Trauma Treatment through Art Therapy (TT-AT): a ‘women and trauma’ group in Tanzania

ABSTRACT

Background

In low–middle income countries the number of patients suffering from PTSD (from adult onset trauma) and from complex-PTSD (who have suffered from childhood emotional, physical and sexual abuse, deprivation and domestic violence) is high, but there is a shortage of clinical psychologists. The International Society for Traumatic Stress Studies (ISTSS) has recommended the development of innovative interventions.

Context

At Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania, a number of mental health professionals have been trained in providing Art Therapy as an ‘additional skill’ within their respective professions. In the Department of Psychiatry we have developed a protocol for a short-term Trauma Treatment with Art Therapy (TT-AT).

Approach

Our intervention is focused on the six patients’ needs outlined by ISTSS in the following areas: Emotion Regulation; Relationships; Self-Identity; Gradual Exposure to Trauma; Integration of Trauma; Personal Resources. We have developed six Art Therapy workshops aimed to address each one of these needs. The approach is supportive and non-interpretative.

Outcomes

The intervention was developed at Muhimbili National Hospital with a ‘Women’s Group’ of four patients, who had experienced different types of trauma. All patients attended regularly and reported improvements to their trauma symptoms.

Conclusion

This short-term art therapy intervention was useful with this population, and may be applicable to patients who suffer from a broad range of traumatic experience.

Implication for research

The protocol is described in detail, and can easily be replicated for clinical purposes and research.

Plain-language summary

There is a need for innovative interventions in the field of trauma, especially when the trauma was experienced during childhood (loss, abuse, deprivation and domestic violence). The task force of the International Society for Traumatic Stress Studies have encouraged the development of innovative interventions, recommending that new interventions are focused on patients’ needs rather than on trauma exposure, and should include emotional strengthening interventions. Six psychological needs were outlined by the International Society for Traumatic Stress Studies in the following areas: emotion regulation; relationships; self-identity/self-esteem; gradual exposure to the trauma; integration of the trauma in one’s life; and personal resources. At Muhimbili University of Health and Allied Sciences, in Dar es Salaam, Tanzania, we developed a Group Art Therapy intervention protocol, which was based on six art therapy workshops, plus time for free art making. The intervention was carried out with a group of four female patients who had all experienced different types of trauma, and began with three strengthening workshops: Filling the body outline, to facilitate the safe expression of emotions; A memory of a positive relationship in childhood, to remember positive relationships; and The fantasy of a tree growing in the desert, to cultivate feelings of hope. The next two workshops were focused on a gradual exposure to the trauma, these included: The fantasy of a traumatised child; and The life-line, to integrate positive and negative memories. The final workshop was devoted to strengthening the awareness of personal resources. The four patients all attended regularly and reported improvements to their trauma symptoms at the end of the intervention.

KEYWORDS:

• Trauma
• complex trauma
• refugees
• group therapy
• symbolic expression

Acknowledgements

We thank Dr Frank Masao and Dr Praxeda Swai for referring their patients. We thank Dr Margaret Hogan, Emma Mills and Liz Stone for carefully reviewing the manuscript, and Jordan Potash for giving useful feedback. We are grateful to Bobbi Stoll and to Dr Marian Liebmann for coming to Tanzania and donating their skills in the field of art therapy with trauma. Dr Lucio Luzzatto has reviewed the manuscript and has been an inspiring presence. We thank the four participants in the Art Therapy Group for their commitment and collaborative attitude.

Disclosure statement

No potential conflict of interest was reported by the authors.

Confidentiality and consent

Confidentiality and anonymity are maintained within the paper. All four patients have given informed consent to publish their artwork, words and clinical content.

Additional information

Notes on contributors

P. Luzzatto

P. Luzzatto, Ph.D. Art Psychotherapist, has a background in Philosophy, Education and Comparative Religions. She trained in Art-Psychotherapy at the University of London, Goldsmith College. She then completed a 2-year course in Psychoanalytic Psychotherapy at the Tavistock Institute and a 1-year course in Supervision at the Westminster Pastoral Foundation. Paola Luzzatto worked for 8 years in London (West Lambeth Health Authority), first leading the Art Therapy Open Studio at Tooting Bec Psychiatric Hospital, then offering Individual and Group art therapy at St Thomas’ Hospital. She then worked for 10 years at the Memorial Sloan-Kettering Cancer Center, New York, where she developed the Art Therapy Service for cancer patients. Paola Luzzatto created the 10-week art therapy intervention ‘The Creative Journey’ that received the 2004 Clinical Award from the American Art Therapy Association. She has written a number of articles on her clinical work in professional journals. She has published an Art Therapy Textbook for Italian students; the biography of the artist Susanne Wenger (who built shrines to the Yoruba divinities in Nigeria); and two books for children on world mythology. Paola Luzzatto is now Honorary Lecturer in the Department of Psychiatry and Mental Health, MUHAS, Dar-es-Salaam, Tanzania.

A. Ndagabwene

A. Ndagabwene is Clinical Psychologist in the Department of Psychiatry and Mental Health at Muhimbili National Hospital, (MNH) Dar es Salaam, Tanzania. Alex trained as an educator and his interest shifted and pursued bachelor and master’s degrees in psychology. At the Hospital he provides clinical psychological services to varieties of clients using different psychological approaches including EMDR, CBT, Trauma-Focused Counselling and the Art Therapy Open Studio. His research work focused on the magnitude and determinants of depression among Prisoners and traumatized individuals.

E. Fugusa

E. Fugusa, Clinical Psychologist in the Department of Psychiatry and Mental Health at Muhimbili National Hospital (MNH) Dar es Salaam, Tanzania, has clinical experience in the use of EMDR with traumatized patients.

G. Kimathy

G. Kimathy, Occupational Therapist and Art Therapy Open Studio Expert in the Department of Psychiatry and Mental Health at Muhimbili National Hospital (MNH) Dar es Salaam, Tanzania, has clinical experience with autistic children and their families.

I. Lema

I. Lema is Clinical Psychologist and Assistant Lecturer in the Department of Psychiatry at Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania. Isaac Lema has a clinical training background in teaching and providing psychological and mental health services to individuals with mental health problems and mental disorders. He is an expert and trainer on mental health in the workplace where he has facilitated various topics such as employee wellness, stress management, work-life balance, burnout, vicarious traumatization, time management and productivity, conflict management, anger management, etc. He has facilitated seminars or a workshop to different professionals from both government and private sectors. He has a good experience in helping individuals who have being exposed in a prolonged stressful environment and promoting their mental wellbeing. He is an expert on Art Therapy Open Studio intervention particularly effective in enhancing psychosocial support for different individuals with mental health problems, distress and mental disorders. He has facilitated different art therapy sessions for individuals and groups on various areas including emotional regulation, anger management, trauma and professional self-care. He is a chairperson of Mental Health Association of Tanzania (MEHATA).

S. Likindikoki

S. Likindikoki is Psychiatrist and Lecturer at MUHAS and Attending Clinician at Muhimbili National Hospital (MNH). His practice covers a wide range of people from minor psychosocial problems to severe mental illnesses. His research focuses on gender-based violence, child protection, mental health, non-communicable diseases and bio-behavioural aspect of HIV prevention. Recently, he has been engaging in the research projects aimed at enhancing health system in respect to vulnerable populations such as heroin users, refugees and migrant populations. As the former Head of Department of Psychiatry and Mental Health, he is a seasoned mentor and advisor to trainees and championed the implementation of the competency-based clinical psychiatry training for undergraduate medical students, master of medicine in psychiatry and master of science in clinical psychology. He is a former Fogarty Scholar under Harvard School of Public Health and served as an investigator on several National Institutes of Health-funded projects. He has had multiple collaborative research projects with: Johns Hopkins Bloomberg School of Public Health, American University, Medical University of South Carolina, Columbia University Mailman School of Public Health, London School of Hygiene and Tropical Medicine, and Medical Research Council of South Africa.