Blog

The ‘Zambia Therapeutic Art’ Course: An innovative approach to increase the psychological skills of Zambian mental health professionals

LA Hill1, J Pearce1, R Paul2,3, JM Ncheka2,3, E Chiluku 4
1. Independent researchers.
2. University of Zambia Psychiatry Department, Lusaka, Zambia.
3. University Teaching Hospital, Lusaka Zambia.
4. Chainama Hill Hospital, Lusaka, Zambia.
Correspondence: Lesley Ann Hill (lesley@zambiatherapeuticart.org)
Download PDF

Citation style for this article: Hill L A, Pearce J, Paul R, et al. The ‘Zambia Therapeutic Art’ Course: An innovative approach to increase the psychological skills of Zambian mental health professionals. Health Press Zambia Bull. 2018;2(2); pp 4 – 7.

There is currently a skills gap in psychological approaches for mental health care in Zambia. An NGO, ‘Zambia Therapeutic Art’ (ZTA) provides an opportunity to begin to address this through its Therapeutic Art training course. A practice-based course was developed using a ‘bottom-up’ approach. This was delivered in key government mental health services and training institutions and evaluated by trainees in 2015 and 2017. Results showed skills were rapidly acquired by trainees, enabling enhanced professional- patient communications. Trainees reported that using the skills resulted in both better diagnosis and treatment and their attitude to patients. Preliminary findings suggest value in the provision of the ZTA course for mental health professionals, enhancing care and giving patients a voice. A training of trainers programme should be piloted to enable roll out of the course and its sustainability in Zambian Mental Health domains.
Introduction
The WHO Comprehensive Mental Health Action Plan 2013-2020 [1] and The Mental Health and Poverty Project in Zambia (2008) [2] recommend the inclusion of psychological approaches in mental health care. Treatment for mental health patients in Zambia however is significantly under-resourced [3] and largely limited to pharmacological approaches; the lack of opportunities for training in psychological approaches having implications for the well-being and recovery of patients [4].
In light of this gap in training and service provision key mental health service providers; University Teaching Hospital (UTH) Psychiatry Department /The University of Zambia School of Medicine, Chainama Hills College Hospital and College of Health Sciences who are all keen to broaden the range of professional skills and services available, partnered with a Scottish NGO ‘Zambia Therapeutic Art’ (ZTA).
Background                                                                                                                                                                                                                                                                                     What is ‘Therapeutic Art’?
The ZTA conceptualisation of ‘Therapeutic Art’ draws on the key principles of ‘Art Therapy’ theory and practice [5] and the ‘Arts in Health’ movement in the UK [6]. ‘Art Therapy’ and ‘Arts in Health’ are supported theoretically and have a strong evidence base for the treatment and improvement of well-being for people of all ages who experience mental health problems [7] [8]. Therapeutic Art practice involves using art (drawing/painting/clay) alongside a mental health professional either individually or in a group. It is a non-judgmental and unpressured approach which enables expression of thoughts and feelings and is particularly useful where people with mental health problems struggle to verbally communicate their difficulties. Improving communication relieves patients’ isolation and distress and helps mental health professionals to rapidly gain understanding of the causes and nature of their problems, aiding prompt diagnosis and treatment.
The Zambia Therapeutic Art Course
ZTA founders and trainers are experienced Art Therapists and trainers in mental health services in Scotland and registered as ‘Art Therapists’ with the Health Care and Professionals Council (HCPC) in the UK. From 2011 to 2015 they designed, developed and delivered a short practice-based training in Therapeutic Art – ‘The ZTA Course’ – specifically for mental health professionals in Zambia. Initially the approach was one of respectful enquiry to see if Therapeutic Art was relevant or useful in the Zambian context. It therefore started small and initially involved the writer providing art materials for Mental Health patients at Chipata General Hospital (2011) and observing whether the staff and patients found this useful to increasing understandings their predicaments and issues. Its perceived usefulness prompted a 5 day workshop in 2012 for staff and students in using the Therapeutic Art method. This training and all subsequent trainings held each year (2013 in Chipata and 2014 to 2017 in Lusaka) have included trainee and stakeholder feedback to inform ZTA where and how the best impacts of their work could be achieved. Findings showed that in order to embed skills effectively ‘skills practice’ during the course was needed; and ensuring maximum impact suggested targeting mental health professionals and students at the central mental health training and services at the University Teaching Hospital Psychiatry Department, Chainama Hills College Hospital and College of Health Sciences; hence the current 6 week practice based course delivered in Lusaka.
Aims
The aims of this intervention are to introduce Therapeutic Art to Zambian mental health professionals and support its use in practice; and collaboratively shape the training and its provision in pursuit of in-country sustainability. The use of Therapeutic Art in mental health care in Zambia contributes to the broader national and global vision of the need for psychosocial interventions in the care and treatment of mental health patients.
Benefits of the course
Therapeutic Art training rapidly upskills the trainees, building on their existing knowledge and skills; and through its practice based approach enables trainees to independently use Therapeutic Art skills as a new skill in their ‘toolbox’ following the course. The short nature of the course half a day per week over 6 weeks, fits into other work and training commitments and to ensure there is time between sessions for putting skills into practice with clients/ patients. The short course and its structure therefore balances the time needed to acquire new skills effectively and the need to minimise staff withdrawal from busy wards or impinge on other training inputs minimises the impacts of withdrawing hospital staff from their work – in respect of the challenges to staffing levels in mental health care. The course is designed to be accessible for mental health professionals at all levels – ward assistants, mental health nurses, physiotherapists, counsellors, psychologists, doctors, clinical officers, clinical neuropsychology trainees, MSc mental health nurses, and MMed psychiatrists. This increases the opportunity for patients to access Therapeutic Art and provides a commonality of understanding of the approach across all staff levels. Trainees are trained in their normal work/study time and workplace – avoiding expensive training overheads.
Course structure and delivery.
The course is structured as shown below, and was delivered in this format to 30 trainees in 2015 and 32 trainees at UTH and Chainama Hills Hospital in 2017.

 The ZTA course

  • Week 1 One lecture on the background and use of Therapeutic Art; including information on key principles and recording guidelines.
  • Weeks 2-5 ‘Learning through doing’ – ‘Hands on’ practice of Therapeutic Art exercises – adhering to the key principles including roleplays and experience of art making in relation to thoughts and feelings; and how to use these techniques with patients. Using ‘Therapeutic Art’ with patients supported by clinical supervision from trainers.
  • Week 6 Trainees undertake both an evaluation exercise – to consolidate learning and provide feedback for ZTA trainers, and a written assessment – resulting in a graded certificate.

Findings
1. Responses of mental health professionals trained in Therapeutic Art in 2015 and 2017
consistently reported positive benefits.

Positive benefits of using ‘Therapeutic Art’ with mental health patients

  • Increased communication and relationship-building between professionals and their patients, proving of benefit to the quality of care
  • Increased knowledge of the patient; their life history, feelings, strengths and concerns; aiding diagnosis, treatment planning and adherence
  • Patients felt ‘heard’; had their feelings recognised and opportunities to express their views supporting self-advocacy and recovery
  • Art making provided a range of positive effects for patients; accessing memory and feelings, enabling concentration and thinking, aiding relaxation, enabling social activity and providing a distraction from symptoms.

2. A ‘learning by doing’ approach has been found to be the most effective way of increasing skills in a short time frame – the course has been shaped accordingly. ‘The course is the right structure … it gives us a chance to practice the skills and build on them’ (MSc Clinical Neuroscience student UTH 2017).
Limitations
Feedback to date has been gathered internally by ZTA trainers and limited to trainees’ perceptions of the benefits of using Therapeutic Art skills with patients during the practice elements of the course.
Conclusions
Preliminary evaluation of The ZTA Course, which has been shaped to fit with international guidelines and local contextual needs, suggests it is effective in broadening skills and knowledge in the workforce to the benefit of patients and professionals. Building on these preliminary findings, operational research is indicated to ascertain the experience of Therapeutic Art by mental health service users/patients by an independent Zambian researcher, and to assess the use of Therapeutic Art skills by trainees in the longer term. Further, a ‘Training-of-Trainers’ programme should be implemented to build capacity and progress sustainability.
References
1 WHO, “ WHO Comprehensive Mental Health Action Plan 2013-2020,” www.who.int/mental_health/action_plan_2013/en/
2 “The Mental Health and Poverty Project:Mental Health Policy Development and Implementation in Zambia,” www.who.int/mental_health/policy/development/Zambia%20Country%20report.pdf, 2008.
3 Mwape, L “Strengthening the health system for mental health in Zambia; evidence based policy brief,” Zambia Forum for Health Research 2011.
4 Roth, A and Fonaghy P, “What works for whom? A critical review of psychotherapy research”,
New York City: Guilford Press, 1996.
5 British Association of Art Therapy, www.baat.org
6 London Arts in Health Forum, www.lahf.org.uk/resources.
7 Staricoff,R. “Can the arts have a positive effect on health? A review of the medical literature,” Arts Council England, 2004.
8 NICE Guidelines “Psychosis and Schizophrenia in Adults,” http://publications.nice.org.uk/ifp178, 2014.