Towards a Purposeful Ending

8/13/2019 Towards a Purposeful Ending

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Towards a Purposeful Ending:A study exploring the impact of Dramatherapy on the quality of life of people

living with dementia.

By Rasha Mechaeil - University of Sussex

Alex Graybow & Peter Cobham - Baobab (Creative Arts Therapies)

bstract

The aim of this study was to explore the effects of Dramatherapy on people

living with dementia. The work was a small scale quantitative study carried

out over 12 weeks comparing the experience of a Dramatherapy group with

an activity group. The subjects lived in the same care home and were

randomly assigned to the groups. Audits assessing quality of life measures

were carried out at regular intervals.

The study found that the clients receiving Dramatherapy showed significant

improvements in quantitative measures of attentiveness and engagement

compared with those taking part in the activity group. The results identified

a cumulative benefit which suggests increasingly positive outcomes for longer

term Dramatherapy.

BackgroundIn his 1930 article The Stages of Life,Carl Jung wrote A human being

would certainly not grow to be seventy or eighty years old if this longevity

had no meaning for the species. The afternoon of human life must also have asignificance of its own and cannot be merely a pitiful appendage to lifes

morning.

The need for a purposeful ending is no different for older people who are

living with dementia. It may be that there is a greater need to support and

nurture a sense of acceptance and reconciliation for this group because

dementia not only causes the loss of cognitive functioning, frequently

individuals also experience the loss of their independence and relationships.


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Dramatherapy works with subjective experience. It provides tools for

emotional expression, an opportunity for social interaction and a place for

independence and choice. It can give purpose and meaning in an environment

where this may be lacking. Dramatherapy also focuses on the importance of

contact and connection. It is not based on cognitive ability and so is

particularly appropriate for people living with dementia.Alex Graybow and Peter Cobham, Dramatherapists working for Baobab

(Creative Arts Therapies) had been subjectively evaluating the benefits of

Dramatherapy at Quantum Care. Quantum Care is an organisation providing

residential homes and services for older people across Hertfordshire.

Quantum Care requested that the Dramatherapy work be more formally

evaluated, which led to this project.

MethodTo evaluate the efficacy of Dramatherapy with a group of individuals living

with dementia, we posed the following question: Can Dramatherapy positively

affect mood and social contact for older people with dementia thus improving quality

of life? We set out to measure eight factors we felt pertained to an

individuals quality of life, namely; anxiety, happiness, social contact, bodyposture, levels of confidence, energy, attention and engagement. We set out

to show the immediate effects of Dramatherapy and whether any of these

could be sustained.

Following conversations with Jenny Rusted, an Experimental Psychologist at

the University of Sussex, we agreed that a method similar to a Randomised

Control Trial (RCT) would be used as a tool for the evaluation. The study

differed from a RCT in that although the clients were randomly assigned to

the group, the assessors were not blind to the membership of the groups andtherefore the data collected may have been influenced by preconceptions and

expectations.

Ethical ConsiderationsConsent was obtained from both the clients and their families. The option to

withdraw consent at any time was also given. The consent process was

carried out by the management at the care home.


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ParticipantsThe Dramatherapists spoke with all the residents with dementia on the

chosen unit. This was to establish who would be interested in attending the

Dramatherapy sessions for the purpose of an evaluation. 4 clients

volunteered to attend the group.

The Dramatherapists then ran a familiarisation session with the potential

group members to assess their response and whether the group will be viable

for the evaluation.

A control group was set up, running at the same time as the Dramatherapy

group. The Control Group carried out an activity. To reduce variables, a

similar activity took place each week. 4 clients were randomly chosen from

this group and were assessed in the same way as those attending the

Dramatherapy sessions.

Data GatheringThe assessments were carried out by five assessors, the two

Dramatherapists and three members of staff who facilitated the activity

group. The Dramatherapists ran workshops for the staff carrying out the

assessment to pilot a suitable questionnaire. This allowed for changes to be

made to the questionnaire, facilitating the process and ensuring that the aims

of the evaluation were understood and supported by the lay assessors.

Each assessor completed a questionnaire pre and post each session, rating

each client on the eight factors (anxiety, happiness, social contact, body

posture, levels of confidence, energy, attention and engagement). One

assessor also completed a questionnaire at the mid-point between each of the

sessions regarding all of the client subjects.

The Dramatherapists kept in depth process notes after each session. These

were used to create a more subjective evaluation of the project.


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Data AnalysisThe data analysis and report was prepared by Rasha Mechaeil, Department of

Psychology, Sussex University, with guidance from Jennifer Rusted,Department of Psychology, Sussex University

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Study designEight older people living with dementia took part in a study investigating the

potential benefits of Dramatherapy. Four of those eight participants were

assigned to a Dramatherapy condition and four acted as control participants,

not engaging in Dramatherapy but involved in normal day centre activities in aregular time slot of similar duration to the Dramatherapy session each week.

There were 12 sessions in total, over a 13 week period. The effects of

therapy were assessed on the basis of eight individual factors, namely,

anxiety, happiness, social contact, body posture, levels of confidence, energy,

attention, and engagement. Assessments were conducted by five assessors,

who each rated each participant on each of the factors pre-session and post-

session. Three of the assessors facilitated the control activity and two of the

assessors ran the Dramatherapy sessions. (assessors 1 and 2). In addition to

the session assessments, one assessor provided an assessment of all

participants on all factors at the mid-point between each of the sessions. Thedata were collated and analysed by researchers at the Department of

Psychology, University of Sussex.

Data descriptionAs is conventional, an alpha level of .05 was employed for all analyses unless

otherwise stated.

Volunteer characteristicsMean age for volunteers assigned to the control and Dramatherapy conditions

is presented in table 1 below.

Group N Mean Age

Control 4 89.5 1.3

Dramatherapy 4 85 8.8

Table 1: mean (SD) age of participants


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An independent measures t-test revealed no significant difference in age

between volunteers in the control group and dramatherapy group [p>.05].

Any treatment effects cannot, therefore, be attributed to age differences

between participants.

Pre-session evaluationsSession 6 is excluded from all analyses due to missing data.

For each of the factors of anxiety, happiness, social contact, confidence, body

posture, energy, attention, and level of engagement, a mixed 2 x 13 (group x

session) analysis of variance (ANOVA) was conducted on pre-sessions to

check for group differences prior to engaging in the sessions. No significant

differences were evident between volunteers assigned to Dramatherapy orcontrol sessions on any of the measures [all, p>.05]. This was true when the

measures recorded by the two assessors who were running the

Dramatherapy sessions were included as well as excluded.

Figures 1 - 8 below present mean pre session scores assigned by assessors

3 - 5 to the control and Dramatherapy groups for each of the 8 factors under

assessment, across the sessions.

Anxiety

Figure 1. Mean (SEM) pre session anxiety over the course of the study

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Happiness

Figure 1. Mean (SEM) pre session happiness over the course of the study

Social contact

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Figure 1. Mean (SEM) pre session social contact over the course of the

study

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Confidence

Figure 1. Mean (SEM) pre session confidence over the course of the study

Body posture

Figure 1. Mean pre (SEM) session scores for body posture over the course

of the study

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Energy level

Figure 1. Mean (SEM) pre session energy levels over the course f the study

Attention

Figure 1. Mean (SEM) pre session attention level over the course of the

study

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Engagement

Figure 1. Mean (SEM) pre session level of engagement over the course of

the study

Cumulative ChangeThe absence of significant differences between participants in pre-session

analyses makes it appropriate to analyze the pre-to-post difference scoresfor each factor to identify change associated with participation in the therapy

session.

For these analyses, sessions were grouped into three phases of four sessions

each with the rationale of identifying cumulative change that is potentially

dissociated by stage of therapy. Sessions were grouped into three stages

comprising sessions 1 4, sessions 5 9, and sessions 10 13 respectively.

Each of the factors under assessment, therefore, was subjected to a 2 x 3

(group x session stage) mixed ANOVA (excluding data provided by assessors

1 and 2)1. Statistically significant changes were revealed for the factors of

attentionand engagement as demonstrated below.

1The same analyses were conducted on the data inclusive of assessments made by

assessors 1 and 2 but yielded no significant findings. It was evident from the raw data that

assessors 1 and 2 tended to provide higher scores in comparison to assessors 3, 4 and 5,

possibly due to greater familiarity of the first two assessors.

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AttentionFigure 9 presents differences in attention between volunteers assigned to the

control group and those assigned to the Dramatherapy group across the three

phases of therapy.

Figure 9. Mean (SEM) pre-to-post differences in attention levels. Stage 1=

sessions 1-4, Stage 2 = sessions 5-9, stage 3 = sessions 10-13.

Results revealed a significant main effect of group [F(1,6)=7.906, p=.03].

This effect is reflected in the positive pre-to-post therapy difference in

volunteers assigned to dramatherapy (figure 9). Moreover, the difference

was not the same through all stages of the programme, as indicated by a

significant group*session stage interaction [F(2,12)=4.620, p=.03].

Multiple independent-measures t-tests (Bonferroni adjusted statistic =

.016) exploring the group*session stage interaction indicated that at stage

three of therapy (sessions 10 13) volunteers who have undergone

Dramatherapy were displaying greater levels of attention relative tovolunteers in the control group [t(6)=-3.703, p=.01].

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EngagementFigure 10 presents differences in levels of engagement between volunteers

assigned to the control group and those assigned to the Dramatherapy group

across the three phases of therapy.

Figure 10. Mean (SEM) pre-to-post differences in engagement levels. Stage

1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.

Results revealed a significant main effect of group [F(1,6)=8.691, p=.03].

This effect again reflects a positive pre-to-post therapy difference in

volunteers assigned to Dramatherapy, with the difference score being higher

in that group relative to the control group across all stages (figure 10).

Furthermore, there was a near significant group*session phase interaction[F(2,12)=3.583, p=.06].

Multiple independent-measures t-tests (Bonferroni adjusted statistic = .016

denoted the largest difference in engagement levels between the two groups

to be seen at stage 3 [t(6)= -2.744, p=.03].

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Anxiety, Happiness, Social Contact, Confidence, Body Posture, EnergyFigures 11 16 below present the changes occurring on each stage of

therapy for the remaining factors. In all cases, when improvements wereobserved, it was the Dramatherapy group showing improvements across

stages of therapy. For these remaining factors, however, observed

differences were not statistically significant between the two groups.

Anxiety

Figure 11. Mean (SEM) pre-to-post differences in anxiety levels. Stage 1=

sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.

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Happiness

Figure 12. Mean (SEM) pre-to-post differences in levels of happiness. Stage


Social Contact

Figure 13. Mean (SEM) pre-to-post differences in social contact. Stage 1=


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Confidence

Figure 14. Mean (SEM) pre-to-post differences in confidence levels. Stage


Body Posture

Figure 15. Mean (SEM) pre-to-post differences in body posture. Stage 1=

sessions 1-4, phase 2 = sessions 5-9, phase 3 = sessions 10-13.

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Energy

Figure 16. Mean (SEM) pre-to-post differences in energy levels. Stage 1=


Summary of session effectsFrom the significant changes occurring on levels of attention, it is apparent

that the effects of Dramatherapy are cumulative and therefore, are most

pronounced towards the final sessions of therapy (stage 3). More specifically,

Dramatherapy sustains the positive increase that occurs in phase 2. In

contrast, there was a significant drop in levels of attention in the control

group relative to the Dramatherapy group at the final phase of therapy (figure

9). Although no significant changes emerged on any of the other factors, the

means suggest a positive effect of therapy. In most measures, assessors

recorded a non-significant drop in levels of these factors in the control group

in stage 3. In contrast, no such drop was seen for volunteers assigned to

Dramatherapy. Such pattern is strongest for the factor of engagement (figure

10). The inverse pattern was true for the factor of anxiety, in which

volunteers assigned to Dramatherapy experiences a decrease in anxiety

levels in phase 3 compared to control participants (figure 11). Energy levels

on the other hand were paralleled in the two groups, in which the decrease in

energy was equally present in volunteers assigned to Dramatherapy (figure

16).

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Maintenance of therapeutic effects Mid session)The mid session data scored by assessor 3 were used as a measure of how

long the effects of sessions were sustained in participants. As before,

sessions were split into three stages, with stage three only comprising

sessions 10 11, due to absent mid-session data for sessions 12-13.

For these analyses, post-to-mid session differences were calculated for each

factor and subjected to a 2 x 3 ANOVA (group x session stage). Such

analysis reflected the maintenance of effects over time in relation to the

previously attended therapy session (post therapy).

Statistically significant group*session stage interactions emerged for factors

of happiness, social contact, attention, and levels of engagement. These

interactions were further explored using multiple independent-measures t-

tests (Bonferroni adjusted statistic = .02). Figures 17-20 below represent

the achieved effects on those factors.

HappinessFigure 17 presents maintenance of happiness levels in the post-session

intervals for the control and Dramatherapy groups.

Figure 17. Mean (SEM) post-to-mid session differences on happiness levels.

Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.

Results revealed a significant group*session stage interaction [F(2,12)=6.006,

p=.02]. Participants assigned to the control group sustained their happiness

levels at stage 2 of therapy, during which participants engaging in therapy

experienced a lapse in levels of happiness ([t(1,6)=6.728, p=.04]. see figure

17).

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Social contactFigure 18 presents maintenance of social contact in the post-session


Figure 17. Mean (SEM) post-to-mid session differences on social contact.


There was a significant group*session stage interaction [F(2,12)=4.568,p=.03], with the largest difference to be seen in social contact at stage 2 of

the sessions, [t(1,6)=10.971,p=.02]. This difference was in favour of control

participants.

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AttentionFigure 19 presents maintenance of attention in the post-session intervals for

the control and Dramatherapy groups.

Figure 19. Mean (SEM) post-to-mid session differences on levels of

attention. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions

10 11.

Results again, demonstrated a group* stage interaction for attention levels,

[F(2,12)=13.631, p=.001]. This reflects a significant difference at stage 1 of

therapy, during which the maintenance of attention was greater for

participants engaging in therapy sessions, [t(1,6)=9.846, p=.02].

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EngagementFigure 20 presents maintenance of engagement level in the post-session



engagement. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 =

sessions 10 11.

A group*stage interaction [F(2,12)=4.345, p=.04] was revealed. The

difference was greatest at stage 3 of therapy, in favour of participants

assigned to Dramatherapy [t(1,6)=24.000, p=.003].

Anxiety, Confidence, Body Posture, EnergyFigures 21-24 below demonstrate the effects of therapeutic sessions on the

maintenance of the remaining factors, namely anxiety, confidence, body

posture, and energy. For these factors, the post-to-mid session differences

were not significantly different between the control and Dramatherapy group.

Nonetheless, for the majority of cases, a positive pattern was observed in

favour of those assigned to Dramatherapy. Non-significant positive effects of

therapy were sustained for confidence (figure 22) and energy levels (figure

24) at stages 1 and 3 of the sessions. Lower levels of anxiety were also

sustained as a result of therapy, throughout the study period (figure 21). On

the contrary, the post-to-mid session difference on body posture was lower

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for participants engaging in therapy relative to control participants at stages

1 and 2. The reverse was apparent at stage 3, however, during which

Dramatherapy participants sustained improvements in body posture more than

control participants did (figure 23).

Anxiety


anxiety. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions

1011.

Confidence

Figure 22. Mean (SEM) post-to-mid session differences on confidence

levels. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10

11.

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Body posture

Figure 23. Mean (SEM) post-to-mid session differences on body posture.


Energy

Figure 24. Mean (SEM) post-to-mid session differences on energy levels.


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Research Conclusions: Effects of Dramatherapy on people with DementiaFindings from this trial suggest that the experience of Dramatherapy has

positive effects on older people living with dementia. The effects were both

cumulative across therapy sessions as well as sustainable between sessions

on some factors. Positive therapeutic effects are first observed in the

evaluations examining the pre-to-post therapy differences. In that set of

analyses, Dramatherapy influence was greatest on levels of attention and

engagement. Additionally, it was more pronounced in the last stage of

therapy, comprising sessions 9-13. A similar pattern was evident on all other

factors, in which scores on the final stages of therapy reflected better

performance in individuals assigned to Dramatherapy.

The final set of data evaluations provided some support for the sustainability

of beneficial therapeutic effects. Findings demonstrated that the positive

effects of therapy are sustainable between sessions on factors of attention

and engagement. This strengthens the initial findings pointing towards

positive therapeutic influences specific to those two factors. Moreover,

maintenance of positive therapeutic influence on levels of engagement was

pronounced towards the final stages of the programme of sessions. This

demonstrates that the experience of Dramatherapy enhances levels of

engagement as the programme progresses, as well as sustaining this

enhancement over time. Implications for the timeframe for such therapeutic

interventions are clear: 12 week programmes can produce positive outcomes

that are cumulative and still increasing; longer term programmes mayproduce even larger benefits.

Although for factors of happiness and social contact, the sustained effects

were in favour of the control group, in the middle stage of therapy, they were

followed by a (non-significant) rise in performance to Dramatherapy

individuals in the final stages of therapy. This again supports the positive

influence of therapeutic effects and sustainability towards the final sessions

of therapy. Means on other factors (confidence, body posture, and energy

levels) also reflect such pattern.

It is thus reasonable to conclude that engagement in Dramatherapy induces

positive effects on attention and engagement levels, factors that are

considered critical to older people living with dementia. Furthermore, such

positive therapeutic effects are sustained between therapeutic sessions. In all

cases, effects are more apparent when therapy is treated as a continuous

process, during which effect size varies across sessions, but cumulatively

leads to positive effects following a 12-week experience of Dramatherapy.

Considering the small sample size and the relatively short time frame of the

intervention implemented for this study, these results are remarkably positive


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and offer a very strong argument for the value of Dramatherapy in this client

group.

Towards a Purposeful Ending

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