Art Therapy, Research and Evidence-based Practice

Andrea Gilroy

• Publisher: SAGE Publications Ltd
• Year: 2006
• Print ISBN: 9780761941149, 9780761941132
• eBook ISBN: 9781446223062
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

`This is an important and topical book coming at a time when there is growing pressure to show evidence of good practice, in order to reassure the prospective client, and to demonstrate financial accountability. It gives valuable guidelines and examples for art therapists. The book is innovative and inspiring, and the author?s enthusiasm shines through. I end with the last line of this topical, readable, relevant book - one that encapsulates its content: ?We need the facts, we need the figures, but we need the stories and the pictures, too? - Therapy Today

`This book makes a major contribution to the field of art therapy by reviewing, in an accessible and informed manner, the issues around the development of research-informed practice. The author offers an overview of different traditions of inquiry that will be of value to practitioners as well as those actually involved in carrying out research? - John McLeod, Tayside Institute for Health Studies, University of Abertay Dundee

`This impressive book is lively, inspiring and innovative. Andrea Gilroy?s energetic enthusiasm for her subject is infectious. She breathes life into the topics of research and EBP. This rich exploration combines a rigorous investigation of the existing literature with intelligent, original and practical suggestions. A thorough, informative approach that challenges existing thinking. This is a must for art therapists - at last a book that places art at the centre of our evidence in a convincingly argued, accessible and rewarding read? - Professor Joy Schaverien PhD

Art Therapy around the world is under increasing pressure to become more "evidence-based". As a result, practitioners now need to get to grips with what constitutes "evidence", how to apply research in appropriate ways and also how to contribute to the body of evidence through their own research and other related activities.

Written specifically for art therapy practitioners and students, Art Therapy, Research & Evidence Based Practice:

" traces the background to EBP

" critically reviews the existing art therapy research

" explains the research process

" links research with the development of clinical guidelines, and

" describes the knowledge and skills needed to demonstrate efficacy.

Drawing on her own experience as a researcher, practitioner and lecturer, Andrea Gilroy looks at the implications of EBP for art therapy and examines common concerns about the threat it may pose to the future provision of art therapy within public services.

Art Therapy, Research Evidence-Based Practice addresses issues which are critical to the future development and even the survival of art therapy. Combining insightful analysis with practical guidance and examples, this is an ideal resource for practitioners and for those in training.

Andrea Gilroy is Reader in Art Psychotherapy at Goldsmiths, University of London.

1	Evidence-based practice: principles, process, policy and proof

Evidence-based Practice (EBP) is a political and social phenomenon particular to our times, its origin and development being intimately related to government policies in the UK’s health, social, justice and educational services. It is characterised by a cycle of activities that seek to guarantee that all interventions are effective and based on rigorous research and to make certain that services are delivered in the most efficient and economic way. Undoubtedly it has the potential to improve practice and ensure the equitable provision of good and effective services across all sectors, including effective but relatively new and innovative practices like art therapy.

All of this seems unquestionably positive but EBP is a contested paradigm and debates about its nature and influence are now embedded in the literatures of healthcare, social welfare, education and the criminal justice system. It has influenced research, practice and provision and, while there is much that could be good, there are fears that some of its effects could be detrimental. This is because EBP’s demand for unequivocal evidence of effectiveness and efficiency has created a situation where one research methodology – the Randomised Controlled Trial (RCT) – is privileged above all others. Perhaps this is not surprising in general healthcare, nor in psychiatry where the medical model and its research methods prevail, but the same standards and criteria have extended to research and practice in other sectors. This privileging of findings from a single method can create pervasive feelings of vulnerability and inadequacy in professions where the availability of such research is limited; these are exacerbated by problems with funding for different kinds of research and inadequate resourcing of other potentially evidence-generating activities through quality-assurance procedures. This suggests that, while EBP could be of enormous benefit to every aspect of state-based provision – including art therapy – its values and systems could also inhibit the development of evidence appropriate to different practices, services and settings.

There are real pressures to provide evidence of art therapy’s clinical and cost effectiveness in all sectors and, in its absence, a potential for service erosion. Art therapy has a developing evidence base, but not one that fits the orthodox framework of EBP. Why not? In order to answer this question it is important to understand exactly what EBP is, how it has been shaped by social, political and economic forces, why it has become so influential, and exactly what is meant by ‘evidence’. In this chapter I describe the paradigm that is EBP and consider its origins and history within the socio-political context of medicine and the effects of government policies on research funding. Situating EBP in a critical context is essential if art therapy’s engagement with it is to be constructive, strategic and meaningful to the discipline.

The history of evidence-based medicine

The last few decades have seen enormous changes in Britain’s public sector. Services are being provided by new, large and specialised organisations, resources are being pooled and functions transferred in an effort to eradicate the divisions between health and social care. This has gone hand in hand with numerous government initiatives: the move to community care; the monitoring of changes in provision and the cost-effective use of resources; the creation of internal markets and a huge increase in quality-assurance procedures. All of this has been coupled with serious concern about the effectiveness and quality of treatments in the NHS and about the interventions and methods of social care, justice and education.

This sets the scene for the development of Evidence-based Medicine (EBM). It began with a text by Archie Cochrane (1972), a British epidemiologist who commented on the worrying variation in practice and outcomes in medicine and the lack of empirical evidence to support many treatments being offered in the NHS. The structure and process of EBM were developed during the early 1980s in Canada through papers that aimed to guide doctors through the critical appraisal of the immense amount of research at their disposal so that they could update and improve their practice and reduce treatment inequities. The Evidence-based Medicine Working Group (1992) at McMaster University in Ontario, Canada, claimed this as a ‘paradigm shift’ in the teaching and practice of medicine. EBM rapidly gathered momentum and by the 1990s was common parlance in international healthcare, being described as an ‘emerging clinical discipline’ that brought ‘the best evidence from clinical and health care research to the bedside, to the surgery or clinic, and to the community … a process of life-long, problem-based learning’ (EBM Editorial, 1995: 5).

EBM has since become central to British and American government care-related policies and a worldwide social movement, spawning a huge industry with many journals, web pages, books, CD Roms and so on. Central to these are collaborative organisations that collate, review and disseminate up-to-date information about the latest research in medicine, namely the Cochrane Collaboration, the NHS Centre for Reviews and Dissemination and the National Institute for Clinical Excellence (NICE, a special health authority). The Cochrane Collaboration is key, being an international organisation that maintains up-to-date information about various healthcare interventions; this has within it the UK Cochrane Centre and a number of specialist groups who focus on specific issues and client populations.

The principles of evidence-based practice

The origins of EBP are in Evidence-based Medicine (EBM); ‘EBP’ and ‘Evidence-based Health Care’ (EBHC) being terms that encompass the transfer of EBM principles to all spheres of work and policy in the public sector. Although EBP is a relatively recent phenomenon it is so significant that it has been described as a ‘social movement’ (Sturdee, 2001). In essence it is a response to the proliferation and variation of practices and outcomes that are accompanied by a lack of supporting research, exacerbated by the need to provide public services for an increasing population with diminishing resources. EBP in all sectors seeks to demonstrate that ‘the procedures adopted by a profession are safe, effective and cost-effective’ (Roth and Fonagy, 1996: 1) through ensuring that practitioners are working to the best of their abilities because they constantly review, update and adjust their practices according to the latest research findings. Service provision should follow the same principle so that the general public can be assured that they are receiving what are demonstrably the most effective interventions, delivered in the most efficient way.

According to the EBM Working Group (1992) and Goldner and Bilsker (1995), the first authors to discuss EBP in psychiatry, the implementation of EBM/EBP required a change from a ‘Traditional Paradigm’ to a new ‘Evidence-based Paradigm’, a paradigm being a framework or model that encapsulates a set of theories, methods, standards and assumptions about what matters, what happens, what the problems are and how they should be addressed. The new EBP paradigm was said to represent a fundamental change in approach to knowledge, its acquisition and implementation in medicine and psychiatry. The ‘Traditional Paradigm’ placed high value on standard approaches: these were that training, experience and expertise were an acceptable basis on which to make decisions about diagnosis and treatment; costs were not necessarily an issue. Value was afforded to clinical authority or expertise that had been accrued over time and, if a senior colleague could not provide an immediate source of expertise then practitioners could turn to textbooks (Richardson, 2001). This ‘traditional’ approach was challenged by the four key principles of the new ‘evidence-based’ paradigm. I think these deserve careful attention so that art therapists can engage with them point by point, and so I first set out each principle in summary form and then offer reflections on how the paradigm is beginning to change.

1. That systematic observations that are reproducible and unbiased can increase confidence in knowledge about practice. The absence of systematic observations must lead to caution about information that is derived from clinical experience and intuition as it may be misleading

This principle suggests that experience and intuition do not ensure continuing best practice. Practice must be based on research that is both replicable and objective. The principle aims to counter difficulties with knowledge that is derived solely from experience; to question decisions made on the basis of intuition; to challenge the ‘received wisdom’ of those whose expertise comes from authority, charisma and longevity in the field; and to act as ‘a healthy corrective to maverick individualism’ (Richardson, 2001: 170).

Freshwater and Rolfe (2004) discuss how EBM and EBP are a mass of contradictions: about authority and no authority, conformity and diversity, practitioner and researcher. They explain how EBP’s attempt to do away with authority and replace it with an egalitarian focus on research originated from senior medical staff, in effect substituting one authority with another and overriding the expertise of the practitioner with the expertise of the researcher who can generate and identify the ‘best’ evidence. EBP seems to be egalitarian, but as diverse sources of ‘evidence’ are welcomed they are also diminished. The language becomes slippery: sometimes ‘evidence’ includes expert opinion and audit findings but, on closer examination means research, or nothing else but RCTs, everything else being deemed ‘weaker’ and without meaning. Nonetheless the opinions of experienced practitioners and the consensus of ‘Expert Panels’ are included in ‘levels of evidence’, experience being considered as credible and reliable evidence when none other is available. Experience and expertise are also considered key to the accurate interpretation and appropriate application of research.

Where does this leave art therapy? With a mixed message. The discipline does have an evidence base but this is derived from various forms of research, from the knowledge and opinion of experienced practitioners and from those the profession deems as ‘experts’. However, for the discipline’s ‘evidence’ to be respected, art therapists from all sectors must challenge the rigidity, authority and power of orthodox EBP. I think this is critical. Why? Because art therapy is a relatively small and new discipline; because we draw on practices and research methods from the arts and social sciences; and because our activities are cross-sectoral and extend beyond the NHS into the social, educational and criminal justice systems. This is not to say that we should abandon RCTs and the other forms of experimental research that EBP requires, rather that art therapy needs to develop a pluralistic evidence base that has meaning for the discipline as a whole.

2. That the study and understanding of disease are necessary, but insufficient, guides for clinical practice

Medicine’s ‘traditional paradigm’ depended on knowing the cause of an illness and its effect, enabling prevention and cure, but the ‘new’ EBP paradigm requires that treatment outcomes be studied too.

I suggested in an earlier paper (Gilroy, 1996) that discomfort with doubt and ambiguity about treatments in psychiatry relate to its origins in medicine – to the cause and effect approach – and to a desire for certainty about ‘what works’, for the absolute knowledge that comes from the positivist approach of the physical sciences (physics, chemistry and biology). Positivism assumes that there is an objective reality that can be reliably observed and measured in a linear fashion, but there is significant debate about whether or not a positivist approach can evaluate the outcomes of psychological and other interventions in an entirely causal way and can adequately investigate the complex experiences of people with mental health problems and disabilities. Outcomes are particularly problematic when the treatment being evaluated cannot be broken down into measurable, component parts because it involves human interaction. Brown et al. (2003) point out that this is so in every area of healthcare, giving the example of nursing that involves social relationships, experience, trust and tacit knowledge. These important aspects of care that affect outcome cannot be addressed in the orthodox EBP framework because they cannot be moulded to fit the favoured research method – RCTs.

3. That the understanding of certain ‘rules of evidence’ is necessary to correctly interpret the literature

This principle is at the heart of EBM/EBP. All clinicians should understand the nature of scientific enquiry in order to discriminate between trustworthy and not so trustworthy research. This refers to the view that only certain kinds of research, that is, certain kinds of knowledge, are admissible as evidence of a treatment’s effectiveness. This means only giving credence to research where certain procedures have been followed, that is:

• there is an explicit hypothesis;
• ‘reliable measures’ have been used;
• subjects have been randomly allocated;
• statistical evaluation has been used;
• there have been large samples;
• blind experimenters have been used;
• the measures have been specific and sensitive to the variable measured.

These procedures are part and parcel of the ‘gold standard’ of research in medicine, the RCT. In EBM/EBP terms a RCT is the only research method that has sufficient rigour to credibly determine whether or not a treatment is effective.

There is of course a huge debate about whether or not RCTs are indeed a ‘gold standard’ and about the relative worth of other quantitative methods and qualitative research in medicine, the psychological therapies and interventions in other sectors. Important research questions are not amenable to investigation through RCTs and there are many areas of theory and practice that do not have sufficient inductive research on which to base RCTs. However, within the medically based EBP framework, RCTs are thought to provide stronger evidence than case series research, which in turn are considered stronger than expert and practitioner consensus about what constitutes best practice (Richardson, 2001). Using this hierarchical structure enables some interventions to be described as empirically ‘supported’, particularly as evidence accrues, but those without such empirical support are considered ‘experimental’ until strong evidence can be gathered.

According to the orthodox EBP paradigm, art therapy is neither empirically supported nor does it have sufficient inductive research on which to base RCTs, despite the fact that a number of RCTs and important qualitative research have been completed in different areas of art therapy practice in America and Britain (see Chapters 8 and 9). It is acknowledged that the absence of outcome-based research does not equate with an absence of knowledge, nor does it infer the ineffectiveness of an intervention ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Biography
• Foreword
• Introduction
• 1 Evidence-based practice: principles, process, policy and proof
• 2 Anxiety, empowerment and strategy
• 3 Developing art therapy guidelines
• 4 Art therapy audit: culture and process
• 5 The methodological debate
• 6 Generating the evidence through qualitative research
• 7 Generating the evidence through quantitative research
• 8 The evidence base for art therapy with adults
• 9 The evidence base for art therapy with children and adolescents
• Endnote
• Appendices Initial Appraisal Checklist Critical Appraisal Checklist
• References
• Index