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8/13/2019 Towards a Purposeful Ending
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Towards a Purposeful Ending:A study exploring the impact of Dramatherapy on the quality of life of people
living with dementia.
By Rasha Mechaeil - University of Sussex
Alex Graybow & Peter Cobham - Baobab (Creative Arts Therapies)
bstract
The aim of this study was to explore the effects of Dramatherapy on people
living with dementia. The work was a small scale quantitative study carried
out over 12 weeks comparing the experience of a Dramatherapy group with
an activity group. The subjects lived in the same care home and were
randomly assigned to the groups. Audits assessing quality of life measures
were carried out at regular intervals.
The study found that the clients receiving Dramatherapy showed significant
improvements in quantitative measures of attentiveness and engagement
compared with those taking part in the activity group. The results identified
a cumulative benefit which suggests increasingly positive outcomes for longer
term Dramatherapy.
BackgroundIn his 1930 article The Stages of Life,Carl Jung wrote A human being
would certainly not grow to be seventy or eighty years old if this longevity
had no meaning for the species. The afternoon of human life must also have asignificance of its own and cannot be merely a pitiful appendage to lifes
morning.
The need for a purposeful ending is no different for older people who are
living with dementia. It may be that there is a greater need to support and
nurture a sense of acceptance and reconciliation for this group because
dementia not only causes the loss of cognitive functioning, frequently
individuals also experience the loss of their independence and relationships.
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Dramatherapy works with subjective experience. It provides tools for
emotional expression, an opportunity for social interaction and a place for
independence and choice. It can give purpose and meaning in an environment
where this may be lacking. Dramatherapy also focuses on the importance of
contact and connection. It is not based on cognitive ability and so is
particularly appropriate for people living with dementia.Alex Graybow and Peter Cobham, Dramatherapists working for Baobab
(Creative Arts Therapies) had been subjectively evaluating the benefits of
Dramatherapy at Quantum Care. Quantum Care is an organisation providing
residential homes and services for older people across Hertfordshire.
Quantum Care requested that the Dramatherapy work be more formally
evaluated, which led to this project.
MethodTo evaluate the efficacy of Dramatherapy with a group of individuals living
with dementia, we posed the following question: Can Dramatherapy positively
affect mood and social contact for older people with dementia thus improving quality
of life? We set out to measure eight factors we felt pertained to an
individuals quality of life, namely; anxiety, happiness, social contact, bodyposture, levels of confidence, energy, attention and engagement. We set out
to show the immediate effects of Dramatherapy and whether any of these
could be sustained.
Following conversations with Jenny Rusted, an Experimental Psychologist at
the University of Sussex, we agreed that a method similar to a Randomised
Control Trial (RCT) would be used as a tool for the evaluation. The study
differed from a RCT in that although the clients were randomly assigned to
the group, the assessors were not blind to the membership of the groups andtherefore the data collected may have been influenced by preconceptions and
expectations.
Ethical ConsiderationsConsent was obtained from both the clients and their families. The option to
withdraw consent at any time was also given. The consent process was
carried out by the management at the care home.
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ParticipantsThe Dramatherapists spoke with all the residents with dementia on the
chosen unit. This was to establish who would be interested in attending the
Dramatherapy sessions for the purpose of an evaluation. 4 clients
volunteered to attend the group.
The Dramatherapists then ran a familiarisation session with the potential
group members to assess their response and whether the group will be viable
for the evaluation.
A control group was set up, running at the same time as the Dramatherapy
group. The Control Group carried out an activity. To reduce variables, a
similar activity took place each week. 4 clients were randomly chosen from
this group and were assessed in the same way as those attending the
Dramatherapy sessions.
Data GatheringThe assessments were carried out by five assessors, the two
Dramatherapists and three members of staff who facilitated the activity
group. The Dramatherapists ran workshops for the staff carrying out the
assessment to pilot a suitable questionnaire. This allowed for changes to be
made to the questionnaire, facilitating the process and ensuring that the aims
of the evaluation were understood and supported by the lay assessors.
Each assessor completed a questionnaire pre and post each session, rating
each client on the eight factors (anxiety, happiness, social contact, body
posture, levels of confidence, energy, attention and engagement). One
assessor also completed a questionnaire at the mid-point between each of the
sessions regarding all of the client subjects.
The Dramatherapists kept in depth process notes after each session. These
were used to create a more subjective evaluation of the project.
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Data AnalysisThe data analysis and report was prepared by Rasha Mechaeil, Department of
Psychology, Sussex University, with guidance from Jennifer Rusted,Department of Psychology, Sussex University
_____________________________________________________________________
Study designEight older people living with dementia took part in a study investigating the
potential benefits of Dramatherapy. Four of those eight participants were
assigned to a Dramatherapy condition and four acted as control participants,
not engaging in Dramatherapy but involved in normal day centre activities in aregular time slot of similar duration to the Dramatherapy session each week.
There were 12 sessions in total, over a 13 week period. The effects of
therapy were assessed on the basis of eight individual factors, namely,
anxiety, happiness, social contact, body posture, levels of confidence, energy,
attention, and engagement. Assessments were conducted by five assessors,
who each rated each participant on each of the factors pre-session and post-
session. Three of the assessors facilitated the control activity and two of the
assessors ran the Dramatherapy sessions. (assessors 1 and 2). In addition to
the session assessments, one assessor provided an assessment of all
participants on all factors at the mid-point between each of the sessions. Thedata were collated and analysed by researchers at the Department of
Psychology, University of Sussex.
Data descriptionAs is conventional, an alpha level of .05 was employed for all analyses unless
otherwise stated.
Volunteer characteristicsMean age for volunteers assigned to the control and Dramatherapy conditions
is presented in table 1 below.
Group N Mean Age
Control 4 89.5 1.3
Dramatherapy 4 85 8.8
Table 1: mean (SD) age of participants
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An independent measures t-test revealed no significant difference in age
between volunteers in the control group and dramatherapy group [p>.05].
Any treatment effects cannot, therefore, be attributed to age differences
between participants.
Pre-session evaluationsSession 6 is excluded from all analyses due to missing data.
For each of the factors of anxiety, happiness, social contact, confidence, body
posture, energy, attention, and level of engagement, a mixed 2 x 13 (group x
session) analysis of variance (ANOVA) was conducted on pre-sessions to
check for group differences prior to engaging in the sessions. No significant
differences were evident between volunteers assigned to Dramatherapy orcontrol sessions on any of the measures [all, p>.05]. This was true when the
measures recorded by the two assessors who were running the
Dramatherapy sessions were included as well as excluded.
Figures 1 - 8 below present mean pre session scores assigned by assessors
3 - 5 to the control and Dramatherapy groups for each of the 8 factors under
assessment, across the sessions.
Anxiety
Figure 1. Mean (SEM) pre session anxiety over the course of the study
0
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Happiness
Figure 1. Mean (SEM) pre session happiness over the course of the study
Social contact
-
Figure 1. Mean (SEM) pre session social contact over the course of the
study
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Confidence
Figure 1. Mean (SEM) pre session confidence over the course of the study
Body posture
Figure 1. Mean pre (SEM) session scores for body posture over the course
of the study
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Energy level
Figure 1. Mean (SEM) pre session energy levels over the course f the study
Attention
Figure 1. Mean (SEM) pre session attention level over the course of the
study
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Engagement
Figure 1. Mean (SEM) pre session level of engagement over the course of
the study
Cumulative ChangeThe absence of significant differences between participants in pre-session
analyses makes it appropriate to analyze the pre-to-post difference scoresfor each factor to identify change associated with participation in the therapy
session.
For these analyses, sessions were grouped into three phases of four sessions
each with the rationale of identifying cumulative change that is potentially
dissociated by stage of therapy. Sessions were grouped into three stages
comprising sessions 1 4, sessions 5 9, and sessions 10 13 respectively.
Each of the factors under assessment, therefore, was subjected to a 2 x 3
(group x session stage) mixed ANOVA (excluding data provided by assessors
1 and 2)1. Statistically significant changes were revealed for the factors of
attentionand engagement as demonstrated below.
1The same analyses were conducted on the data inclusive of assessments made by
assessors 1 and 2 but yielded no significant findings. It was evident from the raw data that
assessors 1 and 2 tended to provide higher scores in comparison to assessors 3, 4 and 5,
possibly due to greater familiarity of the first two assessors.
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AttentionFigure 9 presents differences in attention between volunteers assigned to the
control group and those assigned to the Dramatherapy group across the three
phases of therapy.
Figure 9. Mean (SEM) pre-to-post differences in attention levels. Stage 1=
sessions 1-4, Stage 2 = sessions 5-9, stage 3 = sessions 10-13.
Results revealed a significant main effect of group [F(1,6)=7.906, p=.03].
This effect is reflected in the positive pre-to-post therapy difference in
volunteers assigned to dramatherapy (figure 9). Moreover, the difference
was not the same through all stages of the programme, as indicated by a
significant group*session stage interaction [F(2,12)=4.620, p=.03].
Multiple independent-measures t-tests (Bonferroni adjusted statistic =
.016) exploring the group*session stage interaction indicated that at stage
three of therapy (sessions 10 13) volunteers who have undergone
Dramatherapy were displaying greater levels of attention relative tovolunteers in the control group [t(6)=-3.703, p=.01].
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EngagementFigure 10 presents differences in levels of engagement between volunteers
assigned to the control group and those assigned to the Dramatherapy group
across the three phases of therapy.
Figure 10. Mean (SEM) pre-to-post differences in engagement levels. Stage
1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.
Results revealed a significant main effect of group [F(1,6)=8.691, p=.03].
This effect again reflects a positive pre-to-post therapy difference in
volunteers assigned to Dramatherapy, with the difference score being higher
in that group relative to the control group across all stages (figure 10).
Furthermore, there was a near significant group*session phase interaction[F(2,12)=3.583, p=.06].
Multiple independent-measures t-tests (Bonferroni adjusted statistic = .016
denoted the largest difference in engagement levels between the two groups
to be seen at stage 3 [t(6)= -2.744, p=.03].
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Anxiety, Happiness, Social Contact, Confidence, Body Posture, EnergyFigures 11 16 below present the changes occurring on each stage of
therapy for the remaining factors. In all cases, when improvements wereobserved, it was the Dramatherapy group showing improvements across
stages of therapy. For these remaining factors, however, observed
differences were not statistically significant between the two groups.
Anxiety
Figure 11. Mean (SEM) pre-to-post differences in anxiety levels. Stage 1=
sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.
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Happiness
Figure 12. Mean (SEM) pre-to-post differences in levels of happiness. Stage
1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.
Social Contact
Figure 13. Mean (SEM) pre-to-post differences in social contact. Stage 1=
sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.
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Confidence
Figure 14. Mean (SEM) pre-to-post differences in confidence levels. Stage
1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.
Body Posture
Figure 15. Mean (SEM) pre-to-post differences in body posture. Stage 1=
sessions 1-4, phase 2 = sessions 5-9, phase 3 = sessions 10-13.
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Energy
Figure 16. Mean (SEM) pre-to-post differences in energy levels. Stage 1=
sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.
Summary of session effectsFrom the significant changes occurring on levels of attention, it is apparent
that the effects of Dramatherapy are cumulative and therefore, are most
pronounced towards the final sessions of therapy (stage 3). More specifically,
Dramatherapy sustains the positive increase that occurs in phase 2. In
contrast, there was a significant drop in levels of attention in the control
group relative to the Dramatherapy group at the final phase of therapy (figure
9). Although no significant changes emerged on any of the other factors, the
means suggest a positive effect of therapy. In most measures, assessors
recorded a non-significant drop in levels of these factors in the control group
in stage 3. In contrast, no such drop was seen for volunteers assigned to
Dramatherapy. Such pattern is strongest for the factor of engagement (figure
10). The inverse pattern was true for the factor of anxiety, in which
volunteers assigned to Dramatherapy experiences a decrease in anxiety
levels in phase 3 compared to control participants (figure 11). Energy levels
on the other hand were paralleled in the two groups, in which the decrease in
energy was equally present in volunteers assigned to Dramatherapy (figure
16).
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Maintenance of therapeutic effects Mid session)The mid session data scored by assessor 3 were used as a measure of how
long the effects of sessions were sustained in participants. As before,
sessions were split into three stages, with stage three only comprising
sessions 10 11, due to absent mid-session data for sessions 12-13.
For these analyses, post-to-mid session differences were calculated for each
factor and subjected to a 2 x 3 ANOVA (group x session stage). Such
analysis reflected the maintenance of effects over time in relation to the
previously attended therapy session (post therapy).
Statistically significant group*session stage interactions emerged for factors
of happiness, social contact, attention, and levels of engagement. These
interactions were further explored using multiple independent-measures t-
tests (Bonferroni adjusted statistic = .02). Figures 17-20 below represent
the achieved effects on those factors.
HappinessFigure 17 presents maintenance of happiness levels in the post-session
intervals for the control and Dramatherapy groups.
Figure 17. Mean (SEM) post-to-mid session differences on happiness levels.
Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.
Results revealed a significant group*session stage interaction [F(2,12)=6.006,
p=.02]. Participants assigned to the control group sustained their happiness
levels at stage 2 of therapy, during which participants engaging in therapy
experienced a lapse in levels of happiness ([t(1,6)=6.728, p=.04]. see figure
17).
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Social contactFigure 18 presents maintenance of social contact in the post-session
intervals for the control and Dramatherapy groups.
Figure 17. Mean (SEM) post-to-mid session differences on social contact.
Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.
There was a significant group*session stage interaction [F(2,12)=4.568,p=.03], with the largest difference to be seen in social contact at stage 2 of
the sessions, [t(1,6)=10.971,p=.02]. This difference was in favour of control
participants.
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AttentionFigure 19 presents maintenance of attention in the post-session intervals for
the control and Dramatherapy groups.
Figure 19. Mean (SEM) post-to-mid session differences on levels of
attention. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions
10 11.
Results again, demonstrated a group* stage interaction for attention levels,
[F(2,12)=13.631, p=.001]. This reflects a significant difference at stage 1 of
therapy, during which the maintenance of attention was greater for
participants engaging in therapy sessions, [t(1,6)=9.846, p=.02].
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EngagementFigure 20 presents maintenance of engagement level in the post-session
intervals for the control and Dramatherapy groups.
Figure 20. Mean (SEM) post-to-mid session differences on levels of
engagement. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 =
sessions 10 11.
A group*stage interaction [F(2,12)=4.345, p=.04] was revealed. The
difference was greatest at stage 3 of therapy, in favour of participants
assigned to Dramatherapy [t(1,6)=24.000, p=.003].
Anxiety, Confidence, Body Posture, EnergyFigures 21-24 below demonstrate the effects of therapeutic sessions on the
maintenance of the remaining factors, namely anxiety, confidence, body
posture, and energy. For these factors, the post-to-mid session differences
were not significantly different between the control and Dramatherapy group.
Nonetheless, for the majority of cases, a positive pattern was observed in
favour of those assigned to Dramatherapy. Non-significant positive effects of
therapy were sustained for confidence (figure 22) and energy levels (figure
24) at stages 1 and 3 of the sessions. Lower levels of anxiety were also
sustained as a result of therapy, throughout the study period (figure 21). On
the contrary, the post-to-mid session difference on body posture was lower
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for participants engaging in therapy relative to control participants at stages
1 and 2. The reverse was apparent at stage 3, however, during which
Dramatherapy participants sustained improvements in body posture more than
control participants did (figure 23).
Anxiety
Figure 21. Mean (SEM) post-to-mid session differences on levels of
anxiety. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions
1011.
Confidence
Figure 22. Mean (SEM) post-to-mid session differences on confidence
levels. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10
11.
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Body posture
Figure 23. Mean (SEM) post-to-mid session differences on body posture.
Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.
Energy
Figure 24. Mean (SEM) post-to-mid session differences on energy levels.
Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.
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Research Conclusions: Effects of Dramatherapy on people with DementiaFindings from this trial suggest that the experience of Dramatherapy has
positive effects on older people living with dementia. The effects were both
cumulative across therapy sessions as well as sustainable between sessions
on some factors. Positive therapeutic effects are first observed in the
evaluations examining the pre-to-post therapy differences. In that set of
analyses, Dramatherapy influence was greatest on levels of attention and
engagement. Additionally, it was more pronounced in the last stage of
therapy, comprising sessions 9-13. A similar pattern was evident on all other
factors, in which scores on the final stages of therapy reflected better
performance in individuals assigned to Dramatherapy.
The final set of data evaluations provided some support for the sustainability
of beneficial therapeutic effects. Findings demonstrated that the positive
effects of therapy are sustainable between sessions on factors of attention
and engagement. This strengthens the initial findings pointing towards
positive therapeutic influences specific to those two factors. Moreover,
maintenance of positive therapeutic influence on levels of engagement was
pronounced towards the final stages of the programme of sessions. This
demonstrates that the experience of Dramatherapy enhances levels of
engagement as the programme progresses, as well as sustaining this
enhancement over time. Implications for the timeframe for such therapeutic
interventions are clear: 12 week programmes can produce positive outcomes
that are cumulative and still increasing; longer term programmes mayproduce even larger benefits.
Although for factors of happiness and social contact, the sustained effects
were in favour of the control group, in the middle stage of therapy, they were
followed by a (non-significant) rise in performance to Dramatherapy
individuals in the final stages of therapy. This again supports the positive
influence of therapeutic effects and sustainability towards the final sessions
of therapy. Means on other factors (confidence, body posture, and energy
levels) also reflect such pattern.
It is thus reasonable to conclude that engagement in Dramatherapy induces
positive effects on attention and engagement levels, factors that are
considered critical to older people living with dementia. Furthermore, such
positive therapeutic effects are sustained between therapeutic sessions. In all
cases, effects are more apparent when therapy is treated as a continuous
process, during which effect size varies across sessions, but cumulatively
leads to positive effects following a 12-week experience of Dramatherapy.
Considering the small sample size and the relatively short time frame of the
intervention implemented for this study, these results are remarkably positive
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and offer a very strong argument for the value of Dramatherapy in this client
group.