Enhancing Mental Health Care through ‘Therapeutic Art' in Zambia

Background: Mental health care needs a range of inputs to maximise opportunities for effective outcomes. In Zambia, like many developing countries, mental health care is largely limited to pharmacological approaches. In efforts to address this gap a Scottish NGO 'Zambia Therapeutic Art' (ZTA) developed and implemented 'The Zambia Therapeutic Art Course' for Mental Health Professionals (The ZTA Course, MHPs). Objective : To assess the effectiveness and sustainability of The ZTA Course. Methods: A mixed methods approach was used: Evaluation questionnaires were administered to 26 MHPs on completion of the course in Lusaka and Livingstone; of these, 12 were interviewed 6 months post-course. Data was analysed thematically. Results: All 26 MHP trainees, who completed questionnaires, reported an increase in useful skills with 63% reporting improvements in communication and relationship building with patients during the experiential training. All 12 MHPs trainees interviewed 6 months post-course had used Therapeutic Art (TA) skills in their work; 75 % clearly demonstrated their capacity to understand and implement the practice and felt the training was sufficient to do this. The applicability of the course to other health settings and special education was widely noted. Perceived challenges going forward included lack of resources and support systems. Conclusion : The ZTA Course has much potential to improve mental health care in Zambia by addressing the current gap in provision of psychosocial approaches. Increasing patients' ability to communicate with MHPs through using art enabled better therapeutic relationships; improving MHPs understanding of their patients and their difficulties and supporting patients' empowerment


INTRODUCTION Background
WHO global standards of care for mental health recommends a range of inputs to aid treatment and recovery. The dearth of provision for mental health services in Zambia has long been highlighted but not 2,3 yet addressed . In response, ZTA designed and developed a short practice-based course, 'The ZTA Course', with a focus on communication, for MHPs in mental health training and care facilities in 4 Zambia . The content and delivery of the course has been fully approved by the Ministry of Health, management at the Psychiatry Department at University Teaching Hospital (UTH), Chainama Hills Hospital and College of Health Sciences and Livingstone Central Hospital.

Course design
The ZTA Course has been designed in Zambia with 4 years of preparatory and bottom up initiatives to ensure it is fit for purpose and draws from the domains of Art Therapy and Arts in Health (UK) which have a strong evidence bases for improving 5,6,7,8 mental well-being .
Only MHPs/students are trained, so all have a good professional basis on which to add TA as an additional tool. The course is skills-based and designed to be achievable for all MHPs/students; maximising coverage and supporting normalising the use of TA in everyday work. It is brief and can be delivered flexibly -22 hours over 5 days or longer and is delivered in work/study time, avoiding costs and MHPs time away from the workplace. Evaluation of learning and assessment are integral to the course; certificates are provided. research .

General Objective
To assess the effectiveness and sustainability of The ZTA Course.

1.
To identify the impacts of The ZTA Course on participating trainees with reference to TA knowledge and skills and attitude towards patients; and trainees' perceptions of benefits to patients, and to their work practice. 2. To identify whether the course sufficiently prepares trainees to use TA skills in their everyday practice. 3. To explore trainees' perceptions of challenges to sustainability of the course.  To explore further the capacity of The ZTA Course to enable implementation of skills in practice and short-term sustainability, 12 of these participants were interviewed (semi structured interview, audio recorded) by a Zambian health professional after 6 months. This was to reduce response bias and to facilitate better communication of issues relevant to Zambian culture. The number was limited to 12 in respect of workloads of interviewer and interviewees and the need to minimise impacts on service provision. The qualitative interview schedule was designed to: · Get feedback on the efficacy of the design, content and delivery of the course itself in enabling trainees to use skills learned · Discover whether skills learned were being used in practice -barriers and opportunities · Gain trainees' perceptions about how The ZTA Course could be rolled out Thematic analysis of transcripts was undertaken by the authors, in collaboration with the Zambian project partners. An independent Zambian researcher unconnected with the project also reviewed the analysis, verifying the core findings and adding comments.

FINDINGS -FROM EVALUATION QUESTIONNAIRES:
· Impact of The ZTA Course on MHPs knowledge, skills and attitudes · Capacity of the course to enable skills to be used in practice · MHPs perceptions of benefits to patients and work practice

Impact of The ZTA Course on MHPs knowledge, skills and attitudes
Trainees identified increased skills in diagnosing a n d t r e a t m e n t p l a n n i n g ( 4 2 % ) , b e t t e r communication (32%) being more inclusive (21%) and increased ability to motivate patients (5%). They noted changes in their knowledge -that TA enables patients to share experiences (55%), can be used to aid diagnosis (15%), can be used with different groups (15%) and can reduce isolation (4%).
Nearly all (97%) the respondents reported changes in perceptions and feelings about their patients after the training. Changes in attitude included increased ability to develop rapport (37%), more aware of patients' abilities (25%), more aware of them as people (19%) and having more understanding (16%).

Capacity of the course to enable skills to be used in practice
All the respondents (100 %) felt able to use TA skills in their work on completion of The ZTA Course. Perceived challenges were for resources to buy art materials (24%), lack of time to go at the patient's pace (10%) and space (3%).
Seven percent felt the approach was culturally unacceptable (mainly in reference to its use with adults who may feel they are being treated like children).

Perception of benefits to patients
Trainees' perceptions of benefits to patients all point to improving the dignity and value of patients' lives and their recovery. Thirty six percent of the respondents highlighted that TA improved their patients' self-esteem while 25% reported that TA had significant social and communication benefits with staff and other patients (therapeutic relationship). This links with increased acceptance and belonging (22%) and reduced fear and anxiety (11 %).

Perception of benefits to work practice
Nearly half (42%) of the respondents indicated that the training will enable them to combine TA methods with their existing approaches within their current work environment. Increased motivation (8%), better understanding (15%) and trust (19%)

Figure 5: Benefits to MHPs work practice
demonstrate the benefits of improving the therapeutic relationship to MHPs, as well as to clients/patients.

The ZTA Course -Reflections and use of skills in practice
Overall responses to the content, design and delivery of the course and its capacity to enable MHPs to put skills into practice, were very positive.
'It was clear and handled well. It was interesting. The practicals helped us understand. The theory was enough to get the basics and put skills into practice.' (Clinical Officer, Livingstone) 'The course was really great, I enjoyed it, and the fact that it involved us as students actually also doing the art and revisiting our memories from the past …' (MSc Neuropsychology student, UTH) All trainees noted the value of TA in enabling better communication, which aided diagnosis and recovery. A few (less qualified) MHPs felt that more training was needed -suggesting that The ZTA Course could be further tailored to meet the needs of different groups. Many had taken on board the importance of patient choice in using TA 'not all will go for it'. This observation highlights the issue of patient choice in engaging in TA and therefore presents a different model of care/paradigm shift from common MHP experience and practice of compulsory detention and medication (contentious issues for mental health globally). It demonstrates that empowering patients can enable them to contribute to their own recovery and increase their sense of dignity and worth. Engaging in Therapeutic Art as a matter of choice, therefore models a patientled means of recovery and care.  · Providing relief 'She (middle aged woman) had problems with psychosis and anxiety, she had a short temper, she was overreacting, so she really wanted an adjustment on that. I asked her what was on her mind. The implications of the drawing came out more than the oral interview that we had. It is very beneficial. It was helpful in the management in that this patient felt well contented, she felt…she was at easy and peace'. (Psychosocial counsellor Chainama Hills Hospital)

Moving forward -sustainability and scale up
While this study demonstrates the very effective use of skills 6 months following the training, further work is needed for long term sustainability and scale up: systems of recording, follow up and support for trained MHPs ongoing TA practice were identified. Comments that 'time was needed for people to understand what it's about' and that training more MHPs would 'help us all be on the same page and know what we are talking about' showed more work was needed to embed the approach in mental health care.
In addition, challenges in using TA skills reflect the wider issue of scarcity of resources for mental health nationally. The low level of human resourcing means MHPs time for using TA with patients is constrained; the cost of art materials and space was also highlighted. A 'training of trainers' programme was viewed as the best way forward to scale up and embed it in Zambian mental health care systems. Its potential value beyond hospital and clinical settings such as special needs schools, HIV, primary health care, drug and alcohol rehabilitation, recovery from illness and in prisons was widely noted.

Key finding from this study: Enabling better communication through TA strengthens the therapeutic relationship
The capacity for the Therapeutic Art Course to enable changes in the practice of MHPs which improve the therapeutic relationship is strongly indicated in this study; and improving the therapeutic relationship has been identified as a key factor in predicting favourable outcomes. In addition to individual difficulties in communicating due to illness and shame, barriers to communication can be structural. This is due to normalised attitudes and behaviours in relation to hierarchy in medical systems and issues such as stigma that can unwittingly pervade attitudes to mental health throughout populations -including 17 amongst mental health professionals .
MHPs in this study frequently reported a shift in attitude and understanding of their patients following The ZTA Course -and the use of art to communicate can be hypothesised as somehow breaking through these structural elements. They noted that they saw patients more as people, were less judgmental and more tolerant and recognised that they had previously underestimated patients' competencies. This they felt had impacted on their engagement in conversations with them and that following The ZTA Course, rapport was improved and the capacity for trust increased. MHPs' professional development, motivation and morale in their challenging work with people with mental health problems is therefore supported. Relationships are a two-way process, so empowering patients to share their thoughts and feelings through art also helps MHPs to enjoy and be effective in their work -a 'win win' situation.

STRENGTHS AND LIMITATIONS OF THE STUDY
This study is collaborative; ZTA trainers from Scotland, UK and Zambian MHPs, supporting the ongoing working partnership and shows how a training intervention may be effectively evaluated.
The use of mixed methods demonstrated how TA skills are used as well as frequency, while the cohort enabled views about the course, its sustainability and scale up, to be gained from MHPs from different professions and establishments. The study highlights the potential for the Therapeutic Art Course to enhance the therapeutic relationship -of significance to global mental health approaches and academic research on this topic.
Limitations of the study are that questionnaires were carried out by ZTA trainers (Western) at the end of the course so may be biased: future data gathered by Zambian trainers will enable a comparison.

CONCLUSION
The ZTA Course for MHPs has potential to contribute to improving mental health care in Zambia by addressing the deficit of psychosocial approaches to mental health care. The custom-made course The ZTA Course has been found to be effective through its practice-based focus in enabling MHPs to use TA skills in their everyday work and that this is sustainable 6 months post course. Importantly MHPs report that the use of TA seemed to reduce structural and individual barriers to MHP/patient communication and improve the therapeutic relationship; empowering patients, increasing their dignity and supporting recovery as well as increasing skills and motivation for MHPs. To ensure sustainability, ongoing support for trained MHPs, exploring how TA can be embedded in health institutions/systems and resourcing issues need to be addressed. Further research is needed to assess how TA is experienced by patients as well as ongoing collaborative monitoring, evaluation and learning to ensure The ZTA Course continues to achieve its aims, is contextually and culturally appropriate and moves towards functioning independently in Zambia. A plan for scale up through training trainers is envisioned. The applicability of The ZTA Course in the global mental health domain should be explored.

MHPs -Mental Health Professionals
MoH -Ministry of Health TA -Therapeutic Art UTH -University Teaching Hospital ZTA -Zambia Therapeutic Art