal and sharing their image with the therapist. Therapeutic Activity. The participant was supplied with glue, scissors, acrylic paint, pastels, an 18" by 24" piece of paper, and various magazines. They were then invited to create a collage to represent themselves including symbols that represented their likes, dislikes, talents, desires, personal qualities or simply images that they believed to be symbolic of an aspect of their life. This exercise is designed to increase self-awareness and recognize personal identity. Closing Activity. The participant was asked to share any comments that they wished to make regarding their therapeutic experience. Specifically, they were asked to share three of the images and to describe how they symbolize an aspect of themselves. Session #4: Opening Activity. The participant discussed any thoughts, feelings or unfinished business since or from the last session. The participant then expressed herself through metaphor by imagining that they were earth, wind, fire or water and sharing their image with the therapist. 34 Therapeutic Activity. The participant was supplied with an 18" by 24" piece of paper, pastels and pencil crayons. They were then invited to imagine their lives as if it were a time line. The time line was labeled as their "life line" and could be any shape or length that they wished. Next, the participant was asked to imagine the lifeline as a representation of their life from birth to the present and to further imagine the significant events in their life occurring somewhere on the lifeline. The participant then used images, shapes, and symbols to record these significant life events on their time line. The participant was encouraged to include events that evoked both positive and negative feelings. Examples might include the death of a loved one, a memorable holiday, visiting a particular place, a friendship ending, etc. Closing Activity. The participant was asked to describe their lifeline as well as to share any reflections that they had regarding their therapeutic experience. Session #5: Opening Activity. The participant discussed any thoughts, feelings or unfinished business since or from the last session. The participant then expressed themselves through metaphor by imagining themselves as any form of transportation and shared their image with the therapist. Therapeutic Activity. The participant was supplied with a 18" by 24" piece of paper, pastels, acrylic paint and pencil crayons. The participant was then guided through a short progressive relaxation exercise designed to assist them in relaxing all of their muscle groups and to focus fully on the imagery exercise. They were then asked to imagine their earliest memory of experiencing sadness and depression. They were guided through the imagery exercise evoking the recollection of their surroundings, the 35 people and objects in their environment, how their body felt, how old they were, what they were doing, etc. The participants were then invited to express the images, thoughts and feelings that were evoked during the early recollection and express them through their art. Therefore, the participant used shapes, colors and various abstract and symbolic forms to express that which was evoked throughout the exercise. Closing Activity. The participant was asked to share any thoughts or feelings regarding their therapeutic experience including the image that was evoked, whether this was a positive or negative image, the manner in which they expressed the image through their art and any other information that they wished to comment on. Session #6: Opening Activity. The participant discussed any thoughts, feelings or unfinished business since or from the last session. The participant then expressed themselves through metaphor by imagining themselves as a tree of any kind and described themselves as such to the therapist. Therapeutic Activity. The participant was supplied with an 18" by 24" piece of paper, pastels, acrylic paint and pencil crayons. The participant was then guided through a short progressive relaxation exercise designed to assist them in relaxing all of their muscle groups and to focus fully on the imagery exercise. The participant was then invited to imagine their feelings of depression and to sense where they felt their feelings of depression in their body. If the individual was having difficulty getting in touch with these particular feelings it was suggested that they imagine a time in their life when they felt "down" or "depressed". Then the participant was invited to imagine what the depression might look like. For example, to imagine the shape, the color, the size, etc. 36 The participant was invited to imagine a healing image such as a warm light overhead, their own healing source within, cool and cleansing water, or any other image that felt healing to them and to imagine their own special healing source comforting and healing their feelings of depression. The participant was then invited to express the images, thoughts and feelings that were evoked during the imagery exercise through their art by using shapes, colors and various abstract and symbolic forms to express that which was evoked throughout the exercise. Closing Activity. First the participant was asked to tell a story of what might be happening in the picture by giving the depression a voice and talking for the depression. Then, the participant was asked to share any thoughts or feelings regarding their therapeutic experience. This might any feelings that were experienced as a result, whether or not they chose to imagine a healing source, the manner in which they expressed the image through their art and any other information that they wished to comment on. Session #7: Opening Activity. The participant discussed any thoughts, feelings or unfinished business since or from the last session. The participant then imagined their favorite childhood toy or activity and shared it with the therapist. Therapeutic Activity. The participant was supplied with an 18" by 24" piece of paper, pastels, acrylic paint and pencil crayons. The participant was then guided through a short progressive relaxation exercise designed to assist them in relaxing all of their muscle groups and to focus fully on the imagery exercise. The participant was invited to imagine all of the qualities within themselves that brought them a feeling of strength and 37 security. This was called their internal support system. For example, a unique talent, characteristic such as sensitivity, belief system or faith, etc. The participant was then invited to imagine all of the things in their lives outside of themselves that bring them a feeling of strength. This was called their external support system. For example, a particular place, community, pet, person, objects, something in nature, activity, etc. The participant then created a picture in which all of the inner sources of strength were expressed through image or symbol in the middle of a large circle while the outer sources of strength were placed outside of the circle. The final image showed the contrast between the participant's inner supports or resources and outer supports. Closing Activity. The participant was asked to share any thoughts or feelings regarding their therapeutic experience. For example, the images that were evoked, the contrast between the images of their inner and outer resources, feelings that were experienced during the activity, whether they tended to rely on one person rather than a number of people and any other aspects that they wished to comment on. Session #8: Opening Activity. The participant discussed any thoughts, feelings or unfinished business since or from the last session. The participant then expressed themselves through metaphor by imaging that they could be any flower that they wished and then shared their image with the therapist. Therapeutic Activity. The participant chose a mural theme by first brainstorming ideas, such as water, forest, sky, animal, and abstract themes. The participant was provided with a large 36" by 48" piece of paper, acrylic paint, pastels, shiny beads, glue, sparkles, and felt markers. Relaxing classical music was played while the participant 38 found an empty area on the mural to begin composing her perception of the theme. The music was stopped at three-minute intervals when the participant took one step to the right in order to work on another aspect of the mural. Closing Activity. The collage was hung as a visual display of the participant's achievement and they were asked to share any comments that they wished to make regarding their therapeutic experience and mural image. For example, what might be happening in the picture, what emotions come up for them as they view the images, whether they might be able to choose one of the images and talk through the image, etc. Finally, as part of the closure process the individual was asked to express any thoughts and feelings regarding their entire therapy experience including the ways in which it was helpful or beneficial as well as any difficulties or disappointments throughout the process. Post-Test. At the end of treatment the therapist met with the subject and their guardian and administered the same psychological inventories in precisely the same manner as previously. If the subjects required more intervention at anytime throughout treatment due to an increased level of distress the data was not to be included in the study. At the end of treatment the primary therapist met with the subject and their guardian and determined if further intervention was required. In these cases the primary therapist and the subject decided on a further course of treatment. Procedures: Group Intervention Subjects receiving group art therapy experienced three research stages: pre-test, intervention and post-test. The following details the procedures for each stage. 39 Pre-Test. The subjects and their guardian's met with the primary therapist in order to discuss any further questions or concerns regarding the adolescents mental health or the art treatment itself. The pre-tests were then administered in precisely the same manner as described for the individual pre-test procedure. Art Therapy Intervention. The subjects received one hour of group art therapy per week for eight consecutive weeks. The art intervention used within the group art was standardized so that they were the same as those used for subjects receiving individual art therapy. Session #1. Opening Activity. The group leader introduced herself and welcomed all participants. The group divided up into pairs and each pair was instructed to become acquainted with one another through conversation and to collect as much information as possible. A three-minute time limit was imposed to stimulate rapid two-way communication and motivate interest in the other person. The group leader suggested the following as possible areas of discussion: name, personal history, school background, strengths or soft spots (qualities they wished to develop). This introductory exercise was used to promote reaffirmation of self-concept by hearing it from another person as well as the elimination of feelings of awkwardness from discussing oneself in front of strangers. The group leader expressed the purpose of group therapy as the following: to explore and express the person's inner world, feelings, and experiences as well as to be able to share these with others who may be experiencing similar feelings. The group was reminded that the group is designed for individual's experiencing Depression and that it 40 is believed that the process of creative expression is healing in and of itself and that sharing their experience of the creating process may be of help to others in the group The issue of confidentiality was discussed including the importance of discussing group members' experiences and comments only within the context of the group therapy and under no conditions were they to be discussed elsewhere. If the individual members became concerned regarding safety concerns of any kind (e.g. suicidal thoughts, physical harm, etc.) they were informed that they could arrange an individual meeting with the group leader. It was explained that if it was determined that someone was being hurt or at risk in any way The Ministry for Children and Families or proper authorities would be informed. The group then determined their own boundary issues and agreed on several guidelines that they wished the members to follow. For example, one group rule was that each member was to refrain from any critical comments about the art products or personal disclosures of other members. Therapeutic Activity. The group members explored various art mediums by experimenting with technique on paper. Second, the group members were paired up and were provided with an 18" by 24" piece of paper as well as oil and chalk pastels of various colors. The pairs were instructed to simply take turns making a shape, movement or object on the page using the pastels as a medium. The group was given five minutes to engage in this process. The pairs then decided on one particular feeling that they wished to focus on and began a new picture whereby they again made a shape movement or object on the page while stating that which makes them feel that particular feeling state. For example, "Failing my exam makes me angry". The duo's continued the exercise for 41 ten minutes time. The groups then chose an opposite feeling to focus on and continued the activity for ten minutes time creating a picture on a separate piece of paper. Lastly, the couples compared the qualities of the two separate art products and reflected on their experience together. Closing Activity. The group gathered to share any comments that they wished to make regarding their therapeutic experience. Session #2: Opening Activity. The group discussed any thoughts, feelings or unfinished business from the last session. The group then expressed themselves through metaphor by answering the question, "If you were a rainbow where would you land?" Therapeutic Activity. The leader guided the group through a relaxation and guided imagery activity (see appendix I). The imagery exercise was intended to build relaxation skills and help them to create a healing and strengthening image for themselves. After the imagery activity the group members were supplied with pastels and an 18" by 24" piece of paper and they were invited to create a picture of themselves surrounded by the circle of strength that they imagined during their therapeutic experience. Closing Activity. First, the participants were invited to tell a story of what might be happening in their image. Then, the participants were asked to share any comments that they wished to make regarding their therapeutic experience. For example, whether it was difficult or easy to relax, the feelings evoked by the images, which parts of the exercise were difficult to follow and/or to describe the art image created. 4 2 Session #3: Opening Activity. The group discussed any thoughts, feelings or unfinished business from the last session. The participants then expressed themselves through a metaphor by imagining themselves as an animal and sharing their image with the group. Therapeutic Activity. The group members were supplied with glue, scissors, acrylic paint, pastels, an 18" by 24" piece of paper, and various magazines. They were then invited to create a collage to represent themselves including symbols that represented their likes, dislikes, talents, desires, personal qualities or simply images that they believed to be symbolic of an aspect of their life. This exercise is designed to increase self-awareness and recognize personal identity. Closing Activity. The group gathered to share any comments that they wished to make regarding their therapeutic experience. Specifically, they were asked to share three of the images and to describe how they symbolize an aspect of themselves. Session #4: Opening Activity. The group discussed any thoughts, feelings or unfinished business from the last session. The group members then expressed themselves through metaphor by imagining that they were earth, wind, fire or water and sharing their image with the other participants. Therapeutic Activity. The group members were supplied with an 18" by 24" piece of paper, pastels and pencil crayons. They were then invited to imagine their lives as if it were a time line. The time line was labeled as their "life line" and could be any shape or length that they wished. Next, the participants were asked to imagine the lifeline as a representation of their life from birth to the present and to further imagine the 43 significant events in their life occurring somewhere on the lifeline. The group members then used images, shapes, and symbols to record these significant life events on their time line. The participants were encouraged to include events that evoked both positive and negative feelings. Examples might include the death of a loved one, a memorable holiday, visiting a particular place, a friendship ending, etc. Closing Activity. The participant was asked to describe their lifeline as well as to share any reflections that they had regarding their therapeutic experience. Session #5: Opening Activity. The group discussed any thoughts, feelings or unfinished business from the last session. The group members then expressed themselves through metaphor by imagining themselves as any form of transportation and shared their image with the other participants. Therapeutic Activity. The group members were supplied with a 18" by 24" piece of paper, pastels, acrylic paint and pencil crayons. The participants were then guided through a short progressive relaxation exercise designed to assist them in relaxing all of their muscle groups and to focus fully on the imagery exercise. They were then asked to imagine their earliest memory of experiencing sadness and depression. They were guided through the imagery exercise evoking the recollection of their surroundings, the people and objects in their environment, how their body felt, how old they were, what they were doing, etc. The participants were then invited to express the images, thoughts and feelings that were evoked during the early recollection and express them through their art. Therefore, the participants used shapes, colors and various abstract and symbolic forms to express that which was evoked throughout the exercise. 44 Closing Activity. The group gathered to share any thoughts or feelings regarding their therapeutic experience including the image that was evoked, whether this was a positive or negative image, the manner in which they expressed the image through their art and any other information that they wished to comment on. Session #6: Opening Activity. The group discussed any thoughts, feelings or unfinished business from the last session. The group members then expressed themselves through metaphor by imagining themselves as a tree of any kind and described themselves as such to the other participants. Therapeutic Activity. The group members were supplied with an 18" by 24" piece of paper, pastels, acrylic paint and pencil crayons. The participants were then guided through a short progressive relaxation exercise designed to assist them in relaxing all of their muscle groups and to focus fully on the imagery exercise. The group was then invited to imagine their feelings of depression and to sense where they felt their feelings of depression in their body. If any individuals were having difficulty getting in touch with these particular feelings it was suggested that they imagine a time in their life when they felt "down" or "depressed". Then the group was invited to imagine what the depression might look like. For example, to imagine the shape, the color, the size, etc. The group was invited to imagine a healing image such as a warm light overhead, their own healing source within, cool and cleansing water, or any other image that felt healing to them and to imagine their own special healing source comforting and healing their feelings of depression. The participants were then invited to express the images, thoughts and feelings that were evoked during the imagery exercise through their art. Therefore, 45 the participants used shapes, colors and various abstract and symbolic forms to express that which was evoked throughout the exercise. Closing Activity. First the participant was asked to tell a story of what might be happening in the picture by giving the depression a voice and talking for the depression. Then, the group gathered to share any thoughts or feelings regarding their therapeutic experience. This might include the image that was evoked, any feelings that were experienced as a result, whether or not they chose to imagine a healing source, the manner in which they expressed the image through their art and any other information that they wished to comment on. Session #7: Opening Activity. The group discussed any thoughts, feelings or unfinished business from the last session. The group members then imagined their favorite childhood toy or activity and shared it with the other participants. Therapeutic Activity. The group members were supplied with an 18" by 24" piece of paper, pastels, acrylic paint and pencil crayons. The participants were then guided through a short progressive relaxation exercise designed to assist them in relaxing all of their muscle groups and to focus fully on the imagery exercise. The group was invited to imagine all of the qualities within themselves that brought them a feeling of strength and security. This was called their internal support system. For example, a unique talent, characteristic such as sensitivity, belief system or faith, etc. The group was then invited to imagine all of the things in their lives outside of themselves that bring them a feeling of strength. This was called their external support system. For example, a particular place, community, pet, person, objects, something in nature, activity, etc. The 46 participants then created a picture in which all of the inner sources of strength were expressed through image or symbol in the middle of a large circle while the outer sources of strength were placed outside of the circle. The final image showed the contrast between the participant's inner supports or resources and outer supports. Closing Activity. The group gathered to share any thoughts or feelings regarding their therapeutic experience. For example, the images that were evoked, the contrast between the images of their inner and outer resources, any feelings that were experienced during the activity, the manner in which they expressed the images through their art, whether they tended to rely on one person rather than a number of people and any other aspects that they wished to comment on. Session #8: Opening Activity. The group discussed any thoughts, feelings or unfinished business from the last session. The group members then expressed themselves through metaphor by imaging that they could be any flower that they wished and then shared their image with the other participants. Therapeutic Activity. The group chose a mural theme together by first brainstorming ideas, such as water, forest, sky, animal, and abstract themes. A group decision was used to encourage cohesion and a water and land theme was decided upon. The group was provided with a large 5 by 8 foot piece of paper, acrylic paint, pastels, shiny beads, glue, sparkles, and felt markers. Relaxing classical music was played while each participant found an empty area on the mural to begin composing her perception of the theme. The music was stopped at three-minute intervals when the participants took 47 one step to the right in order to work on another aspect of the mural. The result was a cohesive art image in which every participant was a critical contributor. Closing Activity. The collage was hung as a visual display of the groups' cohesion and ability to work together. The group gathered to share any comments that they wished to make regarding their therapeutic experience and mural image. For example, what might be happening in the picture, what emotions come up for them as they view the images, whether they might be able to choose one of the images and talk through the image, etc. As well, the group was asked to comment on the impact of others altering their contributions to the mural and what it was like to create as group. Second, the group expressed any thoughts and feelings regarding their entire group therapy experience including the way in which it was helpful or beneficial as well as any difficulties or disappointments throughout the process. Finally, the group had a short informal gathering so that they could socialize and say goodbye in their own way. Post-Test. At the end of treatment the subject and their guardian separately received the post-tests. A further meeting took place including the primary therapist, the subject and their guardian whereby it was determined whether continued therapy intervention was needed and the appropriate course of treatment was recommended Procedures: Control Group Pre-Test. The control group subjects and guardians attended an initial pre-test meeting in order to discuss any further questions or concerns regarding the adolescents mental health or the study itself. The time allotted for discussion was fifteen minutes. The adolescent and their guardian were then given the pre-tests in exactly the same manner as described for the individual and group intervention groups. After all tests were 48 completed the guardian was reunited with the adolescent and both were asked to contact the researcher if any concerns arose during the following 8 weeks until treatment (e.g. worsening of symptoms, suicidal thoughts or plans, etc.). The participants were assured that if a mental health emergency occurred or if a therapist became available within the 8 week wait list period that treatment would be provided immediately. Waiting Period. For an eight-week period the subject did not receive any therapeutic intervention other than episodic telephone contact with their primary therapist as needed. Post-Test. At the end of the eight-week period the subject and their guardian again met with the therapist and the three psychological inventories were administered as stated above. The adolescent and their guardian provided information to the researcher regarding their current concerns and intervention was subsequently provided according to their mental health needs. Procedure for Quantitative Analysis of Data Means and standard deviations (Bergman & Spence, 1944; Coombs, i 951) for all samples were compiled for the pre-and post-tests to determine if response was consistent for all samples. Second, one way A N O V A (Winter, 1971; Edwards, 1972) was used to determine the variability between the three groups on all pre- and post-test measures. Scheffe Post-Hoc Comparisons of Groups (Ury, 1967; Kirk, 1972) was used to assess more closely the degree of mean difference for any groups with a significant result on the A N O V A post-hoc comparisons. T-tests (Pitman, 1937; Scheffe, 1943) provide before and after outcome measures within the treatment groups in order to determine the amount 49 of change between pre- and post-test scores. Finally, the Independent Samples T-Test was used to provide before and after outcome measures for combined groups. Procedure for Qualitative Analysis of Data One set of before and after pictures were selected for analysis from each group: individual art therapy, group art therapy and control group. Particular attention was drawn to the symbols used and the significance, complete vs. incomplete objects, the use of color as well as the themes within the statements. The drawings from the House-Tree-Person Assessment are discussed and analyzed through the comparison of the adolescent's pictures and statements before and after treatment to themselves. 50 Chapter IV Results In this chapter all quantitative statistics will be presented including; (a) means and standard deviations to describe the data obtained; (b) pre-test and post-test ANOVA's to assess the mean differences in outcomes before and after the intervention; (c) Scheffe Post-Hoc Comparisons of Groups; (d) T-Tests to assess differences in each group's pre-and post-test scores; and, (e) Independent Samples T-Test to test the significance of the basic treatment versus no-treatment effect. In addition, qualitative data derived from the House-Tree-Person Assessment will be analyzed by comparing the pictures before and after treatment. Description of Means and Standard Deviations Means and standard deviations were compiled to determine whether or not there were any statistically significant differences between group scores on the three measures. Table 2 displays all mean scores and standard deviation scores for all three pre-and post-test measures and groups. [Inset Table 2] Subjective report of depression measured by the CDI indicate that the individual art therapy group had the highest pre-test mean (20.6), followed by the control group (17.4) and the group art therapy group (14.2). A higher CDI score indicates a greater amount of subjective symptoms of depression. Deviation around the mean ranged from 2.3 (group intervention) to 7.22 control group. Post-test means indicate that all groups had a decrease in mean scores on the CDI. Deviation around the mean for post-test 51 scores ranges from 5.0 (group intervention) to 6.7 (individual intervention). Figure 1.1 shows the difference in pre- and post-test means for all three groups and that the control group has the least amount of change in mean scores. [Insert Figure 1.1] Parent report of behavioral and social competence measured by the Child Behavior Checklist shows that the control group had the highest mean score (60.9), followed by the group treatment group (48.6) and the individual treatment group (43.6). A higher CBCL score indicates a larger degree of behavioral and social problems. Deviation around the mean ranged from 17.0 (individual treatment) to 34.1 (group intervention). Post-test means indicate that all three groups had a decrease in mean scores on the CBCL. Deviation around the mean ranged from 18.4 (control group) to 26.6 (individual intervention). Figure 1.2 shows the difference in pre- and post-test means and indicates that the control group had the least amount of change in mean scores. [Insert Figure 1.2] Parent report of child psychiatric symptoms as measured by the Stonybrook Psychiatric Checklist indicates that the pre-test mean was greatest for the control group (24.8), followed by the group treatment group (19.6) and the individual treatment group (12.0). A higher score on the SBPCL indicates a greater amount of symptomology indicating psychiatric difficulty. Deviation around the mean for pre-test SBPCL ranges from 6.4 (individual treatment) to 14.0 (group intervention). Post-test scores indicate that all the individual treatment group (mean = 7.0) and the group treatment group (mean = 15.6) had a decrease in mean score, while the control group mean score increased (23.5). 52 Post-test deviation around the mean ranged from 7.2 (control group) to 14.1 (group treatment). Figure 1.3 shows that the control group had the least amount of change in the mean score on the SBPCL. [Insert Figure 1.3] Pre-Test Analysis of Variance In order to assess initial comparability and ensure that between-group differences were due to changes over the course of intervention, rather than pre-intervention test score differences between groups one-way A N O V A was used for each group. The results of this statistical analysis indicated no significant pre-test score differences between the control and experimental groups on the CDI, CBCL or SBPCL. Table 3 shows that neither scores on the CDI indicate between-group differences (p=40) nor do scores on the CBCL (p=.27). The SBPCL scores indicate the greatest between group difference but not at a level considered significant (p=. 07). The within group differences are noted in table 3. [Insert Table 3] Post-Test Analysis of Variance The post-test one-way A N O V A indicates significant differences in outcomes between groups for the CBCL (p=.05) and the SBPCL (p=.03). However, there was not a significant difference between groups according to the CDI (p=. 10). Scheffe Post-Hoc Tests The Scheffe Post-Hoc test was performed on the significant main effect, that is CBCL and SBPCL, to determine which pair of means was significantly different. This revealed that mean scores for the individual treatment group compared to the control 53 group were significantly different (p=04) according to the SBPCL. This indicates that the individual treatment group showed a significant decrease in psychiatric symptoms after treatment compared to a control group. However, no other significant main effects were found. [Insert Table 4] Before and After Outcome Measures Within Treatment Groups. In order to determine whether there were significant within-group differences (p<05) between pre- and post-test scores for either the control or experimental groups paired t-tests were compared for all three measures. Paired t-tests revealed several significant before and after outcome results between treatment groups. Both treatment groups showed significantly fewer subjective symptoms of depression according to the CDI with the individual treatment group minimally lower (p=.03) than the group treatment group (p=.04). However, the control group did not show significant within group differences on the CDI (p=. 18). Table 5 shows the before and after outcome measures within the treatment groups. [Insert Table 5] The individual art therapy treatment group also showed significant within group differences in behavioral and social competence problems as measured by the C B C L (p=.02). The group art therapy treatment group had a within group difference of p=08. Although this s not a statistically significant p-value the author suspects that a larger n may have resulted in a lower p-value or greater significance. The within group difference for the control group was not significant (p=.25). 54 The within group differences for the SBPCL were not significant for either individual treatment (p=. 20), group treatment (p=. 13), or control group (.18). Independent Sample T-Test To test the significance of the basic treatment versus no-treatment effect, the outcome data for the two treatment groups were combined and compared with the control group, using independent sample t-tests at post-test. Compared with the waiting-list control subjects, persons who received active treatment showed significant post-test improvement in behavioral and social competence problems as measured by the C B C L (p=05) as well as a significant decrease in psychiatric symptoms as measured by the Stonybrook Psychiatric Checklist (p=.02). The combined treatment group did not show significantly fewer subjective symptoms of depression compared to the control group as measured by the CDI (p=.058). [Insert Table 6] Qualitative Analysis of House-Tree-Person The following compares the H-T-P drawings from each group to themselves: individual art therapy, group art therapy and control group. Each drawing is described with particular attention drawn to the symbols used and their significance, the use of color, themes within the statements as well as wholeness vs. incompleteness of drawings. The house is a symbol that may represent the child's family life and relationships, openness to outsiders, the amount of protection the home provides, the nature of the person's ego structure, contact with reality, the relative roles played by the psychological past and future in the child's psychological field, and the degree of rigidity in the personality (Buck, 1948). The person drawing may disclose how the child feels 55 physically and emotionally, what they would like to be, their attitude towards interpersonal relationships or may represent other people in the child's life (Allan, 1988; Buck, 1948). The tree drawing is thought to represent many aspects of the child's psyche: the unconscious picture of the general psychological field, the unconscious developmental picture, the psychosexual level and maturity, and feelings of intrapersonal balance (Allan, 1988). Individual Art Therapy. The adolescent in the individual art therapy treatment group first drew a small house in the upper left corner of the page (see figure 1.4). There is only a small amount of ground drawn, no color was used and a pencil was the only medium used despite being provided with felt pens and pencil crayons. The roof of the house is proportionally large and there is only one small window on the top floor with a cross in it. An overly large roof may mean that the person seeks satisfaction in the fantasy (Oster & Gould, 1987). It is also thought that latent hostility may be present if the house is windowless on the ground floor or it may indicate a family secret (Allan, 1988). The house does not have a chimney, which may represent an inability to express feelings within the family (Buck, 1948). The door does have a handle but a balcony hides it. The door is thought to represent interpersonal accessibility (Oster, et al., 1987). There are no people, animals or organic matter included. [Insert Figure 1.4] The house drawn after treatment has color and includes many significant objects, such as two palm trees (one on both sides of the house), calm water in front of the house, and a rising or setting sun (see figure 1.5). A rising sun can represent birth and renewal, while a setting sun can represent depression (Cooper, 1978). Water can symbolize the 56 source of all life or if tumultuous can represent chaos in the child's life (Cooper, 1978). As well, water can represent life and death, and then regeneration evident in the process of individuation (Jung, 1964). The house has two parts with accessible doors with handles. One of the doors has a large welcoming stairs leading up to it. There are more windows to this house and no crosses in them. [Insert Figure 1.5] The adolescent described the first house as the one where she spent most of her life as a baby, happy and friendly, belongs to her friend's mom, she'd like a room in the basement next to her friends brother, no one has hurt the house and it needs a horse. Horses can symbolize life and death, instinctual animal nature or the intellect (Cooper, 1978; de Vries, 1976). She added that she would like her friend, her friend's brother, herself, her friend's mom, and her mom to live in the house. The adolescent described the second house as being in California with a gorgeous view, happy, a place for people to get away from the city, belongs to her mom and dad, never been hurt, in a quiet and private area, and it needs someone to live there and take care of it. Also, the day is hot and she would like the room with an ocean view window above the balcony. A dramatic difference between this adolescent's house picture is evident after treatment versus before treatment. Positive visual changes include the use of color, stronger lines, a more accessible door, the presence of trees and the sun, more windows, and calm water in front. The second house is described in the present, while the house before treatment was described as one that was previously a safe place for her. This may indicate an increased ability to feel safe in the present with her own family owning the 57 house rather than her friend's family. Both houses are described as being happy and never being hurt. The second house is described as needing someone to live there and take care of it which may reflect a need for nurturing or a stronger connection with the family. The tree drawn before treatment is small and includes nothing else within the scene other than a tire swing hanging from the tree (see figure 1.6). It is placed in the upper left area of the page. A tiny tree may indicate feelings of inferiority or insignificance (Oster, et al., 1987). The tree is brown and no other color is used in the picture. The tree is void of leaves and roots. A lack of roots may represent repressed emotions or lack of a feeling of stability (Oster, et al., 1987). As well, there is no groundline drawn, which may indicate a vulnerability to stress (Oster et al., 1987). Although the adolescent described the tree as alive and healthy, the tree appears to have brittle or dead branches. Dead branches may indicate environmental trauma or the loss of a loved one and this particular client's father had died several years previous (Bluestein, 1978). [Insert Figure 1.6] The tree drawn after treatment is an evergreen tree with a lot of green evident (see figure 1.7). There are no roots, but the tree is grounded. In the second picture there is a smiling girl sitting on a swing that is separate from the tree. Two small blue clouds are included, which can represent tears and the need to cry (Allan, 1988). [Insert Figure 1.7] The first tree is described as being in the back yard of her friends house, healthy, alive, in summer, sunny, never been hurt and needing a tree house. 58 The second tree is described as old, has a little girl swinging on the swing set, pine, in the park, healthy, alive, in summer, hot weather, never been hurt, little children run around it and hide near it, and it needs love and attention the most. There are many positive changes evident when comparing the tree drawn after treatment versus before treatment. For example, there is a groundline drawn, more color is evident, there is the presence of people playing and the tree is a heartier evergreen tree rather than deciduous. Also, the swing is now separate from the tree, which may indicate a separation from childhood or increased independence. In the second picture, the adolescent was also able to identify that the tree needed more love and attention, which may indicate a new awareness of this need within themselves. The person drawn before treatment is small and placed in the upper center of the page (see figure 1.8). It is thought that size is equated with power indicating in this picture a feeling of powerlessness (Burns & Kaufman, 1970). The adolescent chose not to use any color. The person is complete and is drawn with her arms behind her back. Hands held behind the back may indicate a desire to control anger or interpersonal reluctance (Oster, et al., 1987). The person's feet are relatively small and disproportionate facing the opposite way. Legs and feet facing the opposite way can indicate a feeling of frustration and feet that are small can imply an unstable personality (di Leo, 1970). The person's expression is neutral. There is no ground drawn. She is wearing shorts and a tee shirt, but is not wearing shoes. There are no other people, animals or organic matter included. [Insert Figure 1.8] 59 The person drawn after treatment is much larger and colorful (see figure 1.9). As well, other objects are included in the scene, such as a large yellow school bus (parked) behind the person, and a red stop sign to the person's right. The person appears to have their hands in their pockets and part of one hand is evident. The person is wearing bright clothing and red shoes. Ground was again not drawn in this picture. The person has short hair and is smiling widely. [Insert Figure 1.9] The adolescent described the person in the first drawing as being herself in a few years. She is 16 or 17 years old, standing by the ocean, thinking about the ocean, feeling happy, and has never been hurt. The person wants to own a horse, to be going out with her friends brother and to have her dad alive again. The person in the second picture is described as a happy little boy waiting for the school bus. He's eight years old, can't wait for the first day of school, wants to see his friends, feels happy and has never been hurt. He wishes to have a lot of candy, all of the Lego in the world and a racecar. Many significant positive changes are evident when comparing the pictures before and after treatment. For example, the picture of the second person includes the use of color, a connection with school and peers, references to playfulness, presence of shoes, there is no attention to loss and there is a bus present, which can represent psychic movement. Both people are described as happy and never been hurt. Group Art Therapy. The adolescent that received group art therapy treatment initially drew a very colorful and complete house (see figure 2.0). The door was large and welcoming and it has many variably shaped windows. The primary colors of the 60 house are yellow and blue. Grass can be seen around the sides of the house. The house is moderate in size. [Insert Figure 2.0] After treatment the adolescent drew a multidimensional house with only part of the house evident, but yet very large (see figure 2.1). There are many lines within the picture resulting in a more chaotic appearance. The windows have crosses in them. The colors of the house are primarily purple and blue with a black door. There are no people, animals or organic matter included. [Insert Figure 2.1] The adolescent described the first house as being like where her grandma lives, a big mansion, happy, Paginini Virtuoso's home (violinist), that she would like the room with the triangle window, it feels hurt when people don't visit it, and it needs people to visit it. The adolescent made the following statements about the second house: the house has the hallway of opportunities, is busy, she owns it, and she would like the room at the end of the hallway, no one has hurt the house and it needs nothing. The comparison of the first house to the second house indicates that the latter shows fewer positive symbols than the former. The house drawn before treatment is more colorful, complete, has a more welcoming door, it has organic material around it and the windows do not have crosses. The house drawn after treatment is drawn with scattered lines and appears confusing with a long dark hall. However, the statements made about the house are somewhat positive. For example, it has the hallway of 61 opportunities and the adolescent owns the house. The second house has never been hurt, while the first house feels hurt that others don't visit it and needs others to visit it. The tree drawn before treatment is very colorful and complete (see figure2.2). The lines of the tree are moving up in a tumultuous motion and there is water all around the tree. It is thought that a tree's lines flowing up may represent the person's inner self moving from basic reality to emotional unreality (Allan, 1988). The colors brown, black, red and green are used. The tree is very large taking up the whole page. There are no people, animals or other organic matter included. [Insert Figure 2.2] The tree drawn after treatment is less intensely colored with brown used for the trunk and green for the leaves of the tree (see figure 2.3). It is also very large but there is more attention paid to the roots and it is more grounded. The top of the tree is moving off the page which may indicate that the adolescent is prone to escape to fantasy for satisfaction and avoid reality (Allan, 1988). The background is blue, but less of a focal point and less tumultuous. No people or animals are included. [Insert Figure 2.3] The first tree was described as being by the ocean, a mixture, not a real Arbutus, started as something else, wasn't planted, seeds were blown across the ocean, healthy, old, it's night time, the sand isn't good for it's soil, and needs to change seasons because it's too hot. As mentioned before, the ocean can represent unconscious emotions, life and death and regeneration, chaos in a child's life or the life force (Cooper, 1978). So, in this picture the tree (or self) is close to tumultuous waters, which were crossed in order for it to take seed or life form. This may be an example of symbolic representation of the 62 process of chaos, struggle and resolution described by Jung (1964). The statement that the tree "started as something else" may also indicate the adolescent's transformation. The statements made about the second tree include: it's happy and growing, doesn't need anything, thick and lovely, overlooking my view, healthy and alive, spring, weather is pleasant, no one has hurt the tree and it needs nothing. These statements seem to indicate a much more calm and settled psyche with calm waters and the trees needs being met. The comparison of the tree drawings indicates that the second tree has more positive characteristics. For example, the second tree does not have red or black within it (may indicate anger), is rooted, more ground is evident, and the waters are calm. The statements made about the tree are also much more positive in the second picture. The second tree is happy, never been hurt and has what it needs. However, the statements about the first tree indicate concern about the soil, a need for cooler weather, that it wasn't intentionally planted and isn't really what it appears to be. The person drawn before treatment is very large and is incomplete (missing chin and neck). Missing or oversized facial parts may indicate a problem with reception of stimuli, a denial or malfunction of the parts, or a wish for less reception (Buck, 1948). The person's body is also not included (see figure 2.4). The colors used are primarily blue with yellow and green used for the lips and the iris' (no eyelashes). The person appears to be looking straight ahead and the expression is neutral. [Insert Figure 2.4] The person drawn after treatment is more complete and is drawn to the bottom of the neck (see figure 2.5). The size of the person is not as big as the picture drawn before 63 treatment. The person's hair is longer and is brown, while in the other picture it was blue. The person in the second picture has eyes of blue and green with eyelashes that give them a bright appearance. The facial expression is neutral. The lips are red compared to blue and green in the other picture; [Insert Figure 2.5] The first person is described as a woman with cat's eyes, like a cat, observing, 14 years old, looking, feeling curious, not hurt but not noticed, noticed but in the wrong way, and wishes to find someone like herself. The second person is described as being herself, wanting to be older than she is, thinking, wondering what's going to happen next, feeling content and has never been hurt. The comparison of the picture of the person before and after treatment shows that the second picture is more positive in both visual form as well as accompanying statements. The second person is more complete, more realistic (red lips instead of blue and green lips), is smiling slightly and appears less sinister. The statements also indicate that the girl in the first picture is first not feeling noticed and then noticed in the wrong way, while the second girl is content and never been hurt. The first girl wishes to find someone like herself and the second girl wishes to be older than she is. Both of these statements indicate some discontent with life. Control Group. The house drawn before treatment is medium in size, placed in the center and has various objects within the scene (see figure 2.6). For example, a swing set, a garage, a yellow sun and two gray clouds drawn in pencil in the upper left corner. While the sun 64 can represent warmth, the provider of growth or the person in the child's life who supplies understanding for development, it is thought that dark clouds may represent depression (Cooper, 1978). Two very lightly drawn birds are evident which are thought to symbolize transcendence or movement towards a more mature state of development (Jung, 1964 ) or the soul's ascent to heaven (Cooper, 1976). The house has six windows on various levels. The house is green and lightly shaded. There are no people, animals, ground or organic material drawn. [Insert Figure 2.6] The second house is smaller and placed on the left side of the page (see figure 2.7). The house is black with fewer windows. The house has a black chimney which may represent strong emotions within the family (Allan, 1988). The yellow sun is placed in the upper left corner as in the first picture, but there are no clouds. There are many (6) evergreen trees to the right side of the page and the trees are taller than the house. There are also two pink flowers on either side of the house. The house is grounded. [Insert Figure 2.7] The first house is described as representing a family: a dad, a mom, 2 kids and a dog. For children dogs can have a variety of meanings, but often represent a pet or a need for affection (Allan, 1988). They have a set of swings, a garage and it is always nice out. Other descriptors used include: the house is happy, the dad is the owner and decision maker, that she would like the room in the attic (dark and private), it has never been hurt and needs a better paint job. 65 The second house is described as small, quiet, still and quiet neighborhood, relaxed, her family lives there and it belongs to her, would like room in attic (away from everyone else), never been hurt and needs more noise. The comparison of the house drawn before the 8-week control period versus after shows mixed themes. For example, the first house is not as small, has more windows and is green rather than black (positive indicators). However, some of the symbols around the second house are also positive, such as flowers providing balance to each side, many evergreen trees (a forest can symbolize the unconscious) and a bright sun with no clouds covering it. In the first house the sun is somewhat blocked by clouds. There is also a set of swings, but no people on them. The statements made for the first house indicate that the dad is a predominant and controlling figure, while in the second the adolescent is the owner, which is a positive shift. In the second house there is a desire for more activity which may also be a positive theme. The tree drawn before treatment has a very thin trunk and has many thin brown branches with one green tear-shaped leaf on each (see figure 2.8). The trunk is thought to represent the child's psychological strength (Allan, 1988). Three tear-shaped leaves are falling to the ground. There are various other trees with no apparent trunk, but rather green branches connected together. The trees are grounded with no roots. There is a yellow sun in the upper left corner of the page. The tree is drawn on the center of the page and is tall. [Insert Figure 2.8] The tree drawn after treatment is placed in the center of the page and is approximately the same size (see figure 2.9). However, it is an evergreen tree with much 66 more green evident and a sturdy trunk. The tree is grounded with no roots. There are many pink flowers (18 in total) on either side of the tree. There is a yellow sun in the upper left corner of the picture. [Insert Figure 2.9] The first tree is described as growing happily in a field of other trees, healthy, alive (but will be cut down by loggers), spring, the weather is sunny, never been hurt and needing love. The second tree is described, as a fern that is growing, by itself, lonely, in a park or backyard, physically healthy, and it is spring with sunny weather. The adolescent stated that the tree has been hurt, but that it heals quickly because trees are good fighters. She also added that the tree needs understanding and friends the most. The comparison of the first and second tree indicates mixed positive and negative themes. Visually the second tree appears to have more positive themes, such being surrounded by flowers rather than jagged stems and the fact that it is a heartier evergreen rather than a thin sprig like plant. The statements for the second tree are somewhat less positive. For example, it is lonely and has been hurt, needs understanding and friends. Positive is the fact that it heals quickly and is a good fighter. The first tree is reflected on more positively and is said to have never been hurt, but it needs love and will be chopped down by loggers. The person drawn before treatment is placed in the center of the picture and is standing with her arms up (see figure 3.0). The person is dressed in red, blue and black clothing, has no hands and brown curly hair. Missing hands can indicate a child's feeling of helplessness (di Leo, 1970). The person is smiling. There are two red flowers to the 67 left of the page and one quarter of a yellow sun in the upper left corner. To the right of the page is a tree with a solid brown trunk a knothole in the middle of it. Knotholes may have sexual symbolism, such as past sexual abuse or ambivalence surrounding childbearing (Oster, et al., 1987). The tree is grounded with no roots and green leaves. [Insert Figure 3.0] The person drawn after treatment is much larger, is wearing purple and blue clothing and has blonde curly hair (see figure 3.1). The person has no feet or hands and there is no ground. The mouth of the person is out of proportion to the rest of the face with large pink lips. An overly emphasized or large mouth may indicate immaturity or oral-aggressiveness (Oster, et al., 1987). There are no other people, animals, or organic material included. [Insert Figure 3.1] The person drawn before treatment is described as happy and alone, 20 to 30 years of age, standing, smiling, wondering why she's getting her picture taken, and was hurt by her family or a friend (but got over it when she moved away). The person drawn after treatment is described as by themselves, 10 or 11 years of age, is posing for a picture, feeling lonely, and has been hurt (but got over it). The adolescent added that the person wishes to be wealthy, to be popular with a lot of faithful friends and wishes to be independent. The comparison of the first and second person picture appears more positive visually and has more positive themes within the statements. For example, the first person is beside a tree and flowers, has feet, and there is a sun and groundline drawn. The second person is without feet or hands and has nothing else in their environment. 68 The statements indicate that the first person is happy, smiling, wondering and has been hurt but got over it. The second person is described as lonely, wishes to have friends that are faithful, and wishes to be independent. 6 9 Chapter V Discussion The following chapter will further describe and explore the research findings in relationship to the research hypothesis. First, findings related to the ten hypotheses of the study will be presented in this section separately. Each hypothesis was tested in relation to the mean scores of each of the variables used to infer levels of depression. These variables were subjective levels of depression, parent report of behavior problems and social competence, and psychiatric symptoms assessed by the parent. Second, the findings related to the qualitative H-T-P data will be discussed including an overview of group comparisons. Finally, implications for future research will be discussed. Hypothesis #1 Adolescents that receive individual art therapy treatment will have fewer subjective symptoms of depression according to the Children's Depression Inventory compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 1 = mean 3. One-way analysis of variance (ANOVA) was used to determine whether or not there were any statistically significant between group differences in mean scores of the variable used to infer subjective symptoms of depression (CDI). The one-way A N O V A indicated that there was not a statistically significant difference between the group's mean scores after treatment (p=0.10). Therefore, the adolescents that received individual art therapy treatment did not have fewer subjective symptoms of depression compared to the control group. 70 Paired t-tests were used to assess differences in each group's pre- and post-test mean scores. According the paired t-test results there was a significant difference in each groups mean scores on the CDI (t [df=3]=2.87, p=0.03). Therefore, adolescents that received individual art therapy treatment had significantly fewer subjective symptoms of depression after treatment according to the Children's Depression Inventory. In summary, these findings indicate that while there was not a significant difference between groups there was a within group difference in subjective levels of depression for adolescents that received individual art therapy treatment. Therefore, the hypothesis that adolescents that receive individual art therapy treatment will have significantly lower levels of depression compared to themselves is supported by the findings. Hypothesis #2 Adolescents that receive individual art therapy treatment will have fewer behavioral problems and social incompetencies according to the Child Behavior Checklist compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 1 = mean 3. One-way analysis of variance (ANOVA) was used to determine whether or not there were any statistically significant between group differences in mean scores of the variable used to infer behavioral problems and social incompetencies (CBCL). The one-way A N O V A indicated that there was a statistically significant difference between the group's mean scores after treatment (p=.05). Therefore, the three groups mean scores were significantly different from each other post-test. 71 Scheffe post hoc tests were performed on the significant main effect, which is behavioral and social incompetencies, to determine which pair of means were significantly different. There were no statistically significant differences in levels of behavior or social incompetencies after treatment compared to themselves (p=0.12). Paired t-tests were used to assess differences in each group's pre- and post-test mean scores. According the paired t-test results there was a significant difference in each groups mean scores on the CBCL (t [df=3]=3.33, p=0.02). Therefore, adolescents that received individual art therapy treatment had significantly fewer parent-reported behavior and social competence problems after treatment according to the CBCL. In summary, these findings indicate that while there was not a significant difference between groups there was a within group difference in parent reported behavior and social competence problems for adolescents that received individual art therapy treatment. Therefore, the hypothesis that adolescents that receive individual art therapy treatment will have fewer parent-reported behavior and social competence problems compared with themselves is supported. Hypothesis #3 Adolescents that receive individual art therapy treatment will have fewer symptoms of psychiatric difficulty according to themselves and/or to the Stonybrook Psychiatric Checklist compared to a control group (p<05). The null hypothesis is as follows: mean 1 = mean 3. One-way analysis of variance (ANOVA) was used to determine whether or not there were any statistically significant between group differences in mean scores of the 72 variable used to infer psychiatric symptoms (SBPCL). The one-way A N O V A indicated that there was a statistically significant difference between the group's mean scores after treatment (p=0.03). Therefore, the three groups mean scores were significantly different from each other post-test. Scheffe post hoc tests were performed on the significant main effect, which are psychiatric symptoms, to determine which pair of means was significantly different. There was a statistically significant difference in levels of psychiatric symptoms after treatment compared with the control group (p=.04). Therefore, the group that received individual art therapy treatment had significantly fewer psychiatric symptoms compared with the control group. Paired t-tests were used to assess differences in each group's pre- and post-test scores. According the paired t-test results there was not a significant difference in each groups mean scores on the SBPCL (t [df=3]=0.20, p=0.20). Therefore, adolescents that received individual art therapy treatment did not have significantly fewer psychiatric symptoms post-test compared to their pre-test scores. In summary, these findings indicate that while there was a significant difference between groups there was not a within group difference in parent reported psychiatric symptoms for adolescents that received individual art therapy treatment. Therefore, the hypothesis that adolescents that receive individual art therapy treatment will have fewer parent-reported psychiatric symptoms compared to a control group is supported Hypothesis #4 Adolescents that receive group art therapy treatment will have fewer subjective symptoms of depression according to the 73 Children's Depression Inventory compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 2 = mean 3. One-way analysis of variance (ANOVA) was used to determine whether or not there were any statistically significant between group differences in mean scores of the variable used to infer subjective symptoms of depression for group therapy treatment (CDI). The one-way A N O V A indicated that there was not a statistically significant difference between the group's mean scores after treatment (p=0.10). Therefore, the adolescents that received group art therapy treatment did not have fewer subjective symptoms of depression compared to the control group. Paired t-tests were used to assess differences in each group's pre- and post-test mean scores. According the paired t-test results there was a significant difference in each groups mean scores on the CDI (t [df=4]=2.39, p=0.04). Therefore, adolescents that received group art therapy treatment had significantly fewer subjective symptoms of depression compared with themselves after treatment according to the Children's Depression Inventory. These findings indicate that while there was not a significant difference between groups there was a within group difference in subjective levels of depression for adolescents that received individual art therapy treatment. Therefore, the hypothesis that adolescents that receive group art therapy will show a significantly lower level of subjective depression compared to themselves is supported. 74 Hypothesis #5 Adolescents that receive group art therapy treatment will have fewer behavioral problems and social incompetencies according to the Child Behavior Checklist compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 2 = mean 3. One-way analysis of variance (ANOVA) was used to determine whether or not there were any statistically significant between group differences in mean scores of the variable used to infer behavioral problems and social incompetencies (CBCL). The one-way A N O V A indicated that there was a statistically significant difference between the group's mean scores after treatment (p=.05). Therefore, the three groups mean scores were significantly different from each other post-test. Scheffe post hoc tests were performed on the significant main effect, which is behavioral and social incompetencies, to determine which pair of means were significantly different. There were no statistically significant differences in levels of behavior or social incompetencies for the group treatment group (p=0.11). Paired t-tests were used to assess differences in each group's pre- and post-test mean scores. According the paired t-test results there was no a significant difference in each groups mean scores on the CBCL (t [df=4]=1.73, p=0.08). Therefore, adolescents that received group art therapy treatment did not have significantly fewer parent-reported behavior and social competence problems after treatment according to the CBCL. These findings indicate that there was neither a significant between groups or within group difference in parent reported behavior and social competence. Therefore, no 75 statistical result supports the hypothesis that adolescents that receive group art therapy treatment will have fewer behavioral problems and social incompetencies according to the Child Behavior Checklist compared to themselves and/or to a control group. Hypothesis #6 Adolescents that receive group art therapy treatment will have fewer symptoms of psychiatric difficulty according to the Stonybrook Psychiatric Checklist compared to themselves and/or to a control group (p<05). The null hypothesis is as follows: mean 2 = mean 3. One-way analysis of variance (ANOVA) was used to determine whether or not there were any statistically significant between group differences in mean scores of the variable used to infer psychiatric symptoms (SBPCL). The one-way A N O V A indicated that there was a statistically significant difference between the group's mean scores after treatment (p=0.03). Therefore, the three groups mean scores were significantly different from each other post-test. Scheffe post hoc tests were performed on the significant main effect, which are psychiatric symptoms, to determine which pair of means was significantly different. There was not a statistically significant difference in levels of psychiatric symptoms after treatment compared with the control group (p=0.36). Therefore, those that received group art therapy treatment did not have significantly fewer psychiatric symptoms compared with the control group. Paired t-tests were used to assess differences in each group's pre- and post-test scores. According the paired t-test results there was not a significant difference in each 76 groups mean scores on the SBPCL (t [df=4]=1.32, p=0.13). Therefore, adolescents that received group art therapy treatment did not have significantly fewer psychiatric symptoms post-test compared to their pre-test scores. These findings indicate that there was neither a significant between groups or within group difference in parent reported psychiatric symptoms for adolescents that received individual art therapy treatment. Therefore, no statistical result supports the hypothesis that adolescents that receive group art therapy treatment will have fewer parent-reported psychiatric symptoms compared to themselves and/or to a control group. Hypothesis #7 Adolescents that do not receive any treatment will not show any change in subjective levels of depression, behavioral problems or social incompetencies or psychiatric problems according to the three measures (p>.05) compared to themselves. The null hypothesis is as follows: mean 3 does not - mean 3. Paired t-tests were used to assess differences in each group's pre- and post-test scores. According the paired t-test results there was not a significant difference in the control groups mean scores on the subjective levels of depression as measured by the CDI (p=0.18), behavioral problems social incompetencies as measured by the C B C L (p=0.25) or psychiatric problems as measured by the SBPCL (p=0.18). These findings indicate that there was not a significant change in subjective levels of depression, behavioral problems and social incompetencies or psychiatric symptoms for adolescents that did not receive treatment. Therefore, the statistical results fully support the hypothesis. 77 Hypothesis #8 Adolescents that receive individual or group art therapy will have fewer subjective symptoms of depression according to the Children's Depression Inventory compared to a control group (p<05). The null hypothesis is as follows: mean 1 and mean 2 = mean 3. To test the significance of the basic treatment versus no-treatment effect, the outcome data for the two treatment groups were combined and compared with the control group, using independent sample t-tests at post-test. The combined treatment group did not show significantly fewer subjective symptoms of depression compared to the control group as measured by the CDI (p=.058). These findings do not support the hypothesis that art therapy treatment results in fewer subjective symptoms of depression compared to a no-treatment control. Hypothesis #9 Adolescents that receive individual or group art therapy treatment will have fewer behavioral problems and social incompetencies according to the Child Behavior Checklist compared to a control group (p<05). The null hypothesis is as follows: mean 1 and mean 2 = mean 3. To test the significance of the basic treatment versus no-treatment effect, the outcome data for the two treatment groups were combined and compared with the control group, using independent sample t-tests at post-test. Compared with the waiting-list control subjects, persons who received active treatment showed significant post-test 78 improvement in behavioral and social competence problems as measured by the C B C L (p=011). These findings fully support the hypothesis that adolescents that receive art therapy treatment will have fewer parent reported behavioral and social competence problems compared to a no-treatment control. Hypothesis #10 Adolescents that receive individual or group art therapy treatment will have fewer symptoms of psychiatric difficulty according to the Stonybrook Psychiatric Checklist compared to a control group (p<05). The null hypothesis is as follows: mean 1 and mean 2 = mean 3. To test the significance of the basic treatment versus no-treatment effect, the outcome data for the two treatment groups were combined and compared with the control group, using independent sample t-tests at post-test. Compared with the waiting-list control subjects, persons who received active treatment showed significant post-test improvement in psychiatric symptoms as measured by the Stonybrook Psychiatric Checklist (p=.02). These findings fully support the hypothesis that adolescents that receive art therapy treatment will have fewer parent reported psychiatric symptoms compared to a no-treatment control. Summary of Quantitative Research Findings Few research studies to date have demonstrated the effectiveness of short-term art therapy with adolescent's suffering from symptoms of depression. Previous research has 79 focused primarily on the effectiveness of group approaches using cognitive-behavioral techniques (Reynolds & Coats, 1986), social skills training groups (Stark, Reynolds & Kaslow, 1987) and therapeutic support groups (Fine, et al., 1991). In fact, studies on individual psychotherapy for depressed teenagers are scarce (Shaw; 1988). The researcher found no studies to date that compared a group approach to an individual approach with this particular population. In the present study the effectiveness of art therapy as a treatment modality was investigated through the comparisons of adolescent's receiving individual or group art therapy treatment compared to themselves or a control group. The results of the statistical analysis support several of the research hypotheses with the art therapy treatment combined showing the most impressive results. The adolescents that received individual art therapy treatment showed a significant decrease in subjective levels of depression and parent-reported behavior and social competence problems when compared to themselves after treatment. The findings also show a significant change in levels of parent-reported psychiatric symptoms compared to a no-treatment control group. The results involving adolescents that received group art therapy treatment were far less impressive and show that the only significant improvement is subjective levels of depression for each individual compared to themselves after treatment. Although there were significant differences in the levels of parent-reported behavior and social competence problems as well as psychiatric symptoms compared to the other groups, the more conservative Scheffe Post Hoc Comparison did not indicate a significant difference. The post-treatment comparison of the combined treatment groups to the control group indicates significantly fewer parent-reported behavior and social competence 80 problems as well as psychiatric symptoms. However, there was not a significant change in subjective levels of depression after treatment compared to the control group. The present study brings to light several trends that should be discussed further. First, individual art therapy treatment appears to result in greater improvement than group art therapy treatment overall. Previous research suggests that adolescents that participate in group psychotherapy find interactions with others and self-disclosure to the group to be the most beneficial aspects of therapy (Block & Crouch, 1985). Group treatment is also seen as a preferred choice because it reflects the adolescents' desire to utilize a peer group as a replacement for parental support (Linesch, 1990). However, according to Jung (1964) it is the activation of the healing potential that occurs when a child meets and works with an adult that allows the healing process to begin. It may be that in a group structure where the therapist must divide their attention and energy within the group that the healing potential is not as effectively accessed and the adolescent is not as able to go to where they need to therapeutically. In addition, the primary task of adolescence is of individuation and identity formation. It has been previously pointed out that our modern culture fails to provide a supportive structure for this transition such as an ancient rites de passage (Allan, 1992). The individualized attention of the art therapist may facilitate this process more effectively than in a group format where the adolescents receives support primarily from their peers who are also negotiating their way through the inner struggle. Second, the study found that the treatment groups showed significant improvement in subjective levels of depression when compared to themselves, but not when compared to the other groups. This result may be primarily due to statistical factors such as the differences in the initial levels of depression and variability of groups. In 81 attempting to draw conclusions the results of the present study should be considered with caution due to the number of adolescent subjects being relatively low by statistical standards. This limitation makes the findings of the data overly susceptible to individualized subject score variation. Third, it was also found that the combined treatment groups showed significant improvement on the parent reports of difficulty but not on subjective levels of depression. The rational for statistically combining the treatment groups is that it allows the comparison of treatment to no treatment effects. It is not surprising that this procedure resulted in a greater amount of significant findings compared to the isolating of two treatment groups which provides insight into treatment group differences. Also, because no single instrument has proven to be the most valid a trend towards a multidimensional assessment procedure has developed (Crowley, Worchel & Ash, 1992). In a recent study by Worchel and colleagues (1990) only 2% of children identified as depressed through self-report was equally identified as such based on teacher or peer report (Worchel, Hughes, Hall, Stanton, Stanton & Little, 1990). It may be that in the case of depression observable behavioral shifts precede the self-awareness required in reporting internal and external shifts in symptomology. Nevertheless, given the lack of consistency in the literature on instruments that measure depression, a multidimensional approach should be used in any future research of this nature. Fourth, 90% of the subjects used in the study female. Because the researcher was unable to identify possible biases in the referral process the findings of the study are considered relevant to clinical practice. However, this finding is not surprising given the fact that the rate of diagnosed depression among girls is at least three times that amongst 82 boys (Garland, 1994). This may be due to the fact that depression manifests differently in boys with more externalizing or acting out behaviors being evident. In fact, more than 50% of adolescents suffering from depression will simultaneously meet the criteria for oppositional defiant or conduct disorder (Garland, 1994). It is suggested that future studies take this into consideration by carefully screening referrals with external behavioral indicators included. The present study has provided evidence strongly suggesting that the use of short-term art therapy is an effective method of intervention with adolescents suffering from depression. The study further suggests that the greater effectiveness of individual art therapy treatment may be related to the therapist's ability to assist adolescents to express their inner conflicts and move through the developmental task of identity formation and individuation. While the current findings are encouraging, additional follow-up information about long term successful outcome is needed. There is also a need to determine which components of group or individual treatment are specifically effective for the treatment of depressed adolescents. With the incidence of adolescent depression continuing to be prevalent at an alarming rate and given it's cumulative risk to healthy development, it is critical that researchers continue to empirically test the treatments that we employ. Summary of Qualitative Research Findings A before and after H-T-P drawing was selected from one adolescent in each group: individual art therapy, group art therapy and the control group. The drawings and statements made about the drawings were described with attention to the symbols used and their significance, the use of color, themes within the statements as well as wholeness 83 vs. incompleteness of drawings. The following describes the differences in findings between groups. Several trends become evident when comparing the adolescent's pictures before and after pictures. First, the individual's that received art therapy treatment showed more positive changes in the pictures and statements overall compared to the control group. The adolescent that received individual art therapy expressed more positive themes for all three pictures after treatment, while the adolescent receiving group art therapy expressed more positive themes for the tree and person drawing, but not for the house drawing. The adolescent in the control group did not show any particular trends and there was a mix of positive and negative themes in all of the pictures except in the case of the person picture (which indicated more positive themes in the second picture). These findings support and add to the growing body of research indicating that the use of art therapy, even on a short-term basis, can result in significant clinical change in children who are experiencing emotional difficulties (Tibbetts & Stone, 1990; Walsh, 1993). Proponents of art therapy now agree that the process of creating art in itself has a therapeutic benefit and the trends in the present study findings seem to support this belief. Allan (1978) proposes that art therapy is a way of establishing contact with and expressing one's inner world of feelings, and symbols in order for growth to occur in both the conscious and unconscious realm. The qualitative data suggests that the adolescents that participated did in fact utilize the art process as a way to express and explore their inner world and for growth to occur consciously and unconsciously as evidenced by the qualitative and quantitative changes. According to Jung (1964) the individuation process involves a struggle of opposites that is resolved through the rhythm 84 of chaos, struggle, and resolution. Some themes within the drawings and statements of the adolescents provided evidence for this process. For example, in the case of the tree picture of the adolescent receiving group treatment the tree went through a process of being blown across a tumultuous ocean (chaos) to self-implant only to face conditions of improper soil and weather (struggle). However, the next picture appeared to indicate improvement as the tree was well rooted, growing happily and overlooking a lovely view. Other themes of individuation include an expressed desire to be more independent (2 n d person of control group), a shift from others owning the house to the adolescent owning the house (house pictures of control group and group treatment) and the movement of a childhood item from the self symbol (tree pictures of individual treatment). A word of caution is needed, however, in the interpretation of the qualitative results. Only one researcher analyzed the data and in the future a double blind analysis would be more effective. The researcher was aware of the treatment condition of each adolescent making the process less objective in nature. Additionally, the comparisons of themes in the pictures and the statements should include the entire sample for stronger conclusions to be drawn. The comparison of both positive and negative themes should be further explored with the various criteria extensively defined before the onset of the study. Lastly, more extensive analysis of themes may bring to light further understanding of the adolescent psyche during the individuation process. This may include diagnostic as well as curative indicators relating to adolescent depression. 85 Implications for Future Research It is recommended that the study be replicated using a larger sample size and controlling for depression levels, age, sex, and ethnicity. Future research should include follow up data to determine the degree to which improvement is maintained. It is also clear from the lack of research in this area that empirical studies of this nature would be beneficial in the analysis of art therapy treatment for various other diagnoses as well as with other age groups. To enrich our understanding of the healing nature of the art therapy process future research should include a more detailed analysis of the art products created in treatment. An analysis of the art products created within the individual versus group treatment may provide further understanding regarding possible differences in the healing process. Further analysis of the art products may also assist us in understanding the adolescent psyche's task of individuation that is characterized by the rhythm of chaos, struggle, and resolution described by Jung (1964). Finally, to continue to offer a way for adolescents to engage in the act of doing, making, or symbolizing inner struggles through creative arts modalities and to honor the significance of their developmental task is undoubtedly called for. Perhaps by drawing attention to the significance of the adolescent's transition into adulthood and supporting them through it we may prevent the devastation that can result from adolescent depression. 86 References Abramson, L.Y. , Metalsky, G.I. & Alloy, L B . (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review. 96. 358-372. Achenbach, T.M. & Edelbrock, C.S. (1983). Manual for the Child Behavior Checklist and Revised Child Behavior Profile. University of Vermont, Department of Psychiatry. Burlington, VT. Allan, J. (1988). Inscapes of the child's world: Jungian counseling in schools and clinics. Dallas, TX: Spring Publications. Allan, J. (1992). Written paths to healing: Education and Jungian child counseling. Dallas, TX: Spring Publications Allan, J. & Boland, J. (1981). Elementary school counseling in non-urban areas of BC. B.C. Counselor. 3. 30-37. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders. Washington, D.C.L Author. Anderson, J . C , Williams, S., McGee, R. & Silva, P. (1987). DSM-III disorders in preadolescent children. Archives of General Psychiatry. 44, 69-76. Beck, A., Ward, C , Mendelson, M . , Mock, J., Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry. 4, 561-571. Beck, A.T., Rush, A.J., Shaw, B.F. & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Bergman, G., & Spence, K.W. (1944). The logic of psychological measurement. Psvchol. Rev.. 51. 1-24. Bloch, S. & Crouch, E. (1985). Therapeutic factors in group psychotherapy. Oxford: Oxford University Press. Bluestein, V. (1978). Loss of a loved one and the drawing of dead and broken branches on the H-T-P. Psychology in the schools. 15, 56-59. Bowlby, J. (1988). Developmental psychiatry comes of age. American Journal of Psychiatry. 145, 1-10. Brown, R., & Lewinsohn, P. (1979). Coping with depression course workbook. Eugene, OR: University of Oregon. Buck, J.N. (1948). The H-T-P test. Journal of Clinical Psychology. 4. 151-159. Buck, J.N. (1947). House-Tree-Person projective drawing technique: Manual and interpretative guide. W.L. Warren (Rev. ed.) New York: Western Psychological Services. Burns, R . C , & Kaufman, S.H. (1970). Kinetic family drawings. New York: Brunner/Mazel. Burke, P., & Puig-Antich, J. (1990). Psychobiology of childhood depression. Handbook of developmental psychopathology. New York, 327-339. Cantwell, D.P. (1983). Childhood depression: what do we know, where do we go? In S.B. Guze, F.J. Earls & J.E. Barrett (Eds). Childhood psychopathology and development. (pp. 67-85). New York: Raven Press. Clarke, G.N. (1985). A psychoeducational approach to the treatment of depressed adolescents. Unpublished doctoral dissertation. University of Oregon, Eugene, OR. (Cited in Lewinsohn et al., 1989). Clarke, G.N., & Lewinsohn, P. (1984). The coping with depression course adolescent version: A psychoeducational intervention for unipolar depression in high school students. Eugene, OR: University of Oregon Press. Clarke, G.N., Hawkins, W. (1995). Targeted prevention of unipolar depression in an at risk sample of high school adolescents: a randomized trial of group cognitive intervention. Journal of the American Academy of Child & Adolescent Psychiatry. 34. 312-321. Cooms, C H . (1950). Psychological scaling without a unit of measurement. Psvchol. Rev.. 57. 145-158. Cooper, J.C. (1978). An illustrated encyclopaedia of traditional symbols. London: Thames & Hudson Ltd: Coopersmith, S. (1987). Coopersmith self-esteem inventory manual. Consulting Psychologists Press, Palo Alto, Ca. Corder, B., Whiteside, R., & Haizlip, T. (1981). A study of curative factors in group psychotherapy with adolescents. International Journal of Group Psychotherapy, 31. 345-354 Crowley, S. L., Worchel, F. F. (1993). Assessment of childhood depression: Sampling multiple data sources with one instrument. Journal of Psychoeducational Assessment Sep Vol 11 (3), 242-249. de Vries, A. (1976). Dictionary of symbols and imagery. London: North-Holland Press. Edwards, A.L. (1972). Experimental design in psychological research. Holt, Rinehart Winston, New York. Eth, S., Arroyo, W., & Silverstein, S. (1985). A psychiatric crisis team response to violence in elementary schools. In I.H. Berhovitz & J.S. Seliger (Eds), Expanding mental health interventions in schools (Vol. 1). Dubuque, Iowa: Kendall/Hunt. Finch, A.J., Saylor, C.F., Edwards, G.L. & Mcintosh, J.A. (1987). Children's Depression Inventory: Reliability over repeated administrations. Journal of Clinical Child Psychology. 16. 339-341. Fine, S., Gilbert, M . , Schmidt, L. , Hayley, G., Maxwell, A. & Forth, A. (1989). Short term group therapy with depressed adolescent outpatients. Canadian Journal of Psychiatry. 34. 97-102. Fine, S., Gilbert, M. , Hayley, G., Forth, A. (1991). Group therapy for adolescent depressive disorder: A comparison of social skills and therapeutic support. Journal of American Academic Child Adolescent Psychiatry. 30:1. 79-85. Fleming, J.E. & Offord, D.R. (1990). Epidemiology of childhood depressive disorders. Journal of American Academic Child Adolescent Psychiatry. 29. 571-580. Garland, J. (1994). Adolescent depression. Canadian Family Physician. 40. 1583-1598. Goldberg, E.H. (1989). Severity of depression and developmental levels of psychological functioning in 8-16 year old girls. American Journal of Orthopsychiatry. 59 (2). 167-178. Heimberg, L.K. (1963). The measurement of future time perspective. Dissertation Abstracts International. 24. 1686-1687. Hepperlin, C M . , Stewart, G.W. (1990). Extraction of depression scores in adolescents from a general purpose behavior checklist. Journal of Affective Disorder. Feb Vol 18 (2). 105-112. 90 H e p p e r l i n , C M . , Stewart, G . W . & R e y , J . M . (1989). E x t r a c t i o n for depression scores i n adolescents f o r m a general-purpose behavior checklist . Journal o f A f f e c t i v e Disorders . 18. 105-112. Hersen, M . , B e l l a c k , A . S . , & H i m m e l h o c k , J . M . (1980). Treatment o f u n i p o l a r depression w i t h social sk i l l s training. B e h a v i o r M o d i f i c a t i o n . 4. 547-557. Garr ison, C , Schluchter, M . , Schoenback, V . , & K a p l a n , B . (1989). E p i d e m i o l o g y o f depressive symptoms i n y o u n g adolescents. Journal o f T h e A m e r i c a n A c a d e m y o f C h i l d and Adolescent Psychiatry . 28 (3). 343-351 G r a y s o n , P. , & C a r l s o n , G A . (1991). The ut i l i ty o f a D S M - I I I - R - b a s e d checkl ist i n screening c h i l d psychiatr ic patients. A m e r i c a n A c a d e m y o f C h i l d and A d o l e s c e n t Psychiatry . 669-673. Jung, C . G . , ed. (1964). M a n and his symbols . N e w Y o r k : Doubleday . K a z d i n , A E . (1981). Assessment techniques for c h i l d h o o d depression. J . A m . A c a d . C h i l d P s y c h i a t r y 20. 358-375. K h a n , J . S . , K e h l e , T . J . , Jenson, W . R . & C l a r k , E . (1990). C o m p a r i s o n o f cognit ive-behavioral , re laxation, and se l f -model ing interventions for depression among m i d d l e - s c h o o l students. S c h o o l P s y c h o l o g y R e v i e w . 19. 196-211. K i r k , R . E . (1978). Introductory statistics. B r o o k s / C o l e , M o n t e r e y , C a . K i r k , R . E . (1972). Statistical issues: A reader for the behaviora l sciences. B r o o k s / Cole , M o n t e r e y , C a . K l e r m a n , G . L . , L a v o r i , p . W . , R i c e , J . , R e i c h , T . , Endicot t , J . , Antreasen, N . C , K e l l e r , M . B . , & H a r s c h l f e l d , R . M . (1985). B i r th-cohort trends i n rates o f major 91 depressive disorder among relatives of patients with affective disorder. Archives of General Psychiatry. 42. 689-693. Kovacs, M . (1985). The Children's Depression Inventory (CDI). Psychopharmacology, Bulletin. 21. 995-998. Kramer, E . (1971). Art as therapy with children. Schocken Books, New York , Kwiatkowska, H . Y . (1978). Family therapy and evaluation through art. Charles C. Thomas, Springfield, IL. Lewinsohn, P . M . , Munoz, R.F. , Yungren, M . A . , & Zeiss, A . M . (1978). Control your depression. Prentice-Hall, Englewood Cliffs, NJ . Lewinsohn, P . M . , Arconard, M . (1981). Behavioral treatment of depression: a social learning approach. Garland, New York, 33-67. Linesch, D . (1988). Adolescent Art Therapy. New York: Brunner Mazel . Mayer, J.D., Gaschlke, Y . N . , Braverman, D . L . & Evans, T.W. (1992). Mood-congruent judgment is a general effect. Journal of Personality and social Psychology, 63, 119-132. McLean, P. D. , & Hakstian, A . R. (1979). Clinical depression: Comparative efficacy of outpatient treatments. Journal of Consulting and Clinical Psychology. 47. 818-836. Naumburg, M . (1966). Dynamically oriented art therapy: Its principles and practice. Grune & Stratton, New York. Oster, G .D. & Gould, P. (1987). Using Drawings in Assessment and Therapy. Brunner/ Mazel Inc., New York, New York. Petti, T .A . (1978). Depression in hospitalized child psychiatry patients. Journal of the American Academy of Child Psychiatry, 17, 49-59. Pitman, E.J.G. (1937). Significance tests which may be applied to samples from any populations. Statist. Soc, 4, 119-130. Poznanski, E. O., Grossman, J.A., Buchsbaum, Y., Benegas, M . , Freeman, L. , & Gibbons, R. (1884). Preliminary studies of the reliability and validity of the Children's Depression Rating Scale. Journal of the American Academy of Child Psychiatry. 23, 191-197. Puig-Antich, J., Lukens, E., Davies, M , Goetz D., Brennan-Quattrock, J., & Todak, G. (1985). Psychosocial functioning in prepubertal major depressive disorders I. Archives of General Psychiatry, 42, 500-507. Pynoos, R. & Eth, S. (1986). Witness to violence: The child interview. Journal of the American Academy of Child Psychiatry. 25 (3). 306-319. Reich, T., Rice, J., & Mullaney, J. (1986). Genetic risk factors for the affective disorders. Suicide and depression among adolescents and young adults, Washington, DC, 79-103. Reinherz, H. Z., Frost A. (1991). Changing faces. Cortv Health. Oct. Vo 43 Reynolds, W.M., Coats, K. I. (1986). A comparison of congnitive-behavioral therapy and relaxation training for the treatment of depression in adolescents. Journal of Consulting & Clinical Psychology. 54 (5). 653-660. Reynolds, W.M., & Stark, K.D.Q986). Self-control in children: A multimethods examination of treatment outcome measures. Journal of Abnormal Child Psychology. 14. 13-23. Reynolds, W.M. (1991). Efficacy of the SIQ for the identification of suicidal youth. Annual meeting of the American Psychological Association. San Fancisco. Reynolds, W.M. (1992). Internalizing disorders in children and adolescents. John Wiley & Sons, Inc., New York. Riley, S. (1994). Rethinking adolescent art therapy treatment. Journal of Child and Adolescent Group therapy. Vol 4(2). 81-97. Rhyne, J. (1973). The gestalt art experience. Brooks/ Cole, Monterey, CA. Scheidlinger, S. (1985). Group treatment of adolescents: an overview. American Journal of Orthopsychiatry, 55. 102-111. Scheffe, H. (1943). Statistical inference in the non-parametric case. Ann. Math. Statist., 14, 305-332. Shaw, J. (1988). Childhood depression. Medical Clinic of North America. 72, 831-845. Smith, K., Crawford, S. (1986). Suicidal behavior in high-school students. Suicide and life-Threatening Behavior, 16, 313-325. Spitz, R.A. & Wolf, K . M . (1946). Anaclitic depression: II, An inquiry into the genesis of psychiatric conditions in early childhood. Psychoanalytic Study of the Child. 2, 313-347. Springer, J.F., Phillips, J.L. (1992). A creative therapy program for children in families affected by abuse of alcohol or other drugs. Journal of Community Psychology, 55-74. Stark, K.D., Reynolds, W.M. & Kaslow, N.J. (1987). A comparison of the relative efficacy of self-control theory and behavioral problem solving therapy for depression in children. Journal of Abnormal Psychology, 15, 91-113. Stark, K.D., Reynolds, W.M. & Kaslow, N.J. (1991). Assessment of depressive symptomology in school children: An exploration of variables that mediate rater variance. Unpublished manuscript. Tibbetts, T. J., Stone, B. (1990). Short-term art therapy with seriously emotionally disturbed adolescents. Arts in Psychotherapy. Sum Vol 17 (2). 139-146. Ury, H. (1967). In response to Noether's letter, "Needed - a new name". American Statistician. 21 (4). 53. Virshup, E. (1975). Latency group art therapy: Teaching socialization skills through art. Child Welfare. 54. 624-644. Walsh, S.M. (1993). Future images: An art intervention with suicidal adolescents. Applied nursing Research. 6 (3). 111-118. Weiler, E . , & Weiler, R. (1990). Depressive disorders in children and adolescents. In: Garfinkel, B., Carlson, G., Weiler, E. , editors. Psychiatric disorders in children and adolescents. Philadelphia: WB Saunders Co. Whitaker, A., Johnson, J., Schaffer, D., Rapoport, J.L., Kalikow, K., Walsh, B.T., White. K., & Richard, A. (1971). Art counseling in an educational setting: Self-concept change among pre-adolescent boys. Journal of School Psychology, 9, 218-225. Worchel, F.F., Hughes, J.N., Hall, B.M., Stanton, S.B., Stanton, H , & Little, V.Z. (1990). Evaluation of subclinical depression in children using self, peer, and teacher report measures. Journal of Abnormal Child Psychology. 18. 271-282 Whitaker, A., Johnson, J., Shafer, D., Rapoport, J.L., Kalikow, K., Walsh, B.T., Davies, M . , Braiman, S. & Dolinsky, A. (1990). Uncommon troubles in young people: Prevalence estimates of selected psychiatric disorders in a non-referred adolescent population. Archives of General Psychiatry, 47. 487-496. 95 Winter, B .F . (1971). Statistical principles in experimental design. M c G r a w - H i l l , New York. Wolf, R. (1973). Art therapy in the elementary school setting. American Journal of Art Therapy. 1. 1-20. Wolfe, V . V . , Finch, A . J . , Sayor, C.F. , Blount, R . L . , Pallmeyer, T P . , & Carke, D.J. (1987). Negative affectivity in children: A multitrait-multimethod investigation. Journal of Consulting and clinical Psychology, 55, 245-250. 96 Table 1 Demographic Data for ail Groups Demographic Treatment Individual Group Control n 5 5 10 Age M 14.00 14.20 14.30 Sex of Participants: (%) Boys (%) Girls (n-=5) 100% (n=5) 100% (n=2) 20% (n=8) 80% Ethnicity of Participants: Caucasian Asian African American Aboriginal Other (n=5) 100% (n=4) 80% (n=l) 20% (n=9) 90% (n=l) 10% Family Structure: Both Biological Parents Single / Divorced Parents, lives with mother Single / Divorced Parents, lives with father Stepfamily Foster Family Widowed Parent (n=5) 100% (n=2)40% (n=2) 40% (n=l) 20% (n=2) 20% (n=3) 30% (n=l) 10% (n=2) 20% (n-2) 20% Socioeconomic Status: Low Middle High (n=2) 40% (n=3) 60% (n=l) 20% (n=2) 40% (n=2) 40% (n=2) 20% (n=6) 60% (n=2) 20% Setting: Kitsilano Mental Health Team Surrey Central Mental Health Team (n=5) 100% (n=5) 100% (n=4) 40% (n=6) 60% 97 Table 2 Descriptive Statistics for Pre and Post Tests Pre - Test Group N Mean Std.Deviation Measure Childrens Individual 5 20.6 5.9 Depression Group 5 14.2 2.3 Inventory Control 10 17.4 7.2 Total 20 17.4 7.2 Child Individual 5 43.6 17.0 Behavioral Group 5 48.6 34.1 Checklist Control 10 60.9 22.2 Total 20 53.5 24.5 Individual 5 12.0 6.4 Stonybrook Group 5 19.6 14.0 Control 10 24.8 7.8 Total 20 20.3 10.4 Post - Test Measure Childrens Individual 4 12.3 6.7 Depression Group 5 8.0 5.0 Inventory Control 10 15.4 6.0 Total 19 12.8 6.4 Child Individual 4 30.8 26.6 Behavioral Group 5 32.4 23.5 Checklist Control 10 58.8 18.4 Total 19 46.0 24.6 Individual 4 7.0 9.0 Stonybrook Group 5 15.6 14.1 Control 10 23.5 7.2 Total 19 18.0 11.4 98 Table 3 Analysis of Variance (ANOVA) for Pre and Post Tests Sum of Mean Pre-Test Group Squares df Square F Sig. Childrens Between Groups 102.4 2 51.2 1.40 0.27 Depression Within Groups 620.4 17 26.5 Inventory Total 722.8 19 Child Between Groups 1157.7 2 578.9 0.96 0.40 Behavioral Within Groups 10259.3 17 603.5 Checklist Total 11417.0 19 Between Groups 549.4 2 274.7 3.13 0.07 Stonybrook Within Groups 1492.8 17 87.8 Total 2042.2 19 Post-Test Childrens Between Groups 184.0 2 92.0 2.67 0.10 Depression Within Groups 551.2 16 34.4 Inventory Total 735.2 18 Child Between Groups 3493.4 2 1746.7 3.79 0.05* Behavioral Within Groups 7377.6 16 461.1 Checklist Total 10870.9 18 Between Groups 815.2 2 407.6 4.33 0.03* Stonybrook Within Groups 1505.7 16 94.1 Total 2320.9 18 * The mean difference is significant at the 0.05 level. 99 Table 4 Scheffe Post - Hoc Comparisons of Groups Mean Dependent Difference Std. Error Sig. Variable (I) Groups (J) Group (I-J) Group -1.7 14.4 0.99 Child Individual Control -28.1 12.7 0.12 Behavioral Individual 1.7 14.4 0.99 Checklist Group Control -26.4 11.8 0.11 Posttest Individual 28.1 12.7 0.12 Control Group 26.4 118 0.11 Group -8.6 6.5 0.44 Individual Control * -16.5 5.7 0.04* Stonybrook Individual 8.6 6.5 0.44 Posttest Group Control -7.9 85.3 0.36 Individual * 16.5 5.7 0.04* Control Group 7.9 5.3 0.36 * The mean difference is significant at the 0.05 level. 100 Table 5 Before and After Outcome Measures Within Treatment Groups Psychological Individual Group Control Test Children's Depression Inventory t(df=3)=2.87, p=0.03* t(df=4)=2.39, p=0.04* t(df=9)=0.98, p=0.18 Child Behavior Checklist t(df=3)=3.33, p=0.02* t(df=4)=1.73, p=0.08 t(df=9)=0.072 p=0.25 Stonybrook Psychiatric Checklist t(df=3)=0.95, p=0.20 t(df=4)=1.32, p=0.13 t(df=9)=0.098 p=0.18 The mean difference is significant at the 0.05 level. 101 Table 6 Independent Samples T-Test Levene's Test for Equality of T-test for Equality of Variances Means F Sig. t df Sig. (2-tailed) Chidrens Depression Equal variances assumed 0.011 0.918 -2.034 17.000 0.058 Inv.- Posttest Equal variances not assumed -2.036 16.853 0.058 Childrens Behavioral Equal variances assumed 0.550 0.468 -2.834 17.000 0.011 * Checklist -Posttest Equal variances not assumed -2.798 15.271 0.013 Stonybrook -Posttest Equal variances assumed 3.070 0.098 -2.574 17.000 0.020 * Equal variances not assumed -2.505 12.673 0.027 * The mean difference is significant at the 0.05 level. 102 Figure 1.1 Pre- and Post-Test Means for Children's Depression Inventory 103 Fi2ure 1.2 Pre- and Post-Test Means for Child Behavior Checklist 104 ure 1.3 Pre- and Post-Test Means for Stonybrook Psychiatric Checklist 105 Figure 1.4 House Picture Before Individual Art Therapy Treatment 106 Figure 1.5 House Picture After Individual A r t Therapy Treatment 107 Fieure 1.6 Tree Picture Before Individual Art Therapy Treatment 108 Figure 1.7 Tree Picture After Individual Art Therapy Treatment 109 Figure 1.8 Person Picture Before Individual Art Therapy Treatment 110 Figure 1.9 Person Picture After Individual Art Therapy Treatment I l l Figure 2.0 House Picture Before Group Art Therapy Treatment 112 Figure 2.1 House Picture After Group Art Therapy Treatment 114 Figure 2.3 Tree Picture After Group Art Therapy Treatment 115 Figure 2.4 Person Picture Before Group Art Therapy Treatment 116 Figure 2.5 Person Picture After Group Art Therapy Treatment 117 Figure 2.6 House Picture Before 8 Week Control Period 118 Figure 2.7 House Picture After 8 Week Control Period 119 Figure 2.8 Tree Picture Before 8 Week Control Period 120 Figure 2.9 Tree Picture After 8 Week Control Period 121 Figure 3.0 Person Picture Before 8 Week Control Period 122 Figure 3.1 Person Picture After 8 Week Control Period 123 Appendix A Letter of Contact Regarding Research Project T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A Dear School Counsi'lor/GVMHS Therapist, Department of Counselling Psychology Faculty of Education 2125 Main Mall ^INFORMATION S H E E T - A R T T H E R A P Y R E S E A R C H PROTECT Vancouver, B.C. Canada V6T 1Z4 Tel: (604) 822-5259 Fax: (604) 822-2328 As you know, when youth and children are experiencing difficulties, it can be very helpful to work through these in a therapeutic environment. A Greater Vancouver Mental Health Service team may be able to provide this support to a child and family. We offer a broad range of services, including individual, family and group therapies. I am a Youth and Family therapist at Greater Vancouver Mental Health Service (GVMHS), Kitsilano Mental Health Team, and am a Master of Arts Degree candidate in Counseling Psychology at the University of B.C. I am researching the degree to which art therapy helps children who are suffering from symptoms of depression, and am currently accepting referrals of participants in this study from other GVMHS therapists and from School Counselors. The project will involve three groups of .5-7 individuals, ages 13-15, and their parents. The first group will take part in Group Art Therapy, and the second group will receive Individual .Art Therapy at the Kitsilano Team. A third group will act as a control group and will be made up of individuals who are' on any GVMHS team waitlist. I will see those participants at whichever team they are referred to (NOTF.: no one will be part of the control group if needing urgent service). I will use 3 assessment tools prior to the start of art therapy and after the 8 therapy sessions are completed to measure any improvements which might be a result of receiving art therapy. Participants from the control group will be assessed, but not receive art therapy. However, the participants from the control group may receive art ' therapy as part of treatment once a therapist is available and given that the treatment approach is available. For participants in the two groups receiving art therapy, the time commitment is 10 hours per child: eight 1-hour art therapy sessions and two 1-houi assessment tool sessions. A psychiatric assessment (one additional hour) may be giver, by a team member if deemed helpful by the therapist arid family to determine what, if any, additional services are recommended. There is also a time commitment for the parents, of 2 hours, one before art therapy begins and one after the complete art therapy process ends. For participants from the control group, the time commitment is 2 hours. 1 would also like to photograph eadi participants' art work ro show slides as part of my thesis (without naming the individuals) and to place a photograph on the health record of each participant. At the end of the 8 sessions, each participant may take her/his art work home. If you believe an individual would benefit from this therapy, please discuss this with the family and make a referral to me. I have provided a similar information sheet for you to share with the parents of any student you refer tc the project. I would be happy to discuss the project and/or potential referrals with you. Yours truly, Michele Hucul. B.A., M.A. (Candidate) Family & Child Therapist Kitsilano Mental Health Team Telephone: 736-2381 124 Appendix B • Letter to Prospective Client >' T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A Department of Counselling Psychology Faculty of Education 2125 Main Mall Date: : Vancouver, B.C. Canada V6T 1Z4 Tel: (604) 822-5259 )ear Participant, Fax: (604) 822-2328 Art Therapy Research Project I am a Youth and Family therapist at Greater Vancouver Mental Health Service (GVMHS), Kitsilano Mental Health Team, and am a Master of Arts Degree candidate in Counseling Psychology at the University of B.C. As part of my final work, I am researching the degree to which art therapy helps children who are suffering from symptoms of depression. I hope you will participate in this project and want you to have the following information to help you make an informed decision. • You have a choice about taking part in the research; you do not have to participate if you do not want. There is no financial compensation involved in participating. • You can receive appropriate services from GVMHS without partitipating in the research project. • You may change your mind about participating at any time'during the research. You will still be able to receive service from GVMHS. • GVMHS and UBC must comply with the Freedom of Information and Protection of Privacy Act of BC. This means that we have a legal obligation to protect your privacy. • Any information from the project that is published will not identify you by name. • You can talk to the Director of the Kitsilano Mental Health Team (736-2881) or my thesis supervisor, Dr. John Allan, (Department of Counseling Psychology, Faculty of Education; U.B.C.; 822-4625) if you have any questions about the project. • You may keep a copy of this consent form for your information. Description of the Research Project: I will be selecting participants on a referral from other GVMHS therapists and from School Counselors. The project will involve three groups of 5-7 individuals, ages 13-15, and their parents. The first group will take part in Group Art Therapy, and the second group will receive Individual Art Therapy at the Kitsilano Team. A third group will act as a control group and will be made up of individuals who are on any GVMHS team waitlist. I will see those participants at whichever team they are referred to (NOTE: no one will be part of the control group if needing urgent service). I will use 3 assessment tools (see "Description of the Assessment Tools" section) prior to the start of art therapy and after the 8 therapy sessions are completed to measure any improvements which might be a result of receiving art therapy. Participants from the control group will be assessed, but not receive art therapy. However, the participants from the control group may receive art therapy as part of their treatment once a therapist is available and given that the treatment approach is available. 1 of 2 126 Appendix C Letter to Parent of Prospective Client Dear Parent(s), INFORMATION SHEET - ART THERAPY RESEARCH PROTECT When youth and children are experiencing difficulties, it can be very helpful to work through these in a therapeutic environment. A Greater Vancouver Mental Health Service team may be able to provide this support to your child and family. We offer a broad range of services, including individual, family and group therapies. I am a Youth and Family therapist at Greater Vancouver Mental Health Service (GVMHS), Kitsilano Mental Health Team, and am a Master of Arts Degree candidate in Counseling Psychology at the University of B.C. I am researching the degree to which art therapy helps children who are suffering from symptoms of depression, and am currendy accepting referrals of participants in this study from other GVMHS therapists and from School Counselors. The project will involve three groups of 5-7 individuals, ages 13-15, and their parents. The first group will take part in Group Art Therapy, and the second group will receive Individual Art Therapy at the Kitsilano Team. A third group will act as a control group and will be made up of individuals who are on any GVMHS team waitlist. I will see those participants at whichever team they are referred to (NOTE- no one will be part of the control group if needing urgent service). I will use 3 assessment tools prior to the start of art therapy and after the 8 therapy sessions are completed to measure any improvements which might be a result of receiving art therapy. Participants from the control group will be assessed, but not receive art therapy. However, the participants from the control group may receive art therapy as part of treatment once a therapist is available and given that the treatment approach is available. For participants in the two groups receiving art therapy, the time commitment is 10 hours per child: eight 1-hour art therapy sessions and two 1-hour assessment tool sessions. A psychiatric assessment (one additional hour) may be given by a team member if deemed helpful by the therapist and family to determine what, if any, additional services are recommended. There is also a nine commitment for the parents, of 2 hours, one before art therapy begins and one after the complete art therapy process ends. For participants from the control group, the time commitment is 2 hours. I would also like to photograph each participants' art work to show slides as part of my thesis (without naming the individuals) and to place a photograph on the health record of each participant. At the end of the 8 sessions, each participant may take her/his art work home. As your child's school counselor has explained, she/he has referred you to our service. 1 will be contacting you to follow up on this referral to see if you would like to receive GVMHS service and/or participate in this study. I hope you will participate in this project and look forward to discussing it with you. Yours truly, Michele Hucul, B.A, M.A (Candidate) Family & Child Therapist Kitsilano Mental Health Team Telephone: 736-2881 127 Appendix D Demographic Data Sheet Demographic Data Sheet 1. Date: 2. Child's Name: 3. Guardian's Name: 4. Child's Date of Birth: 5. Sex of Child: a. Male b. Female 6. Child's Ethnicity: a. Caucasian b. Asian African c. American d. Aboriginal e. Indo-Canadian f. Other Family Structure: a. Child lives with both biological parents in household b. Single/Divorced parents: Child lives with mother c. Single/Divorced parents: Child lives with father d. Stepfamily (parent has remarried) e. Foster family f. Widowed parent: Child lives with mother g. Widowed parent: Child lives with father Family's Socioeconomic Status: a. Low (under 25,000 per year) b. Medium (25,000 - 45,000 per year) c. High (over 45,000 per year) Location of Mental Health Service: a. Kitsilano Mental Health Team b. Surrey Central Mental Health Team Appendix E 128 Children's Depression Inventory Name: Age: Birthdate: Grade in school: Sex: Today's date: CDI | | | M H S Maria Kovacs, Ph.D. Kids sometimes have different feelings and ideas. This form lists the feelings and ideas in groups. From each group of three sentences, pick one sentence that describes you best for the past two weeks. After you pick a sentence from the first group, go on to the next group. There is no right answer or wrong answer. Just pick the sentence ^ that best describes the way you have been recently. Put a mark like this JCnext to your answer. Put the mark in the box next to the sentence that you pick. Here is an example of how this form works. Try it. Put a mark next to the sentence that describes you best. Example: • I read books all the time. • I read books once in a while. • I never read books. When you are told to do so, tear off this top page. Then, pick the sentences that describe you best on the first page. After you finish the first page, turn to the back. Then, answer the items on that page. Remember, pick out the sentences that describe you best in the PAST TWO WEEKS. . -" • • • . * 14120-2060; [in Canada] 65 Ovorloa Boulevard. Suite 210, Toronto. Ontario M4H 1P1. Telephone: (800) 456-3003 IU.S.A.1, (8O0) Kf:i;26&6bYi[Canad^  •^S^^^i^f^!^0t"W^^S Copyright © 1982, Maria Kovacs, Ph.D., © 1991, 1992, Multi-Health Systems. All rights reserved. 129 Appendix E Continued Children's Depression Inventory CDI Item 1 • I am sad once in a while. Q I am sad many times. Q I am sad all the time. Item 2 IZI Nothing will ever work out for me. CTJ I am not sure if things will work out for me. • Things will work out for me O.K. Item 3 • I do most things O.K. • I do many things wrong. [TJ I do everything wrong. Item 4 D I have fun in many things. f~J I have fun in some things. Q Nothing is fun at all. /Item 5 D I am bad all the time. • I am bad many times. L~] I am bad once in a while: Item 6 • I think about bad things happening to me once in a while. D I worry that bad things will happen to me. D I am sure that terrible things will happen to me. Item 7 [TJ I hate myself. Q I do not like myself. ITJ I like myself. Copyright © 1982, Maria Kovacs, Ph.D., © 1991, 1992, Multi-Health Systems, Inc. All rights reserved. Item a (TJ All bad things are my fault. ITJ Many bad things are my fault. • Bad things are not usually my fault. Item 9 Fj] I.do not think about killing myself. CTJ I think about killing myself but I would not do it. LTJ I want to kill myself. Item 10 ITJ I feel like crying every day. • I feel like crying many days. [TJ I feel like crying once in a while. Item II O Things bother me all the time. [TJ Things bother me many times. D Things bother me once in a while. • I like being with people. C3 I do not like being with people many times. ITJ I do not want to be with people at all. Item 13 ITJ I cannot make up my mind about things. L~J It is hard to make up my mind about things. ITJ I make up my mind about things easily. hem 14 • I look O.K. [TJ There are some bad things about my looks. ["J I look ugly. Remember to f i l l out the other side 130 Appendix E Continued Children's Depression Inventory C D I Remember, describe how you have been in the past two weeks Item 15 • I have to push myself all the time to do my school work. [TJ I have to push myself many times to do my schoolwork. L~J Doing schoolwork is not a big problem. Item 16 (TJ I have trouble sleeping every night, rj I have trouble sleeping many nights. ED I sleep pretty well. Item 17 IZ] I am tired once in a while. Cl I am tired many days, rj I am tired all the time. Item 18 Q Most days I do not feel like eating. • ' M a n y days I do not feel like eating. D I eat pretty well. Item I!) D I do not worry about aches and pains. [H I worry about aches and pains many ' times. L7I I worry about aches and pains all the time. Item 20 IZ1 I do not feel alone. Q I feel alone many times. O I feel alone all the time. Copyright© 1982, Maria Kovacs, Ph.D., © 1991, 1992, Multi-Health Systems, Inc. All rights reserved. i*ublished by Multi-Health Systems, Inc., [m'the United Statesl 908 Niagara Falls Boulevard, North Tonawanda, New York 14120-2060; [in Canada) 65 Overlea Boulevard, Suite 210, Toronto, Ontario M4H IP 1. Telephone: (S00) 456-30031U.S.A.], (800)268- 6011 [Canada], (416)424-1700[U.Sj\. or Canada]. hem 21 Cl I never have fun at school. D I have fun at school only once in a while. rj I have fun at school many times. Item 22 D I have plenty of friends. CD I have some friends but I wish I had more. D I do not have any friends. 7 Q My schoolwork is alright. [H My schoolwork is not as good as before. • I do very badly in subjects I used to be good in Item 24 Q I can never be as good as other kids. LI I can be as good as other kids if I want to. Q I am just as good as other kids. Item 25 D Nobody really loves me. [H I am not sure if anybody loves me. FJ I am sure that somebody loves me. Item 2tl D I usually do what I am told. D I do not do what I am told most times. D I never do what I am told. Item 27 D I get along with people. rj I get into fights many times. D I get into fights all the time. S g j M H S Remember to fill out the other side 131 Appendix F Stonybrook Psychiatric Checklist Stony Brook C H I L D S Y M P T O M I N V E N T O R Y - 4: P A R E N T C H E C K L I S T N A M E OF PERSON COMPLETING F O R M D I R E C T , O N S : C H E C K WHICH ^ T . H O BEST DESCRIBES V O U * CHILD'S O V E ^ L B E H . V . O B . « E * C „ T O T H E BEST O F Y O U R ABILITY. C A T E G O R Y A FAILS T O GIVE C L O S E A T T E N T I O N T O DETAILS OR M A K E S CARELESS MISTAKES . . • • . , . . n , T O r , „ T V PAYING A T T E N T I O N T O TASKS OR P L A Y ACTIVITIES 3. nnPS N O T S E E M T O LISTEN W H E N SPOKEN T O D I R E C T L Y N E V E R SOME-TIMES O F T E N HAS D I F F I C U L T Y F O L L O W I N G T H R O U G H ON .NSTRUCTIONS A N D FAILS T O FINISH THINGS IS EASILY DISTRACTED BY O T H E R THINGS GOING ON 9 . is F O R G E T F U L IN D A I L Y ACTIVITIES 1 0 . FIDGETS WITH HANDS OR F E E T OR SQUIRMS IN S E A T H A S DIFFICULTY REMAINING S E A T E D W H E N ASKED T O DO SO „ . , M . . p n . r r OR CLIMBS ON THINGS W H E N ASKED NOT TO DO SO V E R Y O F T E N ©11 994 C H E C K M A T E I I.US. L T D . . P .O. BOX 696. S T O N Y B R O O K . NY 11790-0696. 132 Appendix F Continued Stonybrook Psychiatric Checklist C A T E G O R Y B t>'-VER S O M E , TIMES O F T E N V E R Y O F T E N r 1 9 . LOSES T E M P E R •20. ARGUES WITH A D U L T S 2 I DEFIES OR REFUSES W H A T Y O U T E L L HIM/HER TO DO 22. T H l N r . 5 T O D E L I B E R A T E L Y A N N O Y OTHERS 23. 24. 25 . 26 . B L A M E S OTHERS FOR OWN MISBEHAVIOR OR MISTAKES IS T O U C H Y OR EASILY A N N O Y E D BY OTHERS IS A N G R Y A N D R E S E N T F U L ; T A K E S A N G E R O U T O N OTHERS OR TRIES TO GET E V E N C A T E G O R Y C PLAYS H O O K E Y F R O M SCHOOL 28. 29 . STAYS O U T A T NIGHT W H E N NOT SUPPOSED TO , , P S TO G E T THINGS OR T O AVOID R E S P O N S I B L Y ("CONS- OTHERS) 30. BULLIES, T H R E A T E N S , OR INTIMIDATES OTHERS STARTS PHYSICAL FIGHTS HAS RUN A W A Y F R O M H O M E OVERNIGHT 31. 32 . 33 . HAS S T O L E N THINGS W H E N OTHERS W E R E NOT LOOKING -,4, HAS D E L I B E R A T E L Y D E S T R O Y E D OTHERS' PROPERTY 35 . HAS D E L I B E R A T E L Y S T A R T E D FIRES 36. HAS S T O L E N THINGS FROM OTHERS USING PHYSICAL FORCE 37 . HAS BROKEN INTO S O M E O N E ELSE'S HOUSE. BUILDING. OR CAR 38. HAS USED A w ^ P O N WHEN FIGHTING (BAT. BRICK. B O T T L E . E T C . ) 39 . HAS BEEN P H Y S I C A L L Y C R U E L T O ANIMALS 40. HAS B E E N P H Y S I C A L L Y C R U E L T O PEOPLE 41. HAS B E E N PRFOCCUPIED WITH OR INVOLVED IN S E X U A L ACTIVITY C A T E G O R Y D 42. IS O V E R C O N C E R N E D A B O U T ABILITIES IN A C A D E M I C . A T H L E T I C . OR SOCIAL ACTIVITIES 43. 44. ACTS RESTLESS OR E D G Y 45. IRRITABLE FOR MOST OF T H E D A Y 4.6. E X T R E M E L Y T E N S E OR U N A B L E T O R E L A X DIFFICULTY F A L L I N G A S L E E P OR STAYING A S L E E P COMPLAINS A B O U T PHYSICAL PROBLEMS (HEADACHES. UPSET S T O M A C H . ETC.) FOR WHICH T H E R E IS NO APPARENT CAUSE Appendix F Continued 133 Stonybrook Psychiatric Checklist C A i l i G U K Y E NEVER S U M b -TIMES ul-lhN VfcKY OFTEN 49 SHOWS EXCESSIVE FEAR TO SPECIFIC OBJECTS OR SITUATIONS (ANIMALS. HEIGHTS. STORMS, INSECTS, ETC.) 50 CANNOT GET DISTRESSING THOUGHTS OUT OF HIS/HER MIND (WORRIES ABOUT GERMS OR DOING THINGjLP^REECTLY, ETC.) 51 FEELS COMPELLED TO PERFORM UNUSUAL HABITS (HAND WASHING. CHECKING LOCKS, REPEATING THINGS A SET NUMBER OF TIMES) 52 HAS EXPERIENCED AN EXTREMELY UPSETTING EVENT AND CONTINUES TO BE BOTHERED BY IT 53 DOES UNUSUAL MOVEMENTS FOR NO APPARENT REASON (EYE BLINKING TWITCHING, LIP LICKING. HEAD JERKING, ETC.) 54 MAKES VOCAL SOUNDS FOR NO APPARENT REASON (COUGHING, ' THROAT CLEARING, SNIFFLING, GRUNTING. ETC.) TEGORY G IS DEPRESSED FOR MOST OF THE DAY CATEGORY F -i 55 HAS STRANGE IDEAS OR BELIEFS THAT ARE NOT REAL (CHILD'S FOOD IS POISONED. PEOPLE ARE TRYING TO GET HIM/HER. ETC.) 56. HAS AUDITORY HALLUCINATIONS-HEARS VOICES TALKING TO OR TELLING HIM/HER TO DO THINGS 57 HAS EXTREMELY STRANGE AND ILLOGICAL THOUGHTS OR IDEAS 58 LAUGHS OR CRIES AT INAPPROPRIATE TIMES OR SHOWS NO EMOTION W SITUATIONS WHERE MOST OTHERS OF SAME AGE WOULD REACT 59 DOES EXTREMELY ODD THINGS (EXCESSIVE PREOCCUPATION WITH ™ A S Y FRIENDS. TALKS TO SELF IN A STRANGE WAY. ETC.) SHOWS L I T T L E INTEREST IN (OR E N J O Y M E N T OF) PLEASURABLE ACTrVITIES • 62. 63. 64. 65. 66. HAS RECURRENT THOUGHTS OF DEATH OR SUICIDE FEELS WORTHLESS OR GUILTY HAS LOW ENERGY LEVEL OR IS TIRED FOR NO APPARENT REASON HAS LITTLE CONFIDENCE OR IS VERY SELF CONSCIOUS FEELS THAT THINGS NEVER WORK OUT RIGHT i—— • 67. HAS EXPERIENCED A BIG CHANGE IN HIS/HER NORMAL APPETITE OR WEIGHT (CIRCLE YES OR NO) MO YES 68. HAS EXPERIENCED A BIG CHANGE IN HIS/HER NORMAL SLEEPING HABITS CANNOT SLEEP OR SLEEPS TOO MUCH (CIRCLE YES OR NO) YES 69. HAS EXPERIENCED A BIG CHANGE IN HIS/HER NORMAL ACTIVITY LEVEL OVERACTIVE OR INACTIVE (CIRCLE YES OR NO) YES ™-HAS EXPERIENCED A BIG CHANGE IN HIS/HER ABILITY TO CONCENTRATE (CIRCLE YES OR NO) 1 YES HAS EXPERIENCED A BIG DROP IS SCHOOL GRADES OR SCHOOLWORK (CIRCLE YES OR NO) YES 3 134 Appendix F Continued Stonybrook Psychiatric Checklist CATEGORY H NEVER SOME-TIMES OFTEN VERY OFTEN 72. HAS A PECULIAR WAY OF RELATING TO OTHERS (AVOIDS EYE r n M T ^ T « ™ B A f l A I . FYPRESSIONS OR GESTURES, ETC.) N N R „ F L N T N , » Y " d 0 P I * T P WELL WITH OTHER CHILDREN - . ^ n « T t n IN MAKING FRIENDS .. p F s\o T 1 V P < NO-INTEREST IN OTHER PEOPLE'S FEELINGS 76. HAS A SIGNIFICANT PROBLEM WITH LANGUAGE . 7*7 HAS DIFFICULTY MAKING SOCIALLY APPROPRIATE CONVERSATION V '. 78. TALKS IN A STRANGE WAY (REPEATS WHAT OTHERS SAY; CONFUSES „ , . r "Y—" "'•• nnn WORDS OR PHRASES. ETC.) r 7 9 IS UNABLE TO "PRETEND" OR "MAKE BELIEVE" WHEN PLAYING c v f ' c < « r s / P PREOCCUPATION WITH ONE TOPIC SI. GETS VERY UPSET OVER SMALL CHANGES IN ROUTINE OR SURROUNDINGS , 8 .^ MAKES STRANGE REPETITIVE MOVEMENTS (FLAPPING ARMS. ETC.) 83. HAS STRANGE FASCINATION FOR PARTS OF OBJECTS CATEGORY 1 • 1 84 TRIES TO AVOID CONTACT WITH STRANGERS; ABNORMALLY SHY 85. IS EXCESSIVELY SHY WITH PEERS I IS GENERALLY WARM AND OUTGOING WITH FAMILY MEMBERS AND FAMILIAR ADULTS . . • • *r WHEN PUT IN AN UNCOMFORTABLE SOCIAL SITUATION. CHILD CRIES. FREEZES OR WITHDRAWS FROM INTERACTING CATEGORYJ 88. 90. 92. 93. GETS VERY UPSET WHEN CHILD EXPECTS TO BE SEPARATED FROM HOME OR PARENTS r 8 9 . WORRIES THAT PARENTS WILL BE HURT OR LEAVE HOME AND NOT COME BACK WORRIES THAT SOME DISASTE^ *(GETTING LOST, KIDNAPPED. ETC.) WILL SEPARATE CHILD FROM PARENTS 91. TRIES TO AVOID GOING TO SCHOOL IN ORDER TO STAY HOME WITH PARENT . . . . — WORRIES ABOUT BEING LEFT AT HOME ALONE OR WITH A SITTER AFRAID TO GO TO SLEEP UNLESS NEAR PARENT HAS NIGHTMARES ABOUT BEING SEPARATED FROM PARENT COMPLAINS ABOUT FEELING SICK WHEN CHILD EXPECTS TO BE SEPARATED FROM HOME OR PARENTS 94. 95. WETS BED AT NIGHT 97. WETS OR SOILS UNDERWEAR DURING DAYTIME HOURS. THANK YOU! 135 Appendix G Child Behavior Checklist CHILD BEHAVIOR CHECKLIST FOR AGES 4-16 For office use only ID # CHILD'S NAME SEX AGE ETHNIC • Boy • Girl GROUP OR RACE TODAY'S DATE GRADE IN SCHOOL NOT ATTENDING SCHOOL • CHILD'S BIRTHDATE P l e a s e f i l l o u t t h i s f o r m to r e f l e c t y o u r v i e w o f t h e c h i l d ' s b e h a v i o r e v e n if o t h e r p e o p l e m i g h t n o t a g r e e . F e e l f ree t o w r i t e a d d i t i o n a l c o m m e n t s b e s i d e e a c h i t e m a n d in t h e s p a c e p r o v i d e d o n p a g e 2 . P A R E N T S ' U S U A L T Y P E O F WORK, even If not working now. (Please be specific —tor example, auto mechanic, high school teacher, homemaker, laborer, lathe operator, shoe salesman, army sergeant.} FATHER'S TYPE OF WORK: : MOTHER'S TYPE OF WORK:. THIS FORM FILLED OUT BY: Q Mother (name): . Father (name): LZ3 Other-name & relationship to chili Please list the sports your child most likes to take part In. F o r e x a m p l e : s w i m m i n g , b a s e b a l l , s k a t i n g , s k a t e b o a r d i n g , b i k e r i d i n g , f i s h i n g , e t c . O N o n e a . b. C o m p a r e d to other chi ldren of the s a m e age, about how m u c h time does he/she spend In e a c h ? Don't Know • • • Compared to other children of the same age, how well does he/she do each one? Less Than Average Average More Than Average Dont Know Below Average Average Above Average • • • • • • • • • • • • • • • • • • • • • Please list your child's favorite hobbies , activities, and games , other than sports. For example: s tamps , dolls, books, piano, crafts, s inging, etc. (Do not include listening to radio or TV.) D None C o m p a r e d to other chi ldren of the same age, about how m u c h time does he/she spend in e a c h ? Don't Know • • • Compared to other children of the same age, how well does he/she do each one? Less Than Average Average More Than Average Don't . Know Betow Average Average Above Average • • • • • • • • • • • • • • • • • • • • III. P lease list any organizations, c lubs , C o m p a r e d to other chi ldren of the teams, or groups your chi ld belongs to. s a m e age, how active Is he/she In CD None e a c h ? Don't Know Less Active Average More Active a • • • • h • • • • r. • • • • IV. Please list any Jobs or chores your ch i ld has. For example: paper route, babysitt ing, making bed, etc. (Include both 'paid and unpaid jobs and chores.) tH None C o m p a r e d to other chi ldren of the s a m e age, how well does he/she carry them out? Dont Know Below Average Average Above Average • • • • • • • • • • • • C o p y r i g h t 1 9 8 8 T . M . A c h e n b a c h , U . of V e r m o n t , 1 S P r o s p e c t S t . , B u r l i n g t o n , V T 0 5 4 0 1 U N A U T H O R I Z E D R E P R O D U C T I O N F O R B I D D E N BY L A W 11 -88 Edition PAGE 1 136 Appendix G Continued Child Behavior Checklist V. 1. About how many close friends does your child have? • None • 1 • 2 or 3 • 4 or more (Do not include brothers & sisters) 2. About how many times a week does your child do things with friends outside of regular school hours? (Do not include brothers & sisters) • Les s than 1 D f or 2 • 3 or more VI. Compared to other children of his/her age, how well does your child: Worse About Average Better a. Get along with his/her brothers & sisters? • • • • O Has no brothers or sisters b. Get along with other children? • • • c. Behave with his/her parents? • • • d. Play and work by himself/herself? • • • VII. 1. For ages 6 and older—performance In academic subjects: (If child is not being taught, pi ease give reason) Failing Below average Average Above average a. Reading, English, or Language Arts • • • • b. History or Social Studies • • • • c. Arithmetic or Math • • • • d. Science • • • • Other academic • i i i h j p r l s —fnr o v . e. • • • • ample: computer • • courses, fnrnirjn f. • • language, busi-ness. Do not in- g. • • • • elude gym, shop, driver's ed., etc. 2. Is your child in a special class or special school? • No • Yes-what kind of class or school? 3. Has your child repeated a grade? • No • Yes-grade and reason 4. Has your child had any academic or other problems In school? • No • Yes-please describe When did these problems start? Have these problems ended? • No • Yes —when? Does your child have any illness, physical disability, or mental handicap? • No • Yes-please describe • i What concerns you most about your child? Please describe the best things about your child: PAGE 2 137 Appendix G Continued Child Behavior Checklist B e l o w is a l ist of i t e m s that d e s c r i b e c h i l d r e n . Fo r e a c h i tem that d e s c r i b e s your c h i l d now or within the past 6 months p l e a s e ° K ^ e ,1 . l h e. l t e r TVf « r y true or often true of your c h i l d . C i r c l e the 1 if the i tem is somewhat or sometimes true of your c h i l d . If the i tem is not true of your c h i l d , c i r c l e the 0. P l e a s e a n s w e r a l l i t e m s a s w e l l a s you c a n , e v e n if s o m e d o not s e e m to a p p l y to your c h i l d . 0 = Not True (as far as you know) 1 = S o m e w h a t or S o m e t i m e s True 2 = Very True or Of ten True A c t s too y o u n g tor his/her age A l le rgy (describe) : • 3. A r g u e s a lot 4. A s t h m a 5. B e h a v e s l ike o p p o s i t e s e x 6. B o w e l m o v e m e n t s o u t s i d e toi let 7. B r a g g i n g , boas t ing 8. Can ' t concent rate , can' t pay at tent ion for l o n g 9. C a n ' t get his/her m i n d off c e r t a i n t h o u g h t s o b s e s s i o n s (describe) : • 0 1 2 10. Can ' t s i t s t i l l , res t less , or hyperac t i ve 0 1 2 11. C l i n g s to a d u l t s or too d e p e n d e n t 0 1 2 12. C o m p l a i n s of l o n e l i n e s s 0 1 2 13. C o n f u s e d or s e e m s to be in a fog 0 1 2 14. C r i e s a lot 0 1 2 15. C r u e l to a n i m a l s 0 1 2 16. Crue l t y , bu l l y ing , or m e a n n e s s to o thers 0 1 2 17. D a y - d r e a m s or gets lost in his/her t h o u g h t s 0 1 2 18. Del ibera te l y harms se l f or a t t e m p t s s u i c i d e 0 1 2 19. * D e m a n d s a lot of a t tent ion 0 1 2 20. D e s t r o y s his/her own t h i n g s 0 1 2 21. D e s t r o y s th ings b e l o n g i n g to his/her fami l y or o ther c h i l d r e n 0 1 2 22. D i s o b e d i e n t at h o m e 0 1 2 23. D i s o b e d i e n t at s c h o o l 0 1 2 24. Doesn ' t eat wel l 0 1 2 25. Doesn ' t get a l o n g with o the r c h i l d r e n 0 1 2 26. Doesn ' t s e e n i to feel gui l ty after m i s b e h a v i n g 0 1 2 27. Eas i l y j e a l o u s 0 1 2 28. E a t s or d r i n k s th ings that are not f b o d -don't i n c l u d e s w e e t s (descr ibe) : 0 1 2 29. F e a r s ce r ta in a n i m a l s , s i t u a t i o n s , or p l a c e s , o ther than s c h o o l (descr ibe) : 30. F e a r s g o i n g to s c h o o l 0 1 2 31. 0 1 2 32. 0 1 2 33. 0 1 2 34. 0 1 2 35. 0 1 2 36. 0 1 2 37. e 1 2 . 38. 0 1 2 39. 0 1 2 40. 0 1 2 41. 0 1 2 42. 0 1 2 43. 0 1 2 44. 0 1 2 45. 0 1 2 46. 0 1 2 47. 0 1 2 48. 0 1 2 49. 0 1 2 50. 0 1 2 51. 0 1 2 52. 0 1 2 53. 0 1 2 54. 0 1 2 55. 56. 0 1 2 0 1 2 0 1 2 bad F e e l s he/she h a s to be per fec t F e e l s or c o m p l a i n s that no o n e loves him/h F e e l s o t h e r s are out to get him/her F e e l s w o r t h l e s s or in fer ior G e t s hurt a lot, a c c i d e n t - p r o n e G e t s in many f i g h t s G e t s t e a s e d a lot H a n g s a r o u n d w i t h c h i l d r e n w h o get in t roub le H e a r s s o u n d s or v o i c e s that aren't there (descr ibe) : . Impuls i ve or a c t s w i t h o u t t h i n k i n g N e r v o u s m o v e m e n t s or t w i t c h i n g (descr ibe) : ' N i g h t m a r e s T o o fearfu l or a n x i o u s Over t i red c a u s e : a. A c h e s or p a i n s b. H e a d a c h e s c . N a u s e a , f e e l s s i c k d . P r o b l e m s w i t h e y e s (descr ibe) : e. R a s h e s or o the r s k i n p r o b l e m s f. S t o m a c h a c h e s o r c r a m p s g. V o m i t i n g , t h r o w i n g u p h. O ther (descr ibe) : Please see other side 138 Appendix G Continued Child Behavior Checklist 0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True 0 1 0 1 0 1 0 1 0 1 0 1 0 1 2 0 1 2 57. 58. 61. 62. 63. 64. 65. 66. Physicaly attacks people Picks nose, skin, or other parts of body (describe): 59. Plays with own sex parts in public 60. Plays with own sex parts too much Poor school work Poorly coordinated or clumsy Prefers playing with older children Prefers playing with younger children Refuses to talk Repeats certain acts over and over; compulsions (describe): 67. Runs away from home 68. Screams a lot 69. Secretive, keeps things to self 70. Sees things that aren't there (describe): 71. Self-conscious or easily embarrassed 72. Sets fires 73. Sexual problems (describe): 74. Showing of  or clowning 75. Shy or timid 76. Sleeps less than most children 77. Sleeps more than most children during day and/or night (describe): 78. Smears or plays with bowel movements 79. Speech problem (describe): . 80. Stares blankly 81. Steals at home 82. Steals outside the home 83. Stores up things he/she doesn't need (describe): 1 84. Strange behavior (describe):. 85. Strange ideas (describe): 86. Stubborn, sulen, or irritable 87. Sudden changes in mood or feelings 88. Sulks a lot 89. Suspicious 90. Swearing or obscene language 91. Talks about kiling self 92. . Talks or walks in sleep (describe): 93. Talks too much 94. Teases a lot 95. Temper tantrums or hot temper 96. Thinks about sex too much 97. Threatens people 98. Thumb-sucking 99. Too concerned with neatness or cleanliness 100. Trouble sleeping (describe): 101. Truancy, skips school 102. Underactive, slow moving, or lacks energy 103. Unhappy, sad, or depressed 104. Unusualy loud 105. Uses alcohol or drugs for nonmedical purposes (describe): 106. Vandalism 107. Wets self during the day 108. Wets the bed 109. Whining 110. Wishes to be of opposite sex 111. Withdrawn, doesn't get involved with others 112. Worrying 113. Please write in any problems your child has that were not listed above: PLEASE BE SURE YOU HAVE ANSWERED ALL ITEMS. UNDERLINE ANY'YOU ARE CONCERNED ABOUT. 139 Appendix H House-Tree-Person Assessment UBC CNPS 588 "JSE - TREE - PERSON Date: r Name: Direct ions: 1. Place in front of the c h i l d a p l a i n piece of white paper, a penc i l with an eraser, and a box of crayons. 2. Ask the c h i l d to draw a house. Remove the paper and ask for a tree and then a person. Post-Test Questions: . A. Place the house i n front of the c h i l d and ask: HI. What can you t e l l me about th i s house? What's going on in the picture? H2. What kind of house i s i t ? (Happy? Friendly?) H3. Whose house i s i t ? . H4. Who would you l i k e to l i v e in the house? HS. I f you could pick a room where would i t be? .. . Has anyone ever hurt the house? H7. What does the house need? B. Remove the house and place the tree down. T l . What can you t e l l me about th i s tree? What's going on i n th i s picture? T2. What kind of tree i s i t ? T3. Where i s the tree? T4. Is i t a healthy tree? ._ T5. Is the tree al ive? If dead: What caused i t to die? W i l l i t come a l ive again? : A Y CDI:588-draw 140 Appendix H Continued House-Tree-Person Assessment - 2 -What season i s i t ? T7. What i s the weather l i k e ? T8. Has anyone ever hurt the t r e e ? T9. What does the t r e e need most? C. Remove the t r e e and p l a c e the person down. PI. What can you t e l l me about t h i s person? (or t h i s p i c t u r e ) ? P2. How o l d i s the person? P3. What i s s/he doing? P4. What i s s/he t h i n k i n g ? P5. What i s s/he f e e l i n g ? P6. Has anyone ever hurt the person? P7. What k i n d of wishes does t h i s person have? * Adapted from: J o l l e s , I. Use of the H-T-P i n a s c h o o l s e t t i n g . In Buck, J . & Hammer, E. (Eds.) (1969). Advances i n the ho u s e - t r e e - p e r s o n technique: V a r i a t i o n s and a p p l i c a t i o n s . Los Angeles: Western P s y c h o l o g i c a l S e r v i c e s . :KY,CDI:588-draw 141 Appendix I Circle of Strength Guided Imagery Activity Make yourself comfortable and if you can allow yourself to close your eyes... taking a deep breath and relaxing. Once again allow yourself take a deep cleansing breathe and enjoy the peacefulness. Letting go of all of the concerns of the day and allowing yourself to be here and in the moment. Now focus on the sensations around your eyes, eyebrows and eyelids, and allow the muscles there to relax a little bit more... feeling more relaxed and calmer. As you feel the relaxation or imagine that you feel it allow that sensation to drift down... down your cheeks... down your chin...and down your neck. Now allow yourself to take another deep cleansing breath. Focus now on the sensations in your shoulders and allow the muscles there to relax a little bit more... and a little bit more. Feel that relaxation drift down your body... down your arms and all the way into your hands to the very end of your fingertips. As you feel these parts relaxing and the muscles releasing become conscious of the sensations in your chest and in your back and feel the muscles there relaxing a little bit more with each breath. Imagine that you feel calm and relaxed while you focus on the muscles in your stomach and feel that sensations drift down your hips and down your legs. Now feel your whole body relaxing all the way into the tips of your toes. Now, take another deep cleansing breath and feel your whole body relaxing. As you relax allow yourself to scan your body and notice the areas that feel tense of sore. Now imagine a warm white healing light overhead and if you like allow that light to shine on those areas. Feel the warmth and comfort of that light. Take a moment now to enjoy that calm feeling within you. If you wish ... as you relax ... you can imagine yourself going on a special and healing journey. Imagine yourself in a place of you very own ... a place that is healing and strengthening to you. You might imagine yourself somewhere in nature ... perhaps by a lake, a stream or the ocean. You might imagine yourself in a forest, a meadow, a mountain or anyplace that is comfortable to you. Now take a look around you and notice all of the sights. You might see trees, flowers, animals, people or anything else that your imagination brings you. Notice what the weather is like and how it feels to be in this healing and strengthening place. Now find a place in your scene that feels comfortable to you ... a place where you may sit or lie down. Imagine you walking over to the comfortable place and walking a circle around it. Imagine you are walking a circle that is your very own circle of strength and then enter into the circle. Notice how it feels to be in the circle of strength ... a place that is your very own. If you like you can imagine a force field all around the circle that goes as far up as you need and can be any color that you wish. This force field protects you ... and no one else can enter into your circle of strength unless you invite them. Take some time to be in the circle and to be with your self. When you are ready have a look around your scene and notice if there are any changes. The weather or the scenery may be different. Perhaps you notice something or someone that you didn't see before. Simply notice any changes at all. Again take some time to be in the moment and focus your attention on how it feels to be there. 142 It is now time to leave your scene ... but you may return to it any time you wish by simply closing your eyes and imagining yourself there. If you wish you may continue to imagine the circle of strength around you throughout your day bringing you inner strength and peace. Now allow yourself to come back to this room by simply opening your eyes and taking a deep breath. 

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