anthroposophic art therapy The development of a professional anthroposophic art therapy monitoring infrastructure for Annemarie Abbing, MSc1; Prof. Dr. P. Sinapius 2; Prof. Dr. H. Gruber 3; Prof. Dr. E. Baars 1 1) University of Applied Sciences Leiden, The Netherlands (Professorship Anthroposophic Health Care) 2) Fachhochschule Ottersberg, Germany (Instituts für Kunsttherapie und Forschung) 3) Alanus Hochschule, Germany (Institut für Kunsttherapie)

Introductie Kunstzinnige Therapie Problemen: Geen uniforme of gestandaardiseerde documentatie methode: kennis en ervaring blijft impliciet moeilijk overdraagbaar waardevolle kennis en praktijkervaring gaat verloren Onduidelijk welke stakeholders welke informatie willen over de therapie en welke kwaliteitseisen worden gesteld Er is geen overzicht van documentatie methoden die gebruikt worden in KT (nationaal en internationaal) Anthroposophic art therapy has been developed in the beginning of the 20th century as a part of anthroposophic medicine. The main therapeutic approaches, therapeutic painting, drawing and sculpturing are used both in somatic and mental healthcare. Anthroposophic art therapists are in the Netherlands educated at a University of Applied Sciences. Besides this education, the knowledge of the art therapist is mainly based on personal experience. There is no uniform or standardized way of documenting the course of treatment. This makes the experience sufficiently explicit, and hardly transferable to colleagues or patients. This makes that valuable knowledge and experience is lost. Within the Evidence Based Medicine development, anthroposophic art therapy also needs to monitor the therapeutic processes and its effects and present data to several stakeholders. However, until now there is no clarity which stakeholders (e.g. colleagues, insurance companies) need what type and what quality of information. In addition a professional monitoring infrastructure for art therapy is lacking. There is no review of documentation methods of art therapy, which have been developed in practice.

Introductie Doelstellingen van het project: 1. Overzicht: documentatiemethoden voor KT 2. Stakeholders: wensen & eisen 3. Vaststellen: kwaliteitscriteria The objectives of this research were: First: to gain overview of the documentation methods, used for art therapy in clinical practice in the Netherlands Second: to gain overview of the needs and requirements of stakeholders with regard to the documented information And the third objective was to establish quality criteria for documentation of art therapy, leading to a ‘first draft’, which is the Follow-up project, with objective number 4: Develop, implement, test and ultimately validate the documentation method. 4. Ontwikkelen – implementeren - valideren: docu methode

Materials & Methods Online questionnaire: 1. Overzicht: documentatiemethoden voor KT Online enquête Literatuur onderzoek 2. Stakeholders: wensen & eisen Stakeholder interviews 3. Vaststellen: kwaliteitscriteria For the first objective, we wanted to identify what already has been developed in terms of documentation methods and also delineate how art therapists document their work in practice. We used: Online questionnaire: Anthroposophic art therapists in the Netherlands, who are connected to the dutch art therapy association We also performed a systematic literature search for developed methods, in the databases of: PubMed Arthedata Der Merkurstab For the second objecitve, we wanted to delineate who the stakeholders are and what needs and requirements exist with regard to documentation. We used stakeholder interviews, with: Art therapists (and colleague care takers) Referring physician or care takers Patient associations Health insurance companies Researchers 3. And then, following from the results: we formulated quality criteria for documentation of (anthoposophic) art therapy, Which eventualy will lead to the development, implementation and validation of the documentation method. 4. Ontwikkelen – implementeren – valideren: docu methode

Resultaten Literatuur onderzoek Gebruikte databases: PubMed, Arthedata, der Merkurstab: 8 artikelen over documentatie en KT Beschreven methoden: 2 over proces documentatie 1 getest, op kleine schaal 3 met focus op diagnostiek van het kunstzinnig werk 2 met focus op het beschrijven van (zelf)reflectie 0 met focus op documentatie for verschillende stakeholders 1 met algemene criteria voor documentatie We searched the databases for ‘documentation’ and ‘art therapy. We included 8 articles. We found few developed documentation methods and even less were tested. The developed methods mainly focused on the development of the therapists themselves, like improving the diagnosic or reflection methods, but were not suitable for use for other stakeholders. However, we did find general quality criteria and these were taken along in the further process. All methods have useful parts, which are also included in the next phase of this research.

Enquête KT-ers. Demografische gegevens Resultaten Enquête KT-ers. Demografische gegevens N = 77

Resultaten Documentatiemethoden in de praktijk Gebruikte vragenlijsten (VR) of metingen: symptomen (ernst, ontwikkeling, evaluatie van het effect) (VR) cliënttevredenheid (VR) fysiologische metingen 50% : geen vragenlijsten of metingen Andere KT-en: m.n. cliënttevredenheid (VR) of alleen VR voor specifieke symptomen Here you see that most therapists use a self developed method. 18 from the 77 therapists use the method from the Dutch art therapy association and a small group uses an other developed method. And 14 therapists use no method at all. We also wanted to know if art therapists use any kind of questionnaires or other measurements to measure therapy effects or client experiences. Over 50% uses nothing. Some therapists use questionnaires. Mainly to establish the severity of symptoms related to burn out, depression, or stress related symptoms,

Resultaten Stakeholders & belangrijkste doelstellingen voor documentatie: Collega- zorgverleners Verwijzer Onderzoekers Kunstzinnig therapeuten Onderwijs / opleiding Verzekeraar Cliënten

Resultaten Stakeholders & belangrijkste doelstellingen voor documentatie: Collega zorgverleners delen van ervaring overdracht data voor KT-onderzoek Verwijzer terugkoppeling Onderzoekers Kunstzinnig therapeuten reflectie op eigen therapie proces delen van ervaring Opleiding/onderwijs delen van kennis en ervaring aanleveren (kost)effecten Zorgverzekeraar verloop behandeling volgen Cliënten informeren

Resultaten Redenen voor documentatie Order of importance (mean ranking) 1. Client development (1,24) 2. Own therapy process (3,12) 3. Client information (3,95) 4. Own records (4,12) 5. Referring physicians (4,16) 6. Therapeutic team (4,78) 7. Colleagues (5,6) 8. Professional association (6,03) 9. Education (6,17) 10. Health insurance companies (6,21) 11. Research (7,5) We asked the therapists what they think are reasons to document the therapeutic process. You see the mentioned reasons on the left. Anthroposophic art therapists document for several stakeholders. In order to: Follow the development of the client during the therapy period. This was mentioned by 98% of the 77 art therapists. In order to keep their own records / administration To inform the client about the therapy proces To communicate with the referring physician To follow their own therapy process To transfer to collleagues To share knowlegde, for education of colleagues or students To consult the team of therapists It is a rule of the professional association To inform health insurance companies To contribute to research Four responders saw no reasons to document the therapy. In addition, we asked them to put the reasons in order of importance. You can see this in the right graph. Documenting for following the clients development was found most important. Documenting for reasearch was stated as the least important. To see a better ranking, we combined to two graphs by taking the quotient of the N and the ranking. For example: many therapists stated ‘client development’ as a reason for documentation. In the raking, it has been put first place (as most important) by most of the therapists. The mean ranking was 1,24. We take the 76 and divide it to 1,24. Then you have a quotient. These outcomes were put in the graph below. You also see that documentation for ‘research’ was mentionned by not many therapists, and those who did mention this, put it low in the ranking. That makes this reason even less importent, according to the art therapists.

Resultaten Domeinen voor elke stakeholder Kt-en zijn gevraagd om voor elke ‘reden voor documentatie’ per stakeholder: de 1-5 meest belangrijke te documenteren onderwerpen te noemen Antwoorden zijn geclusterd tot 5 domeinen Hier nu 1 voorbeeld: stakeholder: KT reason for documentation: to follow own therapy process Documentation for: following own therapy process Therapist attitude Diagnosis (from the client’s art work and observations) Treatment objectives and plan Observations Reflection on interaction In the online questionnaire, art therapists were asked to fill in 1-5 necessary documentation subjects for each stakeholder and or ‘reason for documentation’. In the analysis-phase, the answers were clustered to 5 domains. As an example, you see the clustered domains for one of the stakeholders below. We also did this for the other categories of stakeholders.

Resultaten Stakeholders – wensen & eisen Interviews met de verschillende stakeholdergroepen: Wensen en eisen voor documentatie van KT Kunstzinnig therapeuten: docu methode moet: voldoen aan ‘gereflecteerde intersubjectiviteit’ invulformulieren op computer of op papier hebben maximaal 15 minuten per sessie vragen Zorgverzekeraars: documentatie methode moet: geschikt zijn om vast te stellen of de gedeclareerde behandeling de meest aangewezen behandeling is, gezien de gezondheidsconditie van de verzekerde Art therapists: documentation method must: fulfill the condition of reflected intersubjectivity (methodische stappen met onderbouwing, bijv, hoe je tot diagnose komt) be traceable or understandable have paper forms or fill-in forms on computer (preferable) have a maximum fill-in time of 15 minutes per session Health insurance companies: documentation method: should be suitable to verify whether the charged treatment is the best appropriate treatment, given the health condition of the insured Referring physicians: Verwijzing omzetten in eigen vraag en doel, verslagje na diagnostiche fase Evaluatie aan het eind

Resultaten Stakeholders – wensen & eisen Verwijzende artsen: beschrijven hoe de verwijzing wordt omgezet in eigen vraag en doel, verslagje na diagnostische fase evaluatie van het proces aan het eind Cliënten: de documentatie methode moet: bijdragen aan: de continuïteit, transparantie, toetsbaarheid, kwaliteitsborging en overdraagbaarheid een gestandaardiseerd format hebben objectief zijn in de beschrijvingen observaties en diagnose beschrijven ook advies voor de cliënt bevatten Onderzoekers: documentatie methode moet: uniform, gestandaardiseerd en getest zijn Bij voorkeur gebruik maken van vragenlijsten We interviewed the stakeholders to gain insight in the needs and requirements they connect to the documentation method. I cannot discuss all outcomes, so as an example I will take the patients.

Conclusions ‘Stakeholder-based first draft’ moet voldoen aan de volgende criteria: Format: Gestandaardiseerde formulieren Richtlijnen over ‘hoe te beschrijven’ per item Digitaal (software), met printbare formulieren ‘Flexibele’ documentatie: basis documentatie aanvullende applicaties (voor de verschillende stakeholders) aanvullende vragenlijsten meetmomenten (tijdschema) Based on this preliminairy research, we were able to state criteria for the format as well as the content of the documentation method.

Conclusions ‘Stakeholder-based first draft’ moet voldoen aan de volgende criteria: Inhoud: De vastgestelde domeinen, geoperationaliseerd: met behulp van bestaande docu methoden en door het ontwikkelen van nieuwe items Vragenlijsten (bijv. Cliëntervaringen, therapie effecten, QoL) Criteria for the content are:

Vooruitblik Verdere ontwikkeling van documentatiemethode (plan => proces => product evaluatie) Plan evaluatie (eerste helft 2012) consensus meetings met de stakeholders vormgeven eerste versie + monitoring infrastructuur Proces evaluatie (2012-2013) implementatie en testen op kleine schaal aanpassingen, gebaseerd op resultaten Product evaluatie (2013-2014) implementatie en validatie, op grotere schaal en voor gebruik in psychologische of psychiatrische setting

Hartelijk dank voor uw aandacht Contact: abbing.a@hsleiden.nl