Developing a Standardized Rating System for the Face Stimulus Assessment

Developing a Standardized Rating System for the Face Stimulus Assessment (FSA)

Using 9 Scales Adapted from the Formal Elements Art Therapy Scale (FEATS)

Presented to

Laura Aubé M.S., L.P.C., A.T.R.-B.C. and Marilyn Walter M.S., L.P.C., A.T.R.

AVILA UNIVERSITY

In partial fulfillment of the

requirements for the degree of

MASTER OF SCIENCE IN COUNSELING AND ART THERAPY

By

Michelle K. Hamilton

ii

For my husband

Jason Hamilton

Who stood by my side, held my hand, and encouraged me to achieve my goals

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ACKNOWLEDGEMENTS

Foremost, thank you Laura Aubé for your guidance and wisdom as the pioneering director of

Avila University’s graduate art therapy program. I am extremely grateful for your dedication,

support, and enthusiasm throughout this entire process.

I would like to express my sincere gratitude to Dr. Donna Betts, who not only inspired this

project, but supported me every step of the way. Your knowledge, encouragement, and sound

advice made this project possible. Your motivation and passion for art therapy is contagious.

My sincere thanks go to the FSA raters Nannie Mead and Sheila Lorenzo. Nannie, your

enthusiasm for research and you’re undying encouragement. A special thanks to my statistician

Josh Ellington, who was an integral part of this project.

Additionally, I would like to thank my professors and colleagues who offered their unending

support – especially Marilyn Walter, Molly Rush, Marilynn Demers, and Linda Blasdel. This

endeavor could not have been possible without your inspiration, wealth of knowledge, and

patience.

I wish to thank my best friend Kasey Browne, who has stuck by me every step of the way. Your

love and support has made this project possible, you inspire me to reach for the stars and remind

me to have fun along the way.

Lastly, and most importantly, I wish to thank my parents, Pam and David Kile. You raised me,

taught me, supported me, and had unrelenting faith in my abilities. There are not enough words

to thank you.

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TABLE OF CONTENTS

List of Tables…………………………………………………………………………………….vii

List of Figures…………………………………………………………………………………...viii

Abstract…………………………………………………………………………………………...ix

1. INTRODUCTION……………………………………………………………………………...1

Overview of the study……………………………………………………………………..1

Purpose of the Study………………………………………………………………………1

Justification of the Study………………………………………………………………….2

Research Question and Hypotheses……………………………………………………….2

Definition of Terms………………………………………………………………………..3

Conclusions………………………………………………………………………………..5

2. LITERATURE REVIEW………………………………………………………………………6

Historical Foundation of Art Therapy Assessment………………………………………..6

Art Therapy Assessments…………………………………………………………7

Limitations of Art Therapy Assessments………………………………………...11

Using the Face Stimulus Assessment……………………………………………………12

Development of the FSA………………………………………………………...12

Limitations of the FSA…………………………………………………………...17

Recommendations for Further Development of the FSA………………………..18

Using the Formal Elements Art Therapy Scale………………………………………….20

Development of the FEATS……………………………………………………...20

Limitations of the FEATS………………………………………………………..24

Recommendations for Further Development of the FEATS…………………….25

v

Conclusions………………………………………………………………………………27

3. METHODOLOGY……………………………………………………………………………28

Development of the Research……………………………………………………………28

Research Questions………………………………………………………………………28

Research Design………………………………………………………………………….28

Sample……………………………………………………………………………………29

Participants……………………………………………………………………….29

Participant Recruitment Process…………………………………………………29

Instrumentation…………………………………………………………………………..29

Materials…………………………………………………………………………29

Measuring Devices……………………………………………………………….30

Procedures………………………………………………………………………………..32

Administration of the FSA……………………………………………………….32

Rating the FSA Drawings………………………………………………………..33

Description and Justification of the Statistical Techniques Used………………………..33

Internal and External Validity ……………………………………………………………34

Ethical Concerns…………………………………………………………………………35

Conclusions………………………………………………………………………………35

4. RESULTS……………………………………………………………………………………..37

Inter-rater Reliability Results…………………………………………………………….37

Analysis of Results………………………………………………………………39

Conclusions………………………………………………………………………………44

vi

5. DISCUSSION…………………………………………………………………………………46

Research Questions………………………………………………………………………46

Inter-rater Reliability Issues……………………………………………………………...47

Limitations of the Study………………………………………………………………….48

Recommendations for Further Research…………………………………………………49

Conclusions………………………………………………………………………………49

APPENDICES…………………………………………………………………………………...51

REFERENCES…………………………………………………………………………………..75

BIOGRAPHICAL SKETCH…………………………………………………………………….79

vii

LIST OF TABLES

1. Kappa Interpretation…………………………………………………………………………..38

2. Inter-rater Reliability and Agreement…………………………………………………………39

3. Descriptive Statistics of FEATS Ratings on a Normative Sample……………………………42

4. Average Score per Scale………………………………………………………………………43

5. Mode Score per Scale…………………………………………………………………………44

6. FEATS Ratings of Modified FSA Drawing Two, Scales 1 and 2…………………………….70



9. FEATS Ratings of Modified FSA Drawing Two, Scales 10 and 11………………………….73

10. FEATS Ratings of Modified FSA Drawing Two, Scale 14………………………………….74

viii

LIST OF FIGURES

1. Gender Distribution Graph……………………………………………………………………40

2. Ethnicity Distribution Graph…………………………………………………………………..41

3. Age Distribution Scatter Plot………………………………………………………………….41

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ABSTRACT

The areas of art therapy research and assessment are quickly growing in size and

popularity. This research study investigated the modified Face Stimulus Assessment (FSA) in the

interest of creating a foundation from which to conduct further research to establish the FSA as a

reliable and valid art assessment tool (Betts, 2003). The study primarily investigates the use of

the modified Formal Elements Art Therapy Scale (FEATS) as a formal rating guide for the FSA

(Gantt & Tabone, 1998). The FSA is a projective drawing assessment comprised of a series of

three drawing tasks. This assessment was originally designed to be used with multicultural, child

and adolescent populations with multiple disabilities and communication problems (Betts, 2003).

Due to its fairly recent development, reliability and validity studies of the FSA have not

been conducted. In the current study, the modified FSA was administered to a sample (N = 30)

of undergraduate college students. The FSA drawings were rated independently by four trained

raters using 9 adapted scales from the FEATS. The findings identified statistically significant

results supporting the use of the modified FEATS with drawing number two of the FSA.

Findings from this study will ultimately aid in supporting application of the FSA as a useful art

therapy tool.

1

CHAPTER 1

INTRODUCTION

Overview of the Study

The Face Stimulus Assessment (FSA) was created by Donna Betts (2003) as a projective

drawing test to provide the assessor with information about the abilities of the client. The FSA

has yet to be established as a reliable and valid art therapy tool. This research paper describes an

investigation into the use of the Formal Elements Art Therapy Scale (FEATS) (Gantt & Tabone,

1998) as a formal rating and scoring instrument to be used with the FSA, in the interest of

providing a foundation for further research.

This research project involved three stages: (1) modification of the FEATS for rating

drawing number two of the modified FSA; (2) application of the adapted FEATS scales for

rating drawing number two of the modified FSA; and (3) calculation of the inter-rater reliability

found among raters of the modified FSA drawings .

Purpose of the Study

The purpose of this study was to investigate the applicability of 9 of the 14 scales from

the Formal Elements Art Therapy Scale (FEATS) (Gantt & Tabone, 1998) to a modified version

of the Face Stimulus Assessment (FSA) (Betts, 2003). For the purposes of this project, the FSA

was administered to 30 volunteer, undergraduate college students enrolled at a local university.

This sample of participants contributed to establishing norms for further validity and reliability

studies of the FSA rating system.

2

Justification of the Study

Findings from this research study will have implications in a variety of areas. The

information gathered will be applicable to furthering the global usage of the FSA and the

FEATS. This information can be used by researchers to establish reliability and validity of the

FSA and its rating system. Testing in this area will support the use of the FSA as a credible art

therapy assessment (D. Betts, personal communication, November 17, 2007; Matteson, 2008).

The FSA is one of only a few instruments that accounts for gender and cultural factors as part of

the procedure. FSA research could have valuable implications for the field of art therapy. Future

investigations could be conducted on the use of the FSA with any number of populations.

The research from this study can also help support the use of the FSA and the FEATS in

clinical and research settings. Further research on the FSA will have benefits to art therapists and

clinicians who want an assessment tool that has global applicability. This research will also help

promote the use of the FEATS in a variety of research settings. As more research is conducted in

the area of art therapy assessment, the field of art therapy will ideally gain more notoriety and

acceptance as a valid from of treatment.

Research Question and Hypotheses

The purpose of this research study is to develop a standardized rating system for the Face

Stimulus Assessment by adapting these 9 scales from the Formal Elements Art Therapy Scale:

Prominence of Color, Color Fit, Energy, Space, Integration, Logic, Realism, Problem-solving,

Developmental Level, Details of Object and Environment, Line Quality and Perseveration (Gantt

& Tabone, 1998).

The central question in this research proposal is: To what extent can scales from the

FEATS be used to successfully rate drawings from the modified FSA? An additional question is:

3

To what extent will inter-rater reliability be achieved among raters of the modified FSA

drawings? The findings from this study will be helpful in further research to establish reliability

and validity for the Face Stimulus Assessment.

Definition of Terms

(1) Adapted FEATS scales: Is a term used to describe the 9 adapted scales from the 14

Formal Elements Art Therapy Scale : Prominence of Color, Color Fit, Energy, Space,

Integration, Logic, Realism, Problem-solving, Developmental Level, Details of

Object and Environment, Line Quality and Perseveration (Gantt & Tabone, 1998).

(2) Art therapy assessment: A specific art task used by art therapists to gather

information about a client‟s level of functioning, ascertain client strengths and

challenges, clarify client problems, identify therapy treatment goals, and measure

client progress.

(3) Client: A person receiving counseling or art therapy services.

(4) Ethnicity: A group of peope who identify with each other, based on a presumed

common ancestry or geneology (Wikipedia contributors, 2008).

(5) FSA (Face Stimulus Assessment): Is a projective drawing assessment, comprised of a

series of three drawings, originally designed to be utilized with multicultural, child

and adolescent populations with multiple disabilities and communication problems

(Betts, 2003).

(6) FEATS (Formal Elements Art Therapy Scale): Is a reliable measurement system

comprised of 14 rating scales derived from “psychiatric symptoms, clinical

observations, and the literature” (Gantt, 1990).

4

(7) FEATS Scales (original operational definitions) (derived from Gantt and Tabone,

1998):

Prominence of Color: The amount of color used to draw and fill in objects in a

picture.

Color Fit: The appropriateness of color used in a picture to the drawing task

Implied Energy: The amount of energy used to complete a picture.

Space: The amount of space used in the picture.

Integration: The degree to which the items in a picture are balanced into a

cohesive whole.

Logic: The degree to which a picture is logical and fits the drawing task.

Realism: The degree to which objects in the picture are clearly represented and

visually identifiable.

Problem Solving: The ability to find a reasonable solution to the problem of

picking an apple from a tree.

Developmental Level: The degree to which the artwork compares to drawings of

adults and children at different developmental stages.

Details of Objects and Environment: The number of additional items in the

picture related to the drawing task.

Line Quality: The amount of control exhibited by the artist in regards to the lines

in the picture.

Perseveration: The presence of elements that appear to be repeatedly drawn

without deliberate intention.

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(8) Inter-rater Reliability: The degree of agreement between 2 or more raters (Wikipedia

contributors, 2008).

(9) Modified FSA (Face Stimulus Assessment): Is a modification of the original FSA

assessment using only drawings 1 and 2 from the original 3 drawing series.

(10) Standardized Rating System: A scoring guide tailored to the specific criteria of the

Face Stimulus Assessment.

Conclusions

This paper will outline a detailed summary of the research conducted using the modified

FEATS when applied to the FSA. The Face Stimulus Assessment is a valuable art therapy tool to

help evaluate and treat a diverse client population. This research project was created to

investigate the applicability of 9 FEATS scales when applied to drawing number two of the FSA.

This research study attempted to establish a solid foundation in order to investigate the

possibilities of establishing reliability and validity for the FSA in future research endeavors.

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CHAPTER 2

LITERATURE REVIEW

Research in assessment is a growing area in the field of art therapy. Many art therapists

have devoted time to researching previously established art therapy assessments as well as

developing new art therapy assessments. This review of the literature will highlight the history of

art therapy assessment including their development, strengths, and limitations (Bucciarelli,

2007). The review of the literature begins with the historical foundations of the art-based

projective drawing assessments. These early art-based assessments provided the foundations for

the development of art therapy assessments today, including the FSA. The development of art

therapy assessments is given, followed by the author‟s conclusions about art therapy

assessments. The major strengths and limitations of these assessments are examined and

discussed. Then, the development of the Face Stimulus Assessment is described, and its current

uses in the clinical setting, current research, and limitations are reviewed. Then, the Formal

Elements Art Therapy Scale is described as well as its implications, current research, and

limitations. Finally, the implications of the literature review are summarized, and the

implications for this research study are noted.

Historical Foundation of Art Therapy Assessment

People have used art for the purpose of self-expression for centuries (Brooke, 1996;

Feder & Feder, 1998). Unlike the use of language, art has no restrictions on the expression of

thought and feeling. Projective methods with the intent to explore subconscious motivations are

not a new addition to the field of psychotherapy. Machover (1949) spent a considerable amount

of time devoted to researching projective methods and compared them to direct verbal

communication. Similarly, Langer (as cited in Brooke, 1996) found that “there is an important

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part of reality that is quite inaccessible to the formative influence of language: that is the realm

of the so-called „inner-experience,‟ the life of feeling and emotion…the primary function of art is

to objectify feeling so that we can contemplate and understand.”

Art therapy assessments allow the therapist to evaluate clients through the art in ways

verbal communication can not. There are five areas in which researchers have investigated the

use and applicability of art therapy assessments: identification of client needs, personality

assessment, prediction of future behaviors, date for developing an individual treatment plan, and

monitoring progress (Feder & Feder, 1998). Many professionals feel that art therapists should be

encouraged to use their unique skills as the foundation for their investigation into creating art

therapy assessments (McNiff, 1998). An important function of art therapy assessment and

research in the area of assessment serves to bring professionalism and respectability to the field

of art therapy.

Art Therapy Assessments

Many of the most well-known art therapy assessments developed by art therapists have

been heavily influenced by previously established projective drawing tasks (Bucciarelli, 2007).

The large number of art therapy assessments that have been developed to date is too extensive to

outline in this paper. The assessments included in this paper are those assessments that are

among the most prominent and researched art therapy assessments to date. The assessments

include the following: the Diagnostic Drawing Series (Cohen, 1994; Cohen, Hammer, & Singer,

1988), the Ulman Personality Assessment Procedure (Ulman, 1965), and the Person Picking an

Apple from a Tree (Gantt & Tabone, 1998) assessment. Other less researched art therapy

assessments commonly utilized within the clinical art therapy setting will also be briefly outlined

in this paper.

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Diagnostic Drawing Series (DDS). The Diagnostic Drawing Series (Cohen, et al., 1988;

Cohen, et al., 1994) was created in 1986, by Cohen, Hammer, & Singer. The intended population

for this assessment is use with an adolescent and adult population (Brooke, 1996). The DDS was

designed to collect clinical information about a client in a single session. The purpose of the

DDS is assessing an individual‟s response to structured and unstructured drawing tasks. The

DDS was introduced to correlate graphic indicators with psychiatric diagnosis that corresponded

to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (Cohen et al,

1988; Brooke, 1996). The materials required for the DDS include 18 by 24 inch white drawing

paper and Alphacolor square pastels (Cohen, et al., 1988; Cohen, et al., 1994). The DDS

handbook indicates that the assessor should administer the DDS by giving the client specific

verbal instructions outlined in the handbook. The series of three drawings include a free drawing,

a tree picture, and a feeling picture. According to the developers of the DDS, the images provide

information about the clients‟ affective state, defensiveness, coping strategies, personal

symbolism, level of compliance, personal introspection, and self-expression (Cohen, et al., 1994;

Bucciarelli, 2007). The DDS drawings are scored using the DDS Revised Rating Guide (Cohen,

1994). The revised rating guide measures 37 formal and content variables across 23 categories

(Cohen, et al., 1988).

In addition to the rating guide, the DDS has a Drawing Inquiry sheet that includes a

qualitative question and answer interview to be used by the clinician and administered to the

participant. Cohen and the developers of the DDS along with other art therapists have worked

collaboratively to analyze and identify clusters of graphic elements in the DDS drawings that

indicate profiles for specific psychiatric diagnoses (Cohen, et al., 1994). To date, substantial

9

numbers of DDS drawings have been collected and compiled into a national archive categorized

by diagnosis (Cohen, et al., 1988; Cohen, et al., 1994; Bucciarelli, 2007).

Ulman Personality Assessment Procedure (UPAP). The UPAP, was created and

developed by Elinor Ulman in 1959, and was intended to be used as an assessment method to

identify diagnostic characteristics of psychiatric inpatients (1965). The UPAP consists of a series

of four drawings which are given with instructions meant to simulate experiences one would

encounter in day-to-day life (Cox et al, 1999). The materials needed include an 18 by 24 inch

grey bogus paper tacked down to an easel (Ulman, 1965). The administrator gives the client a set

of 12 hard pastels to use for the series of tasks. The four drawings include: a free drawing, a

series of physical exercises followed by a directed drawing task; a drawing stimulated by a

scribble; and the choice of a free drawing or another scribble drawing. The UPAP yields

information about the client‟s personality by looking at the form and the content in the drawings

and exploring the way he or she responds to the drawing tasks.

Agell (2000) created a checklist to rate the assessment drawings of the UPAP.

Descriptors in the drawing are rated on a one to five scale. The scale includes eight categories as

follows: line quality, color use, form, perspective, color application, content, paper orientation,

and amount of time used to complete the assessment. Agell‟s checklist includes space for

qualitative descriptions of the assessment drawings.

Person Picking an Apple From a Tree Assessment (PPAT). The PPAT is a widely used

assessment in the field of art therapy. The PPAT assessment uses the Formal Element Art

Therapy Scale (FEATS) as its formal rating guide (Gantt & Tabone, 1998). The PPAT

assessment is a single drawing procedure that requires a 12 by 18 inch sheet of white drawing

paper and a set of 12 felt-tip MR. SKETCHscented watercolor markers. The assessment

10

administrator asks the client to “Draw a person picking an apple from a tree.” There is no time

limit to complete this assessment (Gantt & Tabone, 1998).

The PPAT assessment protocol was developed for use with the FEATS Rating Manual

(Gantt & Tabone, 1998). The FEATS measures 14 different global formal variables of the PPAT

(Cox, Agell, Cohen, & Gantt, 1999). The FEATS yields diagnostic information through the

assessment of characteristics of form (Kaplan, 2000). The FEATS Rating Manual provides both

instructions for rating the PPAT assessment drawings and color examples of how to properly rate

the PPAT drawings. The FEATS Rating Manual includes a FEATS Rating Sheet (see Appendix

C) to document the score of each drawing along the formal elements scales (Cox, Agell, Cohen,

& Gantt, 1999; Bucciarelli, 2007). Gantt and Tabone (1998) have conducted studies that show a

single drawing can detect specific mental disorders and therefore, could be correlated with the

DSM-IV TR (Kaplan, 2000; Bucciarelli, 2007).

Other Art Therapy Assessments & Rating Instruments. There are many other art therapy

assessments and rating instruments in use today that are less popular and have little research to

support their use. Further research with these art therapy assessments could contribute valuable

information to the field of art therapy. Some of these assessments and rating instruments include:

A Favorite Kind of Day (AFKOD) (Manning, 1987); the Bird‟s Nest Drawing (BND) (Kaiser,

1993); the Bridge Drawing (Hays & Lyons, 1981); the Amusement Park Technique (Hrenko &

Willis, 1996); and the Child Diagnostic Drawing Series (CDDS) (Leavitt, 1988). Another rating

instrument is the Descriptive Assessment of Psychiatric Art (DAPA) (Hacking, 1999). Betts

(2005) has dedicated much of her career to the study of art therapy assessment research. The

results of her investigation found that art therapists are still in the early stages of understanding

assessments and rating instruments. Similarly, she found numerous flaws in the assessment

11

procedures and rating instruments as well as the errors in the literature research. She deduced

that art therapists have much work ahead of them in the area of art therapy research. Based on a

review of the literature, Betts found that the most successful approach to assessment procedures

integrates objective measures as well as subjective methods. Her final recommendation was that

researchers continue to explore both objective and subjective approaches to assessment.

Limitations of Art Therapy Assessments

The use of art therapy assessment and projective techniques has long been debated in the

field of art therapy. The problem stems from the lack of research, primarily a lack of reliability

and validity (Feder & Feder, 1998; Betts 2005). Many professionals in the field believe that it is

important for art therapists to develop their own art-based assessments; despite this belief

assessment development has been slow. Over the past 50 years several art therapy assessments

have been developed and gained notoriety (Betts, 2006). Unfortunately, research in the area has

produced varied results.

The use of projective assessments has declined over the past 25 years (Feder & Feder,

1998; Betts, 2006; Bucciarelli, 2007). The interpretation of projective assessments has led to

questionable research findings. Regardless, many mental health professionals, primarily

psychologists and psychiatrists, support the use of projective assessments. The poor research

findings come from the analysis of individual projective assessments. A study by Roback (1968)

investigated the findings of Machover‟s Draw-A-Person (DAP) Test and established that his

findings failed to support Machover‟s (1949) hypothesis that drawing the human body reveals

one‟s needs, conflicts, and expressive actions (as cited in Betts, 2005). Similarly, Klopfer and

Taulbee explored issues related to the validity of projective tests. They explored the TAT, the

12

Rorschach, and Human Figure Drawings. They found that despite poor reliability and validity,

psychologists were likely to continue using projective assessments on the basis of exploring the

inner psyche and internal motivations of their clients.

Using the Face Stimulus Assessment

The Face Stimulus Assessment is a projective drawings test consisting of three stimulus

images for the participant to complete (Betts, 2003). The author of the FSA outlined specific

standardized materials and procedures for the administration of the assessment. Prior to the

present study, a formal rating scale for the FSA did not exist. Betts suggested that reliability and

validity studies should be conducted on the FSA.

Development of the FSA

The Face Stimulus Assessment (FSA) was created by Donna J. Betts beginning in 1998

(2005). Betts developed the FSA after devoting years to researching the importance and

limitations of art therapy assessments. The FSA was first presented at the 32nd Annual AATA

conference in Albuquerque, NM (Betts, 2001). The FSA was originally developed as a projective

drawing assessment to be used with a multicultural child and adolescent population. Betts was

interested in using the FSA with children and adolescents with multiple disabilities, and those

who have communication difficulties (2003).

Betts began working on the FSA while working in a multicultural school, with children

with communication difficulties (2001; 2005). Betts found that working with “clients with

autism, communication difficulties, and, in particular, a lack of motivation benefited from

stimulus drawing such as a picture of a face” (2003). Betts was initially inspired by the work of

Silver (1976) and Stamatelos and Mott (1976) who recognized the importance of focusing on the

client‟s strengths when creating an assessment tool based on artwork (2003). Betts was also

13

influenced by the work of Alley (1988) who found that many authors consider the face the most

important part of the body in face-to-face interactions (2003). Alley (1988) found that the face is

primarily associated with expression, emotion, and identity.

The human face is commonly used in research. Betts decided to study whether the human

face would yield valuable information when used as a stimulus assessment, thus she created a

normalized version of the face-stimulus image (2003). The image is gender neutral, not age

specific, and can be representative of a variety of cultures. Betts felt that the face would make a

good stimulus because humans, as early as infancy, recognize the face and it holds their attention

(Betts, 2003; Alley, 1988). The face is primarily associated with emotional expression as well as

identity.

To initiate her research Betts began by reviewing the appropriateness of drawing tests as

well as the validity and reliability of the instrument (2005). Betts analyzed 35 quantitative

studies related to art therapy assessments and rating instruments (2005). Betts' examination of

analysis tools included: “A Favorite Kind of Day (AFKOD); the Bird‟s Nest Drawing (BND);

the Bridge Drawing; the Diagnostic Drawing Series (DDS), the Child Diagnostic Drawing Series

(CDDS); and the Person Picking an Apple from a Tree (PPAT).” The rating instruments Betts

explored included: “the Descriptive Assessment of Psychiatric Art (DAPA), the DDS Rating

Guide and Drawing Analysis Form (DAF), and the Formal Elements Art Therapy Scale

(FEATS).” From the results of her investigation, Betts found that art therapists are still in the

early stages of understanding art therapy assessments and rating instruments. Similarly, she

found numerous flaws in many of the assessment procedures and rating instruments, as well as

errors in the literature research (Betts, 2005). She deduced that art therapists have much work

ahead of them in the area of art therapy research.

14

Based on a review of the literature, Betts found that the most successful approach to

assessment procedures integrates objective measures as well as subjective methods (2005). Her

final recommendation stated that researchers should continue to explore both objective and

subjective approaches to assessment. Betts also found that many professionals in the field of art

therapy are using assessments without understanding the implications of poor reliability or

validity and without comprehending the usefulness and applicability of these tools.

After her research was complete, Betts published her assessment tool, the Face Stimulus

Assessment. Betts created the FSA partially in the interest of assessment research as well as an

assessment tool for further research by other art therapists. Betts (2003) stated that “art therapy

students and professionals alike should be encouraged to explore inventive means of working

with and evaluating their clients-creative investigation can be fruitful”.

The FSA is a series of three stimulus pictures for the client to complete. The first is a

normalized version of the face-stimulus (Appendix A), the second is an outline of a face and

neck (Appendix A), and the third is a blank page (Betts, 2003). Betts uses a series of three

images to assess the client‟s capacity for “memory and visual retention and his or her ability to

organize the constituent elements of the human face” (Betts, 2003). The FSA can be

administered to a small group or individually. Betts recommends that before the client enters the

room, the art therapist should place the materials on the table where the client will be seated.

The FSA allows 50 minutes to one hour for the completion of the assessment (Betts,

2003). Once the client enters the room, the therapist should ask him or her to be seated. Once

seated, the instructions are to ask the client to “use the markers and this piece of paper”. This is

the only instruction the administrator should give the client during the completion of the FSA.

Once the client completes the first picture, the therapist should remove it from view; for the same

15

standard should be applied to the second and third pictures as well. The FSA administrator has

the option to review the assessment with the client as follow-up. For the purpose of follow-up the

administrator needs to write the client‟s name, and indicate the picture number in the bottom left-

hand corner.

Currently, the scoring system for the Face Stimulus Assessment is an informal rating

procedure (Betts, 2005). A formal rating scale for measuring the FSA has yet to be developed,

for which reliability and validity testing would need to be conducted. For rating picture one Betts

identifies five criteria: motor skill ability, realistic use of natural color, addition of adornment

(hair, eye lashes, jewelry), adjusting the face to look like the client, and use of picture space.

When giving the first drawing it is important to consider all five criteria. The client‟s ability and

use of color and inclusion of adornment can be very telling about the client‟s abilities, their

developmental level, any problems or concerns, strengths, as well as any psychopathology. The

use of realism may indicate how the client sees him or her self. This may include identity

problems or issues related to culture. Motor skill assessment is also an important part of drawing

one.

When considering drawing two, Betts (2005) identified three criteria for consideration:

ignoring the stimulus is the shape of a face, choosing to make the picture into a face (refer to

criteria for drawing 1), and choosing not to make the picture into a face. The second drawing is

also a very important tool for assessing the client‟s ability, strengths, and potential barriers to

treatment. If the client has difficulty organizing the facial structure, the assessment drawing will

allow the opportunity for tendencies to be brought to the surface, possibly memory recall

problems or other cognitive issues (Betts, 2003). If the client ignores the face altogether this may

indicate memory problems as well as learning difficulties. Drawing two is very important for

16

language and hearing impaired individuals who may need to learn about the use of space,

sequential order, grouping, and object placement.

The rating scale for picture three includes four criteria (Betts, 2005). It is important to

consider whether the client chooses to draw a face or not, and if the client does not draw a face,

what might it indicate? If the client does draw a face, might this imply compliance? Betts

suggests that the rater consider how it is similar to or different from the face in Pictures 1 and 2.

If the client does not draw a face, does this imply a rebellion and defiance, or creativity and

compliance on the part of the client? When rating formal aspects of Picture 3, other assessment

indicators might be considered, such as the use of line, space, or color. It is also important to note

whether the client changes the page orientation to a horizontal format. The third picture can be

used to judge the client‟s ability to recall that Pictures 1 and 2 were pictures of a face. If a client

chooses to draw something other than a face on Picture 3, this could possibly indicate poor

memory function, defiance or rebellion, creativity, or even learning disabilities. Overall, picture

three is an opportunity to determine the client‟s abilities and strengths.

The materials specified for use with the FSA have been standardized by the author. She

stipulates the following materials for use with the FSA (Betts, 2005):

· A standard packet of 8 Crayola® markers

· A packet of 8 Crayola® Multicultural markers

· Stimulus picture #1: one 8 ½ x 11” sheet of white Xerox paper depicting the complete

face stimulus

· Stimulus picture #2: one 8 ½ x 11” sheet of white Xerox paper depicting the outline of

the face and neck.

· Stimulus picture #3: one 8 ½ x 11” sheet of blank white Xerox paper.

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Limitations of the FSA

The Face Stimulus Assessment was introduced to the field of art therapy around 2000.

Although only two published studies exist on the FSA (Betts, 2003; Robb, 2001), this does not

indicate that the assessment is not useful or applicable. Robb used the FSA while facilitating the

art therapy process at a 6-week day camp for Russian children from orphanages in the U.S.

(Robb, 2001). She and other art therapists helped in addressing anxiety-provoking problems that

the children experienced (Robb, 2001). She used the FSA as an assessment tool to identify

anxiety as well as PTSD symptoms in the Russian children (Robb, 2001). The use of the FSA by

Robb is a step towards developing more reliability and validity with this instrument. More

research is needed to demonstrate this assessment as a reliable, valid tool for art therapists to use

consistently with their clients.

There are other drawbacks to the use of the Face Stimulus Assessment as an informal

assessment tool. Gantt (2004) points out that when administering informal assessments the

evaluator and the therapist are the same which leads to evaluator bias. She states that the data

collected on an individual cannot be generalized to others. This is applicable to the FSA in this

case since there is little evidence for the type of population best served by this assessment. Gantt

also identifies the possibility of projection on the part of the evaluator leading to

misinterpretations. She states that definitions used in informal assessments may be vague or

inexact. The FSA is guilty of this fallibility. In the description of the Informal Rating Procedure

Betts is vague when it comes to defining particular terms and guidelines. Gantt also lists the lack

of reliability and validity as a criticism to projective drawing tests. Betts clearly identifies that

the FSA has not been shown to have any reliability or validity as it is undergoing research to

further establish itself.

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Betts is the first critic of her own assessment. She identifies that it would be beneficial to

explore whether the FSA can assess the client‟s “psychosocial development, cognitive

development, creative potential, and graphic intelligence” (Betts, 2003). Other potential areas of

examination include self esteem, motor development, behavior, conceptual skills, memory

development, as well as language abilities (Betts, 2003). The FSA may also be used with the

geriatric population, especially dementia and Alzheimer‟s clients, to assess memory function and

motor ability. This could help the treating professionals detect the progression of their disease.

Betts (2003) also gives her recommendations for further research and the development of

a valid and reliable rating method for the FSA. Betts states that researchers need to:

Establish a method to rate those elements in the drawing that graphically demonstrate

identified concepts, abilities, or skills – such as the role of color, figure and size

differentiation, drawing style, compositional strategies, the incidence of bizarre or

unconventional elements, and the use of pictorial space (2003).

Recommendations for Further Development of the FSA

Little research has been conducted to establish the FSA‟s reliability and validity, as well

as its applicability to various populations. The usefulness of the Face Stimulus Assessment

appears to be widespread across a variety of populations. Potential populations could include

children, adolescents, and adults with multiple disabilities, people with communication

difficulties, those with psychosocial development issues, and persons with cognitive

development disorders. Other applications may include those persons with low self esteem,

motor development problems, behavioral issues, conceptual skill problems, geriatrics, memory

development, as well as language disabilities. The wide range of uses for this assessment should

make the FSA appealing to many art therapists who plan to use it in the future.

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Prior to the present study, the rating system for the FSA was only informal. Betts

provides guidelines to follow when rating the drawings which are helpful but lack the element of

standardized scoring. Betts recommended the modified application of the Formal Elements Art

Therapy Scale (FEATS) for rating the FSA. The FEATS measures 14 formal elements including

“prominence of color, problem-solving, space, color fit, developmental level, integration,

implied energy, details of objects and environment, logic, realism, line quality, preservation,

rotation, and person” (Gantt & Tabone, 1998). Due to the global applicability of the variables,

modified FEATS scales could be used with the FSA to help establish reliability and validity.

Betts (2003) suggested that in order to develop a reliable and valid rating system for the

FSA, researchers should investigate a method to rate graphic elements in the drawings that

“demonstrate identified concepts, abilities, or skills-such as the role of color, figure and size

differentiation, drawing style, compositional strategies, the incidence of bizarre or

unconventional elements, and the use of pictorial space (as cited in Golomb, 1992). The rating

system would then need to be tested against a standardized measurement tool that looks at the

same concepts (Betts, 2003).

The FSA is a user-friendly assessment tool. This ease of use will likely be an important

benefit for art therapists as well as other mental health professionals who wish to use this

assessment. The materials needed to administer the assessment are generally accessible. The

assessment itself can easily be ordered through Betts' website for only 20 dollars. Betts research

and development of the FSA is a step in the right direction towards contributing an effective,

reliable, valid assessment instrument to the field of art therapy. The job of continuing this

research rests on the shoulders of art therapy students and professionals in the field if we hope to

demonstrate the worth of the field of art therapy.

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Using the Formal Elements Art Therapy Scale

The FEATS Rating Manual was created to be used in conjunction with the Person Picking

an Apple from a Tree assessment (Gantt & Tabone, 1998). The FEATS measures 14 variables of

the PPAT assessment (Gantt & Tabone, 1998). The 14 scales include: Prominence of Color,

Color Fit, Implied Energy, Space, Integration, Logic, Realism, Problem-solving, Developmental

Level, Details of Objects and Environment, Line Quality, Person, Rotation, and Perseveration.

The FEATS Rating Manual provides instructions for rating the PPAT assessment drawings. The

rating manual provides color examples of actual client drawings and describes how to properly

rate the PPAT drawings. Included in the FEATS Rating Manual is a FEATS Rating Sheet used to

document the score of each drawing along the formal element scales .

Development of the FEATS

At the 1999 American Art Therapy Association Conference in Orlando, Florida, a panel

was assembled to investigate the application of three art therapy assessments: the Person Picking

an Apple from a Tree (PPAT), the Ulman Personality Assessment Procedure (UPAP), and the

Diagnostic Drawing Series (DDS). The panel concluded that the potential for research in this

area, mainly the use of these three art assessments and other drawing assessments were

numerous (Cox, Agell, Cohen, & Gantt, 2000). Cox concluded that research should be conducted

to look at the possibility of comparing drawings from one assessment to the drawings from

another to investigate the possibilities for further use. Cox also suggested that researchers should

investigate the applicability of the FEATS to additional assessments (2000).

The FEATS was developed in order to provide “clinicians and researchers with a

standardized drawing and a sound scientific method of studying it” (Gantt & Tabone, 1998). The

FEATS Manual is a research tool that was created to add to the credibility of the field of art

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therapy; dispel art therapy myths and provide verifiable facts, illustrate a way of researching that

aligns itself with the way art therapists think; present methods for comprehending and

researching non-symbolic aspects of art; and describe the connection between art elements and

diagnosis and clinical state. The FEATS measures specific global variables based on equivalents

of psychiatric symptoms but it is not intended to be used as a manual for psychiatric diagnosis.

The theory behind the FEATS is to accomplish several goals: separate art therapy fact from

fiction, develop more precise definitions for the field, build better theoretical foundations, and

point the way to more precise treatment methods (Gantt & Tabone, 1998).

Each of the 14 interval/Likert-type FEATS scales are scored from zero to five, or

between any two whole numbers to give a half rating i.e., 3.5 (Gantt & Tabone, 1998). The

ability to rate the scales allows the clinician or researcher to convert raw scores into a clinical

score for archival purposes. There are also 10 dichotomous content scales by which to rate the

drawings, these are not rated from zero to five, they are simply scored on a basis of present or

not present. These scales include the color used for the whole picture and the person, visible

features of the person, gender, actual energy, orientation of the face, age, clothing, apple tree,

environmental details, and other features.

The FEATS is used for directing the clinician toward the most beneficial treatment plan

and not for use as a diagnostic tool. However, Gantt and Tabone (1998) found correlations

between Diagnostic and Statistic Manual of Mental Disorders (DSM-IV) symptoms,

observations in the art therapy literature, and the FEATS scales. For example, in the DSM-IV

Major Depression is classified as depressed mood, loss of energy, psychomotor retardation or

agitation, diminished interest, and diminished ability to think or concentrate. The observations in

the art therapy literature that correlate with Major Depression are lack of color, use of dark

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colors, constricted use of space, lack of environment, and lack of detail. Translated to the

FEATS, the scales which might be most useful for diagnosis and treatment might include

Prominence of Color, Color Fit, Energy, Space, Realism, Person, and Perseveration.

Much research has been conducted to study the effectiveness and utility of the FEATS. A

study by Rockwell & Dunham (2006) studied the use of the FEATS with a population of people

diagnosed with Substance Use Disorders, who were court ordered for treatment, in order to

determine the inter-rater reliability for the FEATS. The population in the study included 40

adults. Their research found good inter-rater reliability on the first twelve of the 14 scales, thus

the perseveration and rotation scales were omitted from the study. Twenty drawings were

collected from the experimental group as part of the intake process at a state-licensed, private

counseling facility. Twenty drawings were collected from the control group, which was

comprised of individuals in the community. The results of the inter-rater reliability study were

consistent with other research on the FEATS, in that the correlations revealed a high degree of

consistency between the two raters. Nine of the twelve FEATS scales showed statistically

significant high scores, while the three scales that were not statistically significant were Line

Quality, Problem-solving, and Integration. The authors found that differing interpretations of the

scoring criteria most likely led to the differences.

Another study conducted by Swan-Foster, Foster, & Dorsey (2003) compared the human

figure drawings of pregnant women to determine if there were visual differences between three

different groups including high risk outpatients, high risk inpatients, and low risk outpatient

pregnant women. Depression is a common problem experienced by pregnant women and it can

seriously affect their pregnancy. Many researchers conclude that screening for and treating

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prenatal depression is essential to effectively monitoring and managing the health of mother and

baby.

The study explored the potential for visual differences between drawings taken from the

three prenatal groups (Swan-Foster, Foster, & Dorsey, 2003). The participants were told that the

study was to document “personal experience of pregnancy” and “masterpieces are not required

or expected.” Pre and post-tests with a 5-point Likert scale were used to measure fearful/trusting

and anxious/calm for each drawings. Ten drawings were randomly selected from each group and

rated using the FEATS scales and Content Tally sheets. The results of this study found that

certain formal elements of the drawings may reflect the potential for levels of depression in

relation to the study groups. The results also indicated that that the low risk group scored higher

than the high risk groups, particularly with scales rating color, energy, space, details, and person.

The high risk outpatient group indicated a higher risk for depression than the high risk inpatient

group and often presented with a more “stoic nature.” The data that this study collected can be

used in future research, using a non-verbal tool to investigate the prenatal emotions or

psychological distress. The scores for this study were consistent for all three groups and showed

a strong inter-rater reliability.

The previously mentioned studies are just a few studies that have contributed to

determining the FEATS as a reliable and valid scoring system. Gantt and Tabone (1998) created

the FEATS as a ready-to-use tool for researchers studying a variety of populations. The excellent

inter-rater reliability of the FEATS makes it easy for investigators to conduct validity studies.

Overall, the FEATS is a valuable tool for art therapy researchers investigating a variety of

variables within the field.

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Limitations of the FEATS

The FEATS scales were created by Gantt and Tabone (1998) using a variety of sources

including clinical observations, art therapy and psychology literature and projective drawings of

psychiatric inpatients, and the criteria set from the DSM-IV. While the creation and development

of the scales was a meticulous process, the FEATS scales are continually being researched and

some limitations have emerged. Gantt and Tabone write in the FEATS Manual that although

each scale may be scored from zero to five, the number indicates more or less of a variable;

however a higher score does not necessarily indicate a better score than a lower rating. At this

point there is no way to convert raw scores into clinical scores. With more research and large

scale representative samples, norms can be developed for each scale. If and when this is

established, the correlation of specific scales and psychiatric symptoms can be regarded as the

“actual equivalent of a symptom.”

When looking at art and color in relation to the FEATS scales one must consider the

appropriateness for specific items (Gantt & Tabone, 1998). Gantt and Tabone give the example

of rating abstract art with the Color Fit scale. A researcher would not be able to determine the

appropriateness of Color Fit for an abstract piece of artwork due to the nature of abstract art. This

is an example of how not all FEATS scales can be used to rate all artwork. Researchers must use

discretion in establishing the appropriateness of FEATS scales to rate artwork. The authors also

note that the FEATS, as well as many other art assessments, do not screen for color-blindness.

When considering the Color Fit scale, it may be difficult to rule out color-blindness as a cause

for a low score on this scale.

The authors mention the area of personality characteristics as a severe limitation to the

FEATS scales (Gantt & Tabone, 1998). It is difficult to determine personality characteristics

25

based on a single drawings, like that in the PPAT. A single drawing is only a small element of a

person's potential responses. Thus, the amount of information gathered by the FEATS when

combined with the PPAT is limited. It may be most beneficial at this point to pair the FEATS

with other assessments to paint a larger picture of the persons overall character.

As with many assessments in the field of art therapy research, the FEATS does not have

the same popularity as some traditional psychological assessments. This means less researchers

have access to the FEATS, thus fewer studies have been conducted on its reliability and validity.

Hopefully as the field of art therapy and especially the area of art therapy assessment expand and

grow, assessments like the FEATS will gain popularity as a reliable and valid assessment tool for

mental health practitioners and art therapists alike.

Recommendations for Further Development of the FEATS

Gantt and Tabone (1998) have conducted countless studies in order to make a reliable

and valid instrument and they have a long way to go to reach their goal. The inter-rater reliability

studies have been promising but at this point it is most important for the authors and other

researchers to conduct large scale validity studies to begin to establish the FEATS as a valid

assessment tool.

The authors review several areas of possible extensions that they recommend researchers

consider (Gantt & Tabone, 1998). When using the FEATS with assessments other than the

PPAT, one must consider the media; paintings are not the same as drawings. Paintings tend to

take up more space than drawings which may likely affect the Space scale as well as Prominence

of Color. Research has not been conducted on varying art materials. In order to study this

variable a correlational study would be most appropriate. Previous art experience may also be a

confounding influence, often creativity can be judged as pathology.

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It may also be helpful to study the correlation between the diagnostic information

provided by the PPAT, compared to other assessment drawings (Gantt & Tabone, 1998). This

may mean that some FEATS scales will be limited in their use and may have to be omitted when

used with other assessment drawings. Scales such as Details, Color Fit, Logic, and Person may

only be applicable to drawings that contain people. Other scales such as Color, Implied Energy,

Space, Line Quality, and Integration may be used with abstract art. More research should be

conducted to research the applicability of the scales to various drawings.

The authors also identify areas of further investigation that they have considered. One of

these avenues includes studying participant drawings in response to medication (Gantt &

Tabone, 1998). Pre and post-test studies could be conducted to investigate how various

medications affect patients during the course of treatment. The FEATS scales could also be used

to research varying degrees of depression. Since the authors have found correlations between

DSM criteria and the drawings of depressed clients, further studies could be completed to

explore how scores on the FEATS scales compare to other measures of depression. The FEATS

could also be used to study the progression of diseases such as Alzheimer‟s disease, stages of

mania, or the progression of Schizophrenia. Studies could be used to look at changes over the

span of one‟s life. A longitudinal study could follow clients over the span of decades.

The FEATS may also be appropriate to look at the differences between intake and

discharge pictures as a means to judge and document change (Gantt & Tabone, 1998). Similarly,

FEATS drawings could be used to monitor the progress of clients with substance abuse

problems. It may also be helpful to study FEATS drawings during the twelve step process

throughout one‟s recovery. The FEATS appears to be useful across a variety of setting with

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multiple populations. It is the job of art therapists to continue researching the FEATS and other

art therapy assessment and rating tools.

Conclusions

Research in assessment is a growing area in the field of art therapy with a variety of

implications. The historical foundations of art therapy and assessment were explored and found

to serve the purpose to evaluate clients through art in ways verbal communication can not. The

development, strengths and limitations of art therapy assessments today were reviewed in detail

in relation to assessing client‟s through art. It was found that these initial art-based assessments

provided the foundations for the development of art therapy assessments today. The development

of art therapy assessments was reviewed, followed by recommendations for developing art

therapy assessments in the future.

The major strengths and limitations of these assessments were also reviewed. Next, the

development of the Face Stimulus Assessment was described, as well as its current uses in the

clinical setting, current research, and limitations, and recommendations for future research. Then,

the Formal Elements Art Therapy Scale was described as well as its implications, current

research, limitations, and possibilities for future research. This review of the literature was very

helpful in identifying influences from psychology and art therapy resources that support the

thesis of this research. The literature guided the development of the research question and helped

to determine the path for examining possible solutions.

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CHAPTER 3

METHODOLOGY

Development of the Research

The current research study was a normative study of modified FSA drawings on college

students. This chapter outlines the steps taken to complete the research effort. First, the research

question is reiterated, and the research design is outlined. Next, the selection and organization of

the research sample is described. The data collection is then outlined followed by the methods

used to analyze the data collection and research findings. Finally, the chapter addresses the

validity of the study and the ethical concerns of the research.

Research Questions

The purpose of the study was to contribute to the body of work supporting the FSA as a valid

and reliable art therapy tool. Specifically, the research questions were: To what extent can scales

from the FEATS be used to successfully rate drawings from the modified FSA? As well as, to

what extent will inter-rater reliability be achieved among raters of the modified FSA drawings?

Research Design

This researcher administered FSA drawings to a sample of college students (N = 30).

Once the modified FSA drawings were collected, drawing number two was individually rated by

each of the four raters. Inter-rater reliability was determined through percentage of agreement

and the Kappa statistic on each of the 9 scales to determine the degree of agreement among

raters.

29

Sample

Participants

This research study was conducted using a convenience sample of 30 participants

enrolled at a small Midwestern university in the United States. The participants were ages 19 to

28; one participant either refused or neglected to answer (See Figure 3). Accordingly, 6

participants were male and 24 were female (See Figure 2). The ethnic groups in the sample

included: American Indian or Alaskan Native (n = 0), Asian or Pacific Islander (n = 1), Black,

Not of Hispanic Origin (n = 4), Hispanic (n = 4), White, Not of Hispanic Origin (n = 21), and

participants who did not report their ethnicities (n = 0) (See Figure 3).

Participant Recruitment Process

This researcher initially obtained permission to conduct this study through the local

university‟s research review board. University professors teaching undergraduate psychology

were subsequently approached about the research project to determine their willingness to

participate. This researcher collected FSA pictures in the classroom setting where the

participants were asked to voluntarily participate in this study. Thirty students agreed to

participate and all 30 drawings were collected and scored by the raters for data analysis. The

assessment materials were pre-coded, so participant confidentiality was maintained. Each class

was given the same verbal directions by this researcher in order to maintain standard

administration (see Appendix G).

Instrumentation

Materials

This researcher provided all necessary materials for the FSA drawings protocol. Each

participant received an informed consent form (see Appendix F), a questionnaire (see Appendix

30

E), and the modified FSA drawing materials (see Appendix A). The drawing materials included a

standard packet of 8 Crayola® markers, a packet of 8 Crayola® Multicultural markers, stimulus

picture #1: one 8 ½ x 11” sheet of white Xerox paper depicting the complete face stimulus, and

stimulus picture #2: one 8 ½ x 11” sheet of white Xerox paper depicting the outline of the face

and neck.

After the raw data was collected, 4 trained raters scored the FSA drawings based on the

FEATS Scales Adapted for use with the Face Stimulus Assessment (see Appendix B) (Betts,

2008). The raters completed the Modified FEATS Rating Sheet for each FSA drawing (see

Appendix C) (Betts, 2008).

Measuring Devices

The data collected for this research study was collected from two sources: the FSA

drawings and the demographics questionnaire created by this investigator (see Appendix E). The

data from the FSA drawings were quantified using the FEATS Scales Adapted for use with the

Face Stimulus Assessment (see Appendix C) and the Modified FEATS Rating Sheet Sample

Drawings (see Appendix D) (Betts, 2008).

Questionnaire. The questionnaire collected data on demographic information on

participants including age, gender, ethnicity, and previous art experience. When determining

previous art experience the participants were asked about: (1) experience creating art; (2) formal

art training; (3) preferred medium; (4) previous experience with assessment materials; and (5)

qualitative thoughts about the drawings activity. In the current study this information was not

used to determine a particular sample since all participants were used. This information will

hopefully play an important role in future studies of the FSA.

Modified FSA. According to Betts (2003), the FSA is a projective drawing assessment,

31

comprised of a series of three drawings, originally designed to be utilized with multicultural,

child and adolescent populations with multiple disabilities and communication problems. The

modified FSA is a modification of the original FSA assessment using only drawings 1 and 2

from the original 3 drawing series. Drawing number 1 is a standardized image of the human face.

The image is non gender specific, can be generalized to a variety of cultures, and is not specific

to any age. Drawing 1 looks at formal elements such as color, realism, recognition of the human

face, details of object and use of picture space. Drawing number 2 is an outline of the face and

neck. For this drawing a variety of elements can be considered, including color fit, realism,

details of object and use of picture space. Drawing 3 is a blank page used to determine whether

the participant will draw a face after completing the two prior stimulus drawings. For the

purposes of this study, drawing number 3 will not be used as per hypothesis (a), that drawing 2

reveals the most valid information about the participant.

FEATS. The FEATS is a reliable measurement system comprised of 14 rating scales

derived from “psychiatric symptoms, clinical observations, and the literature” (Gantt, 1990). For

the purposes of this study only 9 scales from the FEATS are used: Prominence of Color, Color

Fit, Energy, Space, Integration, Logic, Realism, Problem-solving, Developmental Level, Details

of Object and Environment, Line Quality and Perseveration (Gantt & Tabone, 1998). Each

FEATS category corresponds to a FEATS scale, rated using increments of half point scores from

zero to five. Gantt and Tabone explain in the Feats Rating Manual that higher scores does not

indicate better qualities in a drawing. Essentially, the numbers on the scales only measure more

or less of a formal element represented in a drawing.

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Procedures

This research study was completed in four stages. First, the FSA and FEATS were

modified to fit the needs of a normative college student population. Next, FSA drawings and

questionnaires were administered to the volunteer participants. Additionally, the raters were

trained to score the FSA drawings and all 30 drawings were rated using the modified FEATS

scales. Finally, the data was compiled, examined, analyzed, and the findings were reported.

Administration of the FSA

This researcher administered and collected FSA drawings to all volunteer participants in

a classroom setting. The assessment materials were coded prior to administration to ensure

participant confidentiality and anonymity. This researcher individually passed out and collected

all required materials for the FSA drawings protocol. First, each participant received two copies

of an informed consent form (see Appendix F), one to sign and be maintained in this researchers

records, and a copy for the participant‟s records. Next, the modified FSA drawing materials (see

Appendix A) were passed out to each participant. The drawing materials included a standard

packet of 8 Crayola® markers and a packet of 8 Crayola® Multicultural markers. Then each

participant was given FSA stimulus picture #1 and instructed to “use these markers and this

piece of paper” as indicated in the FSA administration instructions. Next, this researcher

collected drawing #1 and passed out drawing #2. Finally, each participant was given a

questionnaire (see Appendix E) to complete at the end of the session.

This version of the modified FSA allowed 30 minutes to complete. At the 15 minute

mark, this investigator announced that 15 minutes remained to complete the drawings. Then at

the five minute mark, this investigator announced that 5 minutes remained. At the end of the

session, this researcher collected all remaining materials and the questionnaires.

33

The participants were informed that the original artwork will be stored by this researcher

in a locked file cabinet with a key only accessible to this researcher. Scanned drawings of those

participants who consent to participate will be added to the local University Counseling and Art

Therapy Research Database. All identifiable information will be removed from the artwork for

anonymity and confidentiality. This information will be available for public use for future

research in the field of counseling and art therapy.

Rating the FSA Drawings

Once the drawings were collected, Rater 1 (Donna Betts, creator of the FSA) trained

Rater 2 (this author), Rater 3 (a graduate art therapy student at the local university aware of the

research purpose), and Rater 4 (a graduate art therapy student solicited via Rater 1, blind to the

research purpose). Rater 1 reviewed the criterion for each FEATS category and reviewed the

Modified FEATS Sample Drawings (see Appendix D) with each rater. Then, the raters practiced

independently scoring 3 drawings created and provided by the trainer. After the training session,

the four raters independently rated drawing number 2 from each participant, totaling 30

drawings. The raters recorded each participant‟s score on the Modified FEATS Rating Sheet (see

Appendix C).

Description and Justification of the Statistical Techniques Used

Statistical research conducted by Gantt and Tabone (1998) used an analysis of variance

(ANOVA) for the FEATS and found that 10 of the 12 FEATS scales differentiated amongst two

or more groups (Gantt, 1990, 1993; Betts, 2003b). Additional research on the FEATS, using

larger sample populations will yield more information, including data to support reliability and

validity.

34

Internal and External Validity

Betts recommends using specific materials during the administration of the FSA in an

attempt to standardize the assessment. In order to maintain consistency this researcher used the

recommended materials including: a standard packet of 8 Crayola® markers, a packet of 8

Crayola® Multicultural markers, stimulus picture #1, and stimulus picture #2.

In order to limit subjective biases, this researcher will act as the assessment administrator

over the duration of the project (Bucciarelli, 2007). To reduce data collector bias, this researcher

and two other raters were extensively trained by Donna Betts, the FSA author and creator. This

researcher followed a strict protocol for administering and collecting the drawings and data.

Additionally, all of the assessment drawings were collected in the same setting at a local

university.

For the purposes of this study, the original FEATS scales were modified to fit the specific

criterion of the modified FSA drawings (Betts, 2003). Modification of the original

instrumentation may be a threat to internal validity. In order to avoid validity threats, this

researcher and creator/author Donna Betts were exceedingly cautious in appropriately modifying

the FEATS scales.

One potential threat to internal validity may concern picture raters (Betts, 2003). The

additional rater was carefully chosen by the researcher to guarantee they were able to carry out

the task of rating in a satisfactory manner (Hadley & Mitchell, 1995; Betts, 2003). This

researcher made every attempt to ensure that the additional rater was not informed of the specific

research question in order to prevent this threat from compromising internal validity.

In order to give the results of this research more global applicability, this researcher

initially intended to minimize threats to external validity by collecting a large sample of modified

35

FSA drawings from which to modify the FEATS scales. The original intent was to collect a

sample between 50 and 75 drawings. The final sample size resulted in 30 drawings, which could

be a threat to external validity.

Ethical Concerns

This research study was approved by the university Research Review Board (RRB) to

carry out research with human participants. Each volunteer participant was given two copies of

an informed consent document (see Appendix F), to read and sign before volunteering to

completing the FSA assessment protocol. Each participant was asked to maintain one copy for

their records and one to turn in to be held by this researcher. The purpose of the informed

consent was to maintain participant‟s confidential information throughout the duration of the

research study. The informed consent also highlighted the rights of the participant and the rights

of the researcher in relation to this study. Each participant was asked to sign and date the consent

form to verify that they agreed with the terms of the agreement. The document explained to

participants that participation in the research was voluntary and each participant was allowed to

decline participation or drop out of the study at any time. This researcher was also present during

and after the protocol to answer any questions from the participants.

Conclusions

This chapter describes the research methodology used in the current study. The purpose

of this study is to investigate the applicability of 9 of the 14 scales from the FEATS to a

modified version of the FSA when administered to a normative population of college students

(Gantt & Tabone, 1998; Betts, 2003). All volunteer participants in the study completed an FSA

drawing for a total population of (N = 30). After which, each of the drawings were independently

rated. Statistical analysis of the data was justified, conducted, and reported. The reliability and

36

validity of the research instruments were also investigated and established. The ethical concerns

of the research study were reported and precautions were put in place to ensure the wellbeing,

confidentiality, and anonymity of the research participants. In the following chapter, the results

from the statistical analysis of the data will be presented.

37

CHAPTER 4

RESULTS

This chapter discusses the results of the study. A summary of the significant findings of

the inter-rater reliability are discussed. Then, an analysis of the results is presented. Finally, the

author‟s the conclusions are stated.

Inter-rater Reliability Results

The focus of this research endeavor was to study the results of inter-rater reliability

between modified FSA raters using the 9 adapted FEATS scales. Any correlation among raters

can be used to support the future use of the 9 FEATS scales when scoring the FSA. The results

indeed established strong reliability between raters which supports the research hypothesis.

The study included a total of four raters, including this researcher. Three additional raters were

recruited including two graduate art therapy students, and the creator of the FSA assessment,

Donna Betts. The forth rater, a graduate art therapy student, was blind to the purpose of the study

in order to study and limit subjective biases. This researcher and the two graduate student raters

were trained by Donna Betts to score the FSA drawings with the 9 FEATS scales. In the training

session, the trainer reviewed the 9 formal elements on the adapted FEATS. Each trainee rater

practiced rating 3 sample FSA drawings.

Inter-rater reliability was measured by using Fleiss‟ kappa. Fleiss‟ kappa is a statistical

measurement tool used to assess the reliability of agreement “between a fixed number of raters

when assigning categorical ratings to a number of items or classifying items” (Wikipedia

contributors, Fleiss Kappa, 2008). Fleiss‟ kappa is scored as a number between 0 and 1, and

determines the amount of agreement compared to that which would be expected by chance. The

38

closer the score is to one, the higher the inter-rater agreement. For example, if all raters are in

agreement then κ = 1 (See Table 1.).

Table 1.

Kappa Interpretation

κ Interpretation

< 0 Poor Agreement

0.0 – 0.20 Slight Agreement

0.21 – 0.40 Fair Agreement

0.41 – 0.60 Moderate Agreement

0.61 – 0.80 Substantial Agreement

0.81 – 1.00 Almost Perfect Agreement

The results of the Fleiss‟ kappa run on the rater data indicate strong inter-rater reliability

(See Table 2). The inter-rater reliability indicated is as follows: Scale 1 had a κ = .3556

indicating fair inter-rater reliability; Scale 2 had a κ = .7833 indicating substantial inter-rater

reliability; Scale 3 had a κ = .5167 indicating moderate inter-rater reliability; Scale 6 had a κ =

.7778 indicating substantial inter-rater reliability; Scale 7 had a κ = .4722 indicating moderate

inter-rater reliability; Scale 9 had a κ = .5667 indicating moderate inter-rater reliability; Scale 10

had a κ = .425 indicating moderate inter-rater reliability; Scale 11 had a κ = .5833 indicating

moderate inter-rater reliability; and Scale 14 had a κ = .817 indicating almost perfect inter-rater

reliability. The scales of Perseveration, Color Fit, and Logic showed the strongest inter-rater

reliability. The scales of Implied Energy, Realism, Developmental Level, Details of Object and

39

Environment, and Line Quality show moderate inter-rater reliability. The scale with the lowest

inter-rater reliability was Prominence of Color.

The results are based on the forced inclusion of participant drawing #127, in which rater

S omitted a score on scale 10 (See Appendix J). The most appropriate way to score this scale was

to skip over the missing score and rate the data that was available. A further explanation of this

process is included in Chapter 5.

Table 2.

Inter-rater Reliability and Agreement

Scale κ Amount of Agreement

#1 Prominence of Color .3556 Fair

#2 Color Fit .7833 Substantial

#3 Implied Energy .5167 Moderate

#6 Logic .7778 Substantial

#7 Realism .4722 Moderate

#9 Developmental Level .5667 Moderate

#10 Details of Object and Environment .425 Moderate

#11 Line Quality .5833 Moderate

#14 Perseveration .817 Almost Perfect

Analysis of Results

This research study aimed to determine the applicability of 9 of the 14 scales from the

FEATS to drawings two of the FSA. This researcher collected FSA drawings and questionnaires

40

from a normative sample of undergraduate college student (N = 30). Trained raters used 9

FEATS scales to score the 30 FSA drawings.

The initial analysis of the results reviewed the descriptive demographic information of

the normative population (N = 30). The participants ranged in age from 19 to 28, one participant

either refused or neglected to answer (See Figure 3). The average mean age was 22.517, the

median age was 22, and the mode age was 21. Of the 30 participants, 6 were male and 24 were

female (See Figure 1). The ethnic groups in the sample included: American Indian or Alaskan

Native (n = 0), Asian or Pacific Islander (n = 1), Black, Not of Hispanic Origin (n = 4), Hispanic

(n = 4), White, Not of Hispanic Origin (n = 21), and participants who did not report their

ethnicities (n = 0) (See Figure 2).

Figure 1.

Gender Distribution Graph

0

5

10

15

20

25

Male Female

Male

Female

41

Figure 2.

Ethnicity Distribution Graph

0

5

10

15

20

25

American Indian

or Alaskan Native

Asian or Pacific

Islander

Black, Not of

Hispanic Origin

Hispanic White, Not of

Hispanic Origin

American Indian or Alaskan Native

Asian or Pacific Islander

Black, Not of Hispanic Origin

Hispanic

White, Not of Hispanic Origin

Figure 3.

Age Distribution Scatter Plot

Age

0

5

10

15

20

25

30

0 5 10 15 20 25 30 35

Age

42

The data was analyzed using the computer software SPS to calculate Fleiss‟ kappa. All 9

scales were rated using all 30 drawings. Table 3 displays the minimum and maximum rating for

each FEATS scale.

Table 3.

Descriptive Statistics of FEATS Ratings on a Normative Sample

Scale Minimum

Rating

Maximum

Rating

#1 Prominence of Color 1 5

#2 Color Fit 0 5

#3 Implied Energy 3 5

#6 Logic 0 5

#7 Realism 0 5

#9 Developmental Level 0 5

#10 Details of Object and Environment 0 4.5

#11 Line Quality 1 5

#14 Perseveration 1 5

This normative sample of drawings exhibits a nearly full range of FEATS scales

intervals. The lowest scores were rated on the Color Fit (0.0), Logic (0.0), Realism (0.0),

Developmental Level (0.0), Detail of Object and Environment (0.0), Prominence of Color (1.0),

Line Quality (1.0), and Perseveration (1.0). No drawings had elements rated below a score of

1.0. The majority of the scales displayed minimum scores ranging from 0.0 to 3.0. The Implied

Energy scale was the only scale to receive a minimum score of 3.0. All scales except Details of

Object and Environment shared a maximum rating of 5.0. The majority of the scales had a range

between 1.0 and 5.0. Table IV shows the average score per scale for each of the 30 FSA

43

drawings. The mean score is the sum of all scores divided by the total number of scores (Stemler,

2001). The mean scores range from 0.0 to 5.0. Table 4 show the mode scores for each scale for

each of the 30 drawings. The mode score is the number that occurs most frequently.

Table 4.

Average Score per Scale

Scale # SC 1 SC 2 SC 3 SC6 SC7 SC 9

SC 10

SC 11

SC 14

220 4 2.375 4.375 0.25 0 1.75 0 4 5 235 1.25 2 4.25 4.375 4 4.875 3.125 4 3.5 206 3 3.125 3.625 3.25 2 3.5 2.5 4.25 4.75 227 3.625 4.75 4.25 2.25 1.75 3.75 0.75 4.25 3.75 230 3.75 4.875 4.25 5 3.5 4.25 3.25 3.125 5 205 3 5 3.625 5 3 3.875 3.5 4 4.75 234 3.375 5 4 4.75 4.125 4.625 3.375 4 4.75 204 4.375 5 4 5 4.375 5 3.375 4.125 5 231 3.25 3 4.375 3 2.5 3.625 2.875 4.375 4.875 228 4.5 5 4.375 5 4.125 4.625 3.5 4.375 5 236 4.5 5 4.125 5 3.75 4 3.375 4 5 114 4.5 5 4.125 5 3.75 4 4.125 4.125 5 134 3 1.25 3.375 0.25 0 2.75 0 4 5 300 3.25 3.75 2.875 3.75 1.625 3.625 1.875 4.125 4.75 129 3.25 5 3.875 5 3.875 4 3.5 3.5 5 131 4.625 5 4.125 5 3.75 4 4 4.125 5 132 4.5 5 4 5 3.375 4 3.25 4 5 130 4.5 4.875 4.25 4.875 3.375 4 4 4.125 5 125 1.75 3.75 2.875 5 3.25 4 3.625 3.625 5 124 4.625 3.875 4.125 4.625 3.375 4.125 2.75 4 5 105 3.25 5 4 5 3.375 4.125 4 3.625 5 122 4.5 5 4 5 3.625 4 3.125 4 4.75 128 4.5 5 4 5 3.625 4 3.5 3.5 4.75 127 4.625 5 4 5 3.875 4.625 3.667 3.875 5 107 3.125 5 3.75 5 3.125 4 4 4 5 123 3.625 5 4 5 3 3.375 2.375 3.875 5 135 3.25 5 3.75 5 3 4 3.625 4 5 108 4.375 5 4 5 4.75 5 2.5 3.625 4.75 121 4.5 5 4.125 5 4.75 4.875 2.5 4 5 116 4.625 5 4.375 5 3.75 3.875 3.625 4 5

44

Table 5.

Mode Score per Scale

Scale # SC 1 SC 2 SC 3 SC6 SC7 SC 9

SC 10

SC 11

SC 14

220 4 0 4.5 0 0 3 0 4 5 235 1 2 4 5 4 5 5 5 206 3 4 5 2 4 3 4 5 227 3 5 4 4 5 1 4.5 5 230 4 5 4.5 5 3 4 3 5 205 3 5 4 5 3 4 4 4 5 234 3 5 4 5 4 5 4 4 5 204 4 5 4 5 4 5 4.5 5 231 3 3 4 4.5 3 4 3 4 5 228 5 5 4.5 5 4 5 4 4 5 236 5 5 4 5 4 4 4 4 5 114 5 5 4 5 4 4 4 5 134 3 0 3 0 0 5 0 4 5 300 3 3 3 4 2 2 4 5 129 3 5 4 5 4 4 3.5 5 131 5 5 4 5 3.5 4 4 4 5 132 5 5 4 5 3 4 3 4 5 130 5 5 4.5 5 3 4 4 4 5 125 1 5 3 5 3 4 3 4 5 124 5 4 4 5 3 4 3 4 5 105 3.5 5 4 5 3 4 4 4 5 122 5 5 4 5 3.5 4 3 4 5 128 5 5 4 5 4 4 3.5 3.5 5 127 5 5 4 5 4 5 4 4 5 107 3 5 3.5 5 3 4 4 4 5 123 3 5 4 5 3 3 2 4 5 135 3 5 3.5 5 3 4 4 4 5 108 4 5 4 5 4.5 5 2 4 5 121 5 5 4 5 5 5 2 4.5 5 116 5 5 4 5 3.5 4 3.5 4 5

Conclusions

This chapter presented the results and analysis of the FSA drawings rated with 9 scales

from the FEATS. Significant norms for the FEATS scales were discussed. In addition, the results

for trends in the subgroups gender, ethnicity, and age were highlighted. The findings indicated

45

that inter-rater reliability was strong for most of the 9 FEATS scales. Additional research should

be conducted to investigate the appropriateness of the Prominence of Color scale, due to its

lower inter-rater reliability. Based on these results, it was concluded that the modified FEATS

shows initial strength as a measurement tool to be used with the FSA.

46

CHAPTER 5

DISCUSSION

The final chapter in this research paper highlights the author‟s conclusions about the

entire study. This chapter examines the data collection and the research findings. Limitations of

the study are discussed and the author‟s suggestions for further research are outlined. Finally, the

conclusions and implications of the study are discussed.

This research study looked at 30 drawings from a normative college student population.

The drawings were rated using 9 scales from the FEATS. Statistical techniques were used to

calculate inter-rater reliability between all 4 raters on the 9 FEATS scales. The results were

analyzed and the significant outcomes were reported. The findings produced answers to the

research questions outlined at the beginning of the study. The following sections look at the

collected data, look at the outcomes, and highlight conclusions about the findings.

Research Questions

The underlying idea of this research study was to develop a standardized rating system

for the FSA by adapting 9 scales from the Formal Elements Art Therapy Scale which included:

Prominence of Color, Color Fit, Energy, Space, Integration, Logic, Realism, Problem-solving,

Developmental Level, Details of Object and Environment, Line Quality, and Perseveration

(Gantt & Tabone, 1998).

The research question was: To what extent can scales from the FEATS be used to

successfully rate drawings from the modified FSA? An additional question includes: To what

extent will inter-rater reliability be achieved among raters of the modified FSA drawings? The

findings from this study will be helpful in establishing reliability and validity for the Face

47

Stimulus Assessment. Conclusions about the research results are presented in the following

sections.

Inter-rater Reliability Issues

A total of four raters participated in rating the FSA drawings. The raters included: rater 1

was Donna Betts (D), rater 2 Sheila Lorenzo (S), rater 3 this author Michelle Hamilton (M), and

rater 4 Nannie Mead (N). This researcher attempted to improve inter-rater reliability by

recruiting an experienced trainer to train the raters. The trainer Donna Betts, creator of the FSA,

was chosen due to her experience with the FSA and FEATS and years of experience as an art

therapist and art therapy researcher. Rater 3 and 4 were located in the Midwest and were trained

in a training session via phone and internet by the trainer. Rater 2 was trained in an identical

training session in the presence of the trainer. During the training session, the trainer reviewed

each of the 9 FEATS scales (See Appendix B) and provided the trainees with sample drawings

(See Appendix D) to be used as guides with the modified FEATS.

The first issue related to inter-rater reliability is consistency in training. Ideally, all raters

would have been trained together in one training session. In the interest of distance and time, the

best option was to hold two training sessions. Future studies may investigate the difference in

inter-rater reliability when all raters are trained together. A second issue arises from the use of

this author and the creator of the FSA as raters. This author and the creator of the FEATS, Donna

Betts, participated in the rating process and took a hands-on approach to the research project. To

decrease rater bias, this author and the FSA creator could have been included and their results

compared to the results of the other raters to detect any biases. The third inter-rater reliability

issue concerns rater awareness of the research hypothesis. Rater 2 was the only rater blind to the

study. The final issue related to inter-rater reliability was missing data on drawing #127 scale

48

10. Rater 2 neglected to respond to this question, which affected the inter-rater reliability on the

Details of Objects and Environment Scale. Overall the issues of inter-rater reliability do not

appear to have confounded the results of the study. Additional research should be conducted to

further study the affects of these variables.

Limitations of the Study

There are a number of factors that limit the applicability of the research study results.

First, size and population significantly limit the overall generalizability of the study. The study

participants were recruited from a local university. The sample was a normative convenience

sample, and only 30 participants volunteered to participate. Ideally, the participants would have

been randomly selected. Because the sample was normative, the individual participant

characteristics were not varied in age, race, gender, socioeconomic status, education background,

or psychiatric diagnosis. The majority of the participants in this study were white females

between the ages of 19 and 28. Preferably, the normative population would have been more

representative of a random sample.

Secondly, the study was limited by population sample size. This researcher originally

planned to gather a sample of 50 to 75 participants. Unfortunately, the population size was

significantly smaller. Ideally, the sample size would range from 150 to 200 participants to

achieve statistically significant results. Future research endeavors should investigate the use of a

larger sample size.

Finally, the FSA assessments were administered in a classroom setting to a group of 10 to

15 people over three separate sessions. Environmental variables were somewhat varied between

the three sessions, but this researcher made every attempt to minimize these factors. Ideally, to

49

minimize compounding variables the FSA could have been administered to the randomly

selected participants on an individual basis in a controlled environment.

Recommendation for Future Research

Further research endeavors should attempt to substantiate and support the data collected

in this study and attempt to establish tests for reliability and validity for the use of the modified

FEATS with the adapted FSA. Future studies could be conducted at other larger college

campuses with a random sample of students from a more diverse population of participants.

Studies on the use of the modified FEATS with the FSA will provide helpful information about

specific population characteristics. Additional research could also investigate differences in

gender, age, educational background, socioeconomic status, artistic experience, and ethnicity

among participants.

Further normative studies should also be conducted due to their usefulness in better

understanding art therapy assessments (Bucciarelli, 2007). Larger samples of drawings could

also be used to investigate the correlation between raters. Before the FSA can be used in

experimental studies more normative studies should be conducted and inter-rater reliability

tested further. Future studies should also investigate the use of raters who are blind to the

research purpose. Raters that are not invested in the study should be used to investigate biases.

All future research efforts involving the FSA will ultimately result in strengthening its use as a

valid and reliable art therapy assessment.

Conclusions

The purpose of this study was to investigate the applicability of 9 scales from the FEATS

to a modified version of the FSA using a normative sample of college students. This paper

50

provided justification for the research study, and presented a detailed research question and

hypothesis. The relevant terms were defined in relation to the study.

Additionally, the literature review highlighted the history of art therapy assessments

including their development, strengths, and limitations. Relevant information about various art

therapy assessments were highlighted. Then the FSA and FEATS were described in detail,

including their development and recommendations for further development.

The methodology chapter begins with the development of the research including the

research design and procedures that were used in this study. The study included volunteer

participants from a normative convenience sample of college students at a local university. The

students were asked to complete the FSA and a short questionnaire. The 30 drawings were rated

using the modified FEATS then statistically analyzed using Fleiss‟ kappa to determine inter-rater

reliability. Internal and external validity were examined followed by the ethical concerns of the

study.

Finally, the results were examined and shown to support the research hypothesis. Strong

inter-rater reliability was established for most of the 9 scales, with the exception of the

Prominence of Color scale. This research study contributes to the collection of current FSA

research and provides a foundation for further research endeavors. Outcomes of this study not

only support the use of the modified FEATS with the FSA, but also lends support to further

research to establish reliability and validity for the FSA. This study can provide a foundation for

larger studies to examine the use of the FSA in both clinical and research settings. Researchers

and clinicians can hopefully use the results of this study to jumpstart future research endeavors

involving the Face Stimulus Assessment.

51

APPENDIX A

MODIFIED FSA TEMPLATE

53

APPENDIX B

ADAPTED FEATS SCALES FOR USE WITH THE FSA

FEATS Scales Adapted for use with the Face Stimulus Assessment (FSA)

April 2008

SCALE #1 – PROMINECE OF COLOR

How much color is used? Is the color only used to define an item or shape or is it used to color in

the item or shape?

This variable cannot be rated. The person did not do the drawing or the person did not

use the required materials.

0

Color is used only to outline the forms or objects in the picture, or to make lines; none

of the forms are colored in.

1

Color is used for outlining most of the forms or objects, but only one form or object is

filled in (such as the face, the neck, or the background). [For small elements such as

an earring, it may be difficult to decide whether it is just outlined or filled in as well

as outlined.]

2

Two or more (but not all) forms or objects are colored in. 3

Color is used for both outlining the forms and objects and filling them in. 4

Color is used to outline the forms and objects, to color them in, and to fill in the space

around the forms (for example, a completely colored face).

5

SCALE #2 – COLOR FIT

How well do the colors fit the facial features and objects in the drawing?

Given the colors in the sets of markers, several are suitable for coloring the face and might relate

to an ethnic group identification: each of the eight Multicultural markers, and from the other set

of Crayola markers, black, brown, yellow, orange, or red. However, blue, green, or violet are not

appropriate colors for parts of the body (such as face or hands).

This variable cannot be rated. The person did not use the specified materials, or the

colors are difficult or impossible to distinguish from each other.

0

The entire picture is drawn in only one color, and that color is blue, green, or violet. 1

The entire picture is drawn in only one color, and that color is black, brown, yellow,

orange, red, or any of the eight Multicultural markers.

2

Some colors (but not all) are used appropriately. 3

Most of the colors are used appropriately. 4

All the colors are appropriate to the specific facial features and objects in the picture. 5

54

SCALE #3 – IMPLIED ENERGY

Look at the way in which the picture was drawn, and imagine how much energy and effort it

would take if you drew in the same manner. Consider the energy that is necessary to switch

colors.

This variable cannot be rated; or, the person did not do the drawing. 0

The drawing appears to be done with the least amount of energy possible to do the

task.

1

The drawing appears to be done with relatively little energy. 2

The drawing appears to be done with an average amount of energy. 3

The drawing appears to be done with a considerable amount of energy. 4

The drawing appears to be done with an excessive amount of energy. 5

SCALE #6 – LOGIC

Do the components of this picture fit the task? Remember that this is supposed to be a picture of

a human face.

It is important to distinguish between this scale and the next one on realism. An individual

element may be recognizable, but it is bizarre or illogical in this particular picture. For example,

there may be an animal‟s or an alien‟s face instead of a human face. This would rate a 4 on the

scale if it were the only bizarre or illogical element in the picture. However, sometimes an

element which at first appears to be bizarre is used by the artist in a humorous fashion. If the

total effect seems to be intentionally humorous or satirical, do not rate it as illogical.

This variable cannot be rated because individual items cannot be identified. 0

The picture is not logical at all, or it has more than 3 bizarre items that do not fit the

task.

1

The picture has 3 bizarre items that do not fit the task. 2

The picture has 2 bizarre items that do not fit the task. 3

The picture has 1 bizarre item, but it is generally logical. 4

There are no bizarre or illogical elements in the picture. 5

55

SCALE #7 – REALISM

Can you recognize all the elements in the picture? The more realistic and three-dimensional the

elements are, the higher the rating would be.

The Person scale seeks to determine if “the person in the picture looks like a three-dimensional

person rather than a stick figure” (p. 41). This is related to qualities defined in the Realism scale.

Thus, this scale (Realism) is combined with the original FEATS scale #12, Person. Gantt and

Tabone (1998) asserted that if the person in a PPAT drawing “is severely distorted or fragmented

we assume the artist has a distorted or fragmented sense of self” (p. 41). It follows, therefore,

that a face drawn in the FSA that is severely distorted or fragmented would also reflect upon the

artist‟s sense of self.

The picture is a mass of lines and/or shapes and has no visually identifiable items in

it.

0

There are some elements which might have been intended by the artist to represent a

human face and/or accessories, however, they are no more than suggestive of these

elements.

1

The items are recognizable but simply drawn (ex., a triangle for a nose). 2

The items are somewhat complex (ex., eyes with pupils; ears, eyebrows). 3

The items are relatively realistically rendered (ex., the face has distinct features, such

as lips and/or teeth; the nose has nostrils or suggestion of nostrils; eyelids are shaded).

4

The items are drawn with a great deal of realism (ex., definition in chin; shading of

cheekbones; highlighting of nose; texture in hair).

5

SCALE #9 – DEVELOPMENTAL LEVEL

How would this picture be rated according to Lowenfeld‟s developmental levels? Determining

the developmental level is usually done with children‟s drawings. However, many people stop

drawing in adolescence; therefore, many adults will draw in the style of adolescents, not having

developed their artistic skill any further. The scale is used to give a rough estimate of the

developmental level. If children‟s drawings were being studied, we would need a more finely

gauged scale to rate them accurately.

This variable cannot be rated because the individual elements cannot be identified. 0

The drawing consists solely of scribbles or masses of lines and shapes. 1

The drawing is like those of four- to six-year-olds (ex., geometric shapes are

predominant, exaggerated facial features are typical).

2

The drawing is like those done by latency-age children (ex., more detail for individual

features).

3

The drawing is like those done by adolescents (with overlapping of objects and with

realistic sizes for each element in relation to the others).

4

The drawing is an “adult” drawing and shows some artistic sophistication or training. 5

56

SCALE #10 – DETAILS OF OBJECTS & ENVIRONMENT

How many extra items are there in the drawings? How detailed are the various items?

This variable cannot be rated because individual items cannot be identified. 0

There is nothing but a few elements such as facial features, and these are drawn

simply with little detail (ex., dots or circles for eyes, a suggestion of a nose, and a

basic mouth).

1

In addition to facial features, one or two other details are added (ex., a neckline; hair;

a piece of jewelry; an object in the background).

2

In addition to facial features, there are two or three additional details (ex., a horizon

line; a hat; a beard and/or moustache).

3

In addition to facial features, there are a number of details such as a horizon line,

jewelry, hair bows, glasses, eyelashes.

4

In addition to facial features, other facial details and accessories, there are abundant

and inventive details such as a pattern on clothing and objects in the background (ex.,

the sun; clouds; grass; trees; other objects).

5

SCALE #11 – LINE QUALITY

How much control did the artist have when drawing the lines in the picture? Consider the

“average” of the whole picture.

This variable cannot be rated. 0

In general, the lines appear to be drawn erratically with no apparent control. 1

The lines appear to be drawn with a shaking hand. 2

Some lines are continuous and some lines have gaps in them, or are made of a series

of dots or dashes.

3

The lines are under control. 4

The lines are quite fluid or flowing (even excessively so). 5

57

SCALE #14 – PERSEVERATION

Does it seem that any of the lines or elements were drawn repeatedly and without conscious

control? For example, there may be many small dots all over the face. An element may be

repeated a number of times; however, this is not perseveration if it appears to be intentional. For

example, the drawing rated “5” has several looping rings (the hair and neckline) but it appears as

if the artist had control over them.

In the drawing rated “1” it seems that the artist did not have control as lines are drawn over and

over until a hole is nearly worn in the paper. This example, rating “1” shows motor

perseveration, while the example for rating “3” shows repetition of a single graphic element

(hairs on the head).

This variable cannot be rated. 0

The picture has a great deal of perseveration (ex., a line is drawn over and over until a

hold is worn in the paper).

1

The picture has a considerable amount of perseveration. 2

There is a moderate amount of perseveration (such as many hairs drawn on the head);

or, there is only one area where a line is drawn over and over.

3

There is a slight amount of perseveration. 4

There is no perseveration. 5

58

APPENDIX C

MODIFIED FEATS RATING

60

APPENDIX D

MODIFIED FEATS RATING SHEET SAMPLE DRAWINGS

63

APPENDIX E

DEMOGRAPHIC INFORMATION SURVEY FOR RESEARCH PARTICIPANTS

The purpose of this study is to provide information about the use of an art therapy assessment on

a normative undergraduate college student population. Please provide the following information

along with your drawings for use in this research project:

1. What is your current age? _____

2. What is your gender?

Male

Female

3. What is your ethnic background (choose only one)?

American Indian or Alaskan Native - A person having origins in any of the

original peoples of North America, and who maintains cultural identification

through community recognition or tribal affiliation.

Asian or Pacific Islander - A person having origins in any of the original

peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific

Islands. This area includes, for example, China, India, Japan, Korea, the Philippine

Islands and Samoa.

Black, Not of Hispanic Origin - A person having origins in any of the black

racial groups of Africa. Does not include persons of Mexican, Puerto Rican, Cuban,

Central or South American, or other Spanish cultures or origins (See Hispanic).

Hispanic - A person having Mexican, Puerto Rican, Cuban, Central or South

American, or other Spanish cultures or origins (Regardless of Race). Does not

include persons of Portuguese culture or origin.

White, Not of Hispanic Origin - A person having origins in any of the original

peoples of Europe, North Africa, or the Middle East. Does not include persons of

Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish

cultures or origins (See Hispanic). Also includes persons not included in other

categories.

4. Do you have experience creating art? ______

5. Have you had formal art training (i.e. elementary, high school, or college)? ___________

6. When was the last time you had formal training in art? ___________________________

7. If you do create art what is your preferred medium?______________________________

8. Have you used Crayola Multicultural markers before? ______ If yes, how long

ago?_____

9. What are your thoughts about this activity? (please respond in the space provided or on

the back)

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APPENDIX F

CONSENT FORM

CONSENT TO SERVE AS A SUBJECT IN RESEARCH

I have been informed that this study involves research which will be conducted by Michelle Hamilton, a

student at Avila University. I understand that this project is designed to study the use of an art therapy

assessment on a normative undergraduate college student population. I understand that my participation

in this study will involve the creation of two assessment drawings. I am aware that my involvement in

this study will take approximately 40 minutes.

I understand that I may refuse to participate or withdraw from this study at any time without any penalty

or loss of services that I am entitled to. I understand that my identity as a participant in this study will be

kept in confidence and that no information that identifies me in any way will be released without my

separate written approval. I also understand that there may be risks to my anonymity in the event that

other group members may be able to identify my drawings by the information I provide in the

demographics survey, which includes age, gender, ethnicity, and previous art experience.

I have been informed that upon the completion of this study an Avila University Counseling and Art

Therapy Research Database will be created in which my drawings and demographic information will be

stored. This database will be accessible by the public and will include the drawings as well as the

demographic information I provided.

I am aware that although I may not directly benefit from this study, my participation in this project may

benefit research in the area of counseling and art therapy research, more specifically, research in the area

of art therapy assessment.

If you would like additional information concerning this study before or after it is complete, please feel

free to contact me by phone or mail. If you have concerns or questions about your rights as a research

participant you may contact the Avila University Research Review Board at 816-501-3759 or Sue King at

[email protected].

I understand that I will be signing two copies of this form. I will keep one copy and Michelle Hamilton

will keep the second copy for her records.

I have read this form and understand what it says. I am 18 years or older and voluntarily agree to

participate in this research project.

Sincerely,

Michelle Hamilton, Laura Aube‟ MS, LPC, ATR-BC

Principal Investigator Faculty Supervisor

Master‟s of Counseling and Art Therapy Director of Counseling and Art Therapy

Avila University Avila University

11901 Wornall Road 11901 Wornall Road

Kansas City, MO 64145 Kansas City, MO 64145

816-686-4704 816-501-3792

_____________________________________ ________________________________

Participant‟s Signature Date

65

APPENDIX G

VERBAL DIRECTIONS

VERBAL DIRECTIONS AND REQUIRED STATEMENTS

Required Statements Given to Participants Prior to Administration

“Hello, my name is Michelle Hamilton and I am a graduate student in the Counseling and

Art Therapy program. I am currently conducting a study using a previously established art

therapy assessment with the intent of creating a formal rating scale for this art therapy

assessment. Findings from this research study will have implications in a variety of areas. The

information gathered will be applicable to furthering the global usage of this art therapy

assessment. This information can be used by researchers to establish reliability and validity of

the assessment and its rating system. This assessment could have valuable implications for the

fields of counseling and art therapy. Although you may not directly benefit from this study, your

participation in this project may benefit research in the area of counseling and art therapy

research.

This project is designed to study the use of an art therapy assessment on a normative

undergraduate college student population. If you agree to participate in this study please

understand that your participation will involve the creation of two assessment drawings. Your

participation in this study will take approximately 40 minutes to complete.

Please understand that you may refuse to participate or withdraw from this study at any

time without any penalty or loss of services that you are entitled to. Your identity as a participant

in this study will be kept in confidence and no information that identifies you in any way will be

released without your separate written approval. Please understand that there may be risks to

your anonymity in the event that other group members may be able to identify your drawings by

66

the information you provide in the demographics survey, which includes age, gender, ethnicity

and previous art experience.

If you agree to participate, the original artwork will be stored by this researcher in a

locked file cabinet with a key only accessible to me. Upon completion of this study an Avila

University Counseling and Art Therapy Research Database will be created in which your

drawings and demographic information will be stored. All identifiable information will be

removed from the artwork to protect the anonymity and confidentiality of each study participant.

This database will be accessible by the public and will include the drawings as well as the

demographic information you provided.

I am now going to hand out two copies of a form titled Consent to Serve as a Subject in

Research (Pass out consent forms). Read the consent form and if you agree to these terms and

conditions please sign both copies. You will keep one for your records and I will keep one for

my records” (Collect consent forms).

Verbal Directions Given to Participants Prior to Administration

“Now I am going to pass out the first of two drawing tasks. Each of the two drawings has

been randomly labeled with the same number in order to keep them together once they are

collected. You will have thirty minutes to complete both stimulus drawings. At the 15 minute

mark I will announce that there are 15 minutes remaining. Then at the 25 minute mark I will

announce that there are 5 minutes remaining until the end of the assessment session.

When you are finished with the first drawing please raise your hand and I will collect the

first drawing and give you the second to complete. When the entire group has completed both

drawings and the 30 minute time frame is up, I will give you a short survey which gathers

demographic information including age, gender, and ethnicity. This survey is also labeled with

67

the same number as your two drawings. In the interest of confidentiality and anonymity please

DO NOT LOOK at the drawings of other group members.

Okay, is everyone ready to start? Here is the first drawing. Please do not begin until

instructed to do so. (Pass out the first stimulus drawing and both sets of markers). You may

now begin, the instructions are as follows: “Use these markers and this piece of paper””.

Verbal Directions Given to Participants During Administration

1. At the 15 minute mark I will announce that there are 15 minutes remaining.

- “There are now 15 minutes remaining”

2. At the 25 minute mark I will announce that there are 5 minutes remaining until the end

of the session.

- “There are now 5 minutes remaining”

Verbal Directions Given to Participants After Administration

“The 30 minute time frame is now up. I will come around and collect your drawings

(Collect drawing number two). Thank you for your participation in my research study. If you

would please take a moment to complete the following demographics survey (Pass out

demographics survey). Thank you for your time and participation.”

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APPENDIX H

PERMISSION LETTER FOR FSA

69

APPENDIX I

PERMISSION LETTER FOR FEATS

70

APPENDIX J

FEATS RATINGS OF MODIFIED FSA DRAWING TWO

Table 6.

FEATS Scales (1) Prominence of Color and (2) Color Fit

# Scale 1 Scale 2

D S M N D S M N

220 4 4 4 4 0 3.5 1 5

235 2 1 1 1 2 2 2 2

206 3 3 3 3 3 2 2.5 5

227 3 5 3.5 3 5 5 4 5

230 3 4 4 4 5 4.5 5 5

205 3 4 3 2 5 5 5 5

234 3 4.5 3 3 5 5 5 5

204 4.5 5 4 4 5 5 5 5

231 3 4 3 3 3 3 3 3

228 5 5 4 4 5 5 5 5

236 5 5 4 4 5 5 5 5

114 5 5 4 4 5 5 5 5

134 2 4 3 3 0 0 0 5

300 3 4 3 3 3 4 3 5

129 3 4 3 3 5 5 5 5

131 5 5 4.5 4 5 5 5 5

132 5 5 4 4 5 5 5 5

130 5 5 4 4 5 4.5 5 5

125 1 1 2 3 5 2 5 3

124 5 5 4.5 4 4.5 4 4 3

105 3.5 3.5 4 2 5 5 5 5

122 5 5 4 4 5 5 5 5

128 5 5 4 4 5 5 5 5

127 5 5 4.5 4 5 5 5 5

107 3 3.5 3 3 5 5 5 5

123 4 4.5 3 3 5 5 5 5

135 3 4 3 3 5 5 5 5

108 4.5 5 4 4 5 5 5 5

121 5 5 4 4 5 5 5 5

116 5 5 4 4.5 5 5 5 5

Rater Key:

D= Donna Betts S= Sheila Lorenzo M= Michelle Hamilton N= Nannie Mead

71

Table 7.

FEATS Scales (3) Implied Energy and (6) Logic

# Scale 3 Scale 6

D S M N D S M N

220 4.5 4.5 4.5 4 0 0 0 1

235 4 5 4 4 5 3.5 5 4

206 3.5 4 3 4 5 2 5 1

227 5 4 4 4 4 0 4 1

230 4.5 4.5 4 4 5 5 5 5

205 3.5 4 4 3 5 5 5 5

234 4 4 4 4 5 4 5 5

204 4 4 4 4 5 5 5 5

231 4.5 5 4 4 4.5 1 4.5 2

228 4.5 4.5 4 4.5 5 5 5 5

236 4.5 4 4 4 5 5 5 5

114 4.5 4 4 4 5 5 5 5

134 3 3 4 3.5 0 0 0 1

300 3 3.5 3 2 4 3 4 4

129 3.5 4 4 4 5 5 5 5

131 4.5 4 4 4 5 5 5 5

132 4 4 4 4 5 5 5 5

130 4.5 4 4.5 4 5 4.5 5 5

125 3 2.5 3 3 5 5 5 5

124 4.5 4 4 4 5 4.5 5 4

105 4 4 4 4 5 5 5 5

122 4 4 4 4 5 5 5 5

128 4 4 4 4 5 5 5 5

127 4 4 4 4 5 5 5 5

107 3.5 4 4 3.5 5 5 5 5

123 3.5 4.5 4 4 5 5 5 5

135 3.5 3.5 4 4 5 5 5 5

108 4 4 4 4 5 5 5 5

121 4 4.5 4 4 5 5 5 5

116 5 4 4 4.5 5 5 5 5

Rater Key:


72

Table 8.

FEATS Scales (7) Realism and (9) Developmental Level

# Scale 7 Scale 9

D S M N D S M N

220 0 0 0 0 1 0 3 3

235 4 4 4 4 5 4.5 5 5

206 2 2 2 2 3.5 2.5 4 4

227 0.5 4 2.5 0 1 5 5 4

230 3.5 4.5 3 3 4.5 3.5 5 4

205 3 3 3 3 3.5 4 4 4

234 4 5 3.5 4 4.5 4 5 5

204 4 5 4.5 4 5 5 5 5

231 3 2 2 3 4 2.5 4 4

228 4 4.5 4 4 4.5 4 5 5

236 4 4 4 3 4 4 4 4

114 3 4.5 4 3.5 3.5 4.5 4 4

134 0 0 0 0 1 0 5 5

300 1.5 2 2 1 3.5 2 4 5

129 3.5 4 4 4 4 4 4 4

131 3.5 4 3.5 4 4 4 4 4

132 3 4 3.5 3 4 4 4 4

130 3 4 3.5 3 4 4 4 4

125 3 4 3 3 4 4 4 4

124 3 4 3.5 3 4 4 4.5 4

105 3 4.5 3 3 4 4.5 4 4

122 3.5 3.5 3.5 4 4 4 4 4

128 3 3.5 4 4 4 4 4 4

127 3.5 4 4 4 4.5 4 5 5

107 3 3.5 3 3 4 4 4 4

123 3 3 3 3 3.5 3 4 3

135 3 3 3 3 4 4 4 4

108 4.5 5 5 4.5 5 5 5 5

121 5 4 5 5 5 4.5 5 5

116 3.5 3.5 4 4 4 4 4 3.5

Rater Key:


73

Table 9.

FEATS Scales (10) Details of Object and Environment (11) Line Quality

# Scale 10 Scale 11

D S M N D S M N

220 0 0 0 0 4 4 4 4

235 3.5 4 3 2 5 5 5 1

206 3 3 2 2 4 4.5 4 4.5

227 1 0 1 1 4.5 4.5 4 4

230 3 4 4 2 3 3 3.5 3

205 4 4 3 3 4 4 4 4

234 4 4 3.5 2 4 4 4 4

204 3 4.5 4 2 4.5 4.5 4.5 3

231 2.5 3 3 3 4.5 5 4 4

228 4 4 4 2 4.5 5 4 4

236 3.5 4 4 2 4 4 4 4

114 4 4.5 4 4 4.5 4 4 4

134 0 0 0 0 4 4 4 4

300 1.5 2 2 2 4.5 4 4 4

129 4 4.5 3.5 2 3.5 4 3.5 3

131 4 4 4 4 4.5 4 4 4

132 4 3 3 3 4 4 4 4

130 4 4 4 4 4.5 4 4 4

125 4 4.5 3 3 4 4 3.5 3

124 3 3 3 2 4 4 4 4

105 4 4.5 3.5 4 3.5 4 4 3

122 3 3.5 3 3 4 4 4 4

128 3.5 3.5 4 3 4 3.5 3.5 3

127 4 -- 4 3 4 3.5 4 4

107 4 4 4 4 4 4 4 4

123 2.5 2 3 2 4 3.5 4 4

135 4 3.5 4 3 4 4 4 4

108 2 3 3 2 3.5 4 4 3

121 2 3 3 2 4.5 4.5 4 3

116 4 3.5 3.5 3.5 4 4 4 4

Rater Key:


74

Table 10.

FEATS Scale (14) Perseveration

# Scale 14

D S M N

220 5 5 5 5

235 5 2 5 2

206 5 5 5 4

227 1 5 5 4

230 5 5 5 5

205 5 5 5 4

234 5 5 5 4

204 5 5 5 5

231 5 4.5 5 5

228 5 5 5 5

236 5 5 5 5

114 5 5 5 5

134 5 5 5 5

300 5 5 5 4

129 5 5 5 5

131 5 5 5 5

132 5 5 5 5

130 5 5 5 5

125 5 5 5 5

124 5 5 5 5

105 5 5 5 5

122 5 5 5 4

128 5 5 5 4

127 5 5 5 5

107 5 5 5 5

123 5 5 5 5

135 5 5 5 5

108 5 5 5 4

121 5 5 5 5

116 5 5 5 5

Rater Key:


75

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BIOGRAPHICAL SKETCH

Michelle Hamilton is a Masters of Science candidate at Avila University in the Counseling and

Art Therapy program. She currently works as an art therapist at a psychiatric hospital and as a

traveling art therapist with hospice clients. Upon graduation, Michelle hopes to continue her

education and continue conducting art therapy research.

Developing a Standardized Rating System for the Face Stimulus Assessment

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