The Integration of the Arts Therapies in the Work of a Multidisciplinary Team in a Hospital School Setting

Michal Ulitzur-Zemel, Yael Kaifus, Tai Mann and Haggai Yoel


Alyn Hospital, a pediatric and adolescent rehabilitation center, is a unique national treatment center in Israel that specializes in the diagnosis and rehabilitation of children and adolescents with a variety of congenital and acquired physical disabilities. The center operates several departments including Pediatric Rehabilitation, Pediatric Respiratory Rehabilitation, Day Hospitalization Rehabilitation, an Outpatient Clinic, a Skills Development Center, a Therapeutic Sports Center, an Independent Living Neighborhood, a wing for Ventilator-Assisted individuals and a Rehabilitation Educational and Medical Day Care facility which has its own pre-schools, school and rehabilitation day care.

The school is integrated into Alyn’s medical-rehabilitation structure. It is supervised by the Department of Special Education, which is regulated by the Ministry of Education and has two educational systems. The first consists of six classrooms serving six to ten children each. The students range in age from 3 to 21 and come from a variety of Jewish and Arabic, religious and secular, backgrounds. They have severe physical disabilities, congenital or acquired heart defects, neurological impairments (cerebral palsy, spina bifida), brain injuries, respiratory lung diseases that require artificial respiration, various traumatic injuries (some were injured in military or terror attacks), metabolic disorders and various other syndromes, some of which include intellectual disabilities. Most have language impairments of varying severity. Some of the students reside in the hospital boarding school, whereas others travel to school daily by shuttle bus. The second system has two classrooms designed for specific students who are admitted to the hospital’s rehabilitation department, and others who are admitted to the day care facility. It serves approximately 30 students who have various traumatic injuries.

The therapeutic work is split into individual and group sessions and is integrated into the school framework during the morning hours as part of each class schedule. Each therapist has a dedicated workspace consisting of an art therapy room, a music therapy room and a therapeutic petting zoo located in an inner courtyard adjacent to the school. Each class convenes as a group with each therapist on a weekly basis and some students also receive individual therapy sessions.

Arts therapies are relatively new at Alyn Hospital and have only been operating in this setting since 2012. The team of arts therapists and animal-assisted therapists at Alyn were originally part of the educational staff. The transition from a teaching profession to a therapeutic profession and the establishment of an arts therapies and animal-assisted therapy space within the school was gradual and required a realignment of goals and expectations on the part of the therapists and the system at large. Art and music teaching hours transitioned into therapy hours, and early career therapists were given the task of shaping their new professional identity while at the same time paving the way and consolidating the status and position of arts and animal-assisted therapies within a larger system with unique, complex and challenging characteristics.

Theoretical Background

The key feature of the model presented in this chapter is the location of the school within a rehabilitative hospital. This means that the hospital staff includes professionals from the fields of education, medicine, mental health, nursing and rehabilitation. In addition to the classroom schedule, each student has a personalized work plan tailored to his/her individual needs, which includes healthcare treatment sessions such as physiotherapy, hydrotherapy, occupational therapy, speech therapy, arts therapies and animal-assisted therapy. The diverse array of professionals allows for a broad and comprehensive observation of each client but may also lead to disagreements between professionals. The issue of multiple treatments and the interactions between professionals tends to come to the fore when students are treated by both the arts therapists and the school psychiatrist or psychologist, and when each class receives group therapy from all of these therapeutic disciplines simultaneously. This complex situation requires the therapists to coordinate their goals and collaborate with a broad multidisciplinary team who work with these students and observe and assess them from different standpoints.

The students are typically divided into classes according to age, mother tongue and level of functioning. However, due to the small number of classrooms and the diverse characteristics of the students at Alyn Hospital, each class is made up of students with different levels of physical and mental functioning. Over and above their physical difficulties, some of them also have developmental disabilities, such as learning and language impairments. The educational and therapeutic programs thus need to be adapted to students with physical and developmental disabilities as well as to heterogeneous classes in which students at different levels of cognitive functioning study together.

In contrast to other hospitals where the length of hospitalization is usually time-bound and disrupts their normal routine, for most patients at Alyn Hospital their stay is part of their regular life. Some have lived in the hospital since they were born and others have come in daily for years. These patients in particular have movement, breathing and swallowing disabilities. Some are completely dependent on a respirator for breathing, whereas others are dependent on feeding tubes. Most have mobility difficulties and use wheelchairs and walkers, and some have limited verbal abilities and rely on alternative forms of communication. As a result, arts and animal-assisted therapists need to find creative methods to work with these young students who have limited access to the outside world and restricted movement abilities.

Art, music and animal-assisted therapies are particularly well-suited for the population at Alyn Hospital because they allow these students to better cope with the complex dialectic between health and illness which is intrinsic to a school operating within a hospital setting. They do so by creating a transitional space between the inner and outer worlds where the creative self can function and play (Winnicott, 1971). In these therapy sessions, the students can join in and participate as a function of their abilities. The art media also acts as another important channel of communication and selfexpression that bypasses the structures of language and words. Arts and animal-assisted therapies contribute uniquely to the lives of the students admitted to Alyn Hospital because they utilize therapeutic methods in which the client is active and involved not only emotionally, but through movement, the use of the senses and cognition. Research suggests that these therapeutic methods contribute significantly to reducing stress and anxiety (Curry & Kasser, 2005), provide a distraction from pain and suffering (Nainis et al., 2006), enhance feelings of competence and self-worth and enhance individual coping skills (Favara-Scacco, Smirne, Schiliro, & Di Cataldo, 2001). The process of creativity and expression is an active one, and as such it is experienced as a “work of hope” (Hazut & Segev-Shoham, 2002) in that it encourages the client to initiate, make changes and find solutions, and promotes a sense of control, competence and independence (Malchiodi, 1999).

These students’ complicated medical conditions necessitate accessible facilities and technical adjustments. All the classrooms are situated on the same floor, with a nurses’ station in the center. The dedicated therapy rooms and the therapeutic petting zoo are also located on this floor. There is a limited number of children in each class, and there are several staff members present in every classroom at any given moment. The children in the classrooms mostly remain in stationary positions, either sitting or lying down next to their medical and rehabilitative devices while the staff members move between them. In addition to the regular staff in the classroom, the nursing staff go in and out of the classrooms regularly to provide critical physical care and monitor the students’ physiological indicators. Thus, during group therapy sessions in the classroom, other staff members can also be present in the room. Hence, external factors pervade the therapeutic process and the therapists need to deal with disruptions to the regular therapeutic setting while striving to create a supportive, organized and containing environment (Bion, 2004; Winnicott, 1971); i.e., the experience of being surrounded by a protective and embracing skin (Anzieu, 2016), and provide a secure base (Bowlby, 1990) for development and growth.

During the sessions with each student, to provide an appropriate emotional response the therapists must take a wide range of individual mindbody information into account that influences the client’s functioning and needs. The students’ ongoing medical conditions have critical implications for their mental development. Most students, some from birth, have coped with ongoing or permanent separation from their parents, undergo recurrent and invasive medical procedures that cause discomfort, pain, distress and anxiety, as well as a loss of a sense of control or a complete lack of control, and some face the constant threat of death (Malchiodi, 1999). It can be assumed that their continued dependence on the medical staff and medical devices directly impacts these students’ sense of separateness, differentiation, autonomy and self-efficacy; the recurrent stress and anxiety also reduce their feelings of security and mental well-being.

These students’ precarious health conditions have implications for their immediate circle of classmates as well. These distressing situations are often reflected and resonate in their classmates’ gazes and reactions. Some students at Alyn Hospital are constantly at risk of death and some unfortunately pass away at a very young age. Occasionally students witness the deterioration of a classmate and are forced to deal with his/her loss. Encountering the death of classmates is burdensome and difficult, and in the past the educational staff lacked the appropriate tools to cope with this reality. To palliate this need, the arts therapy team was asked to develop a new channel for coping with this issue, both for the students and the staff.

The therapists themselves encounter severe illnesses, pain and loss, and as a result may feel helpless and are at risk of burnout, secondary traumatization and compassion fatigue. In order to contain their clients, the therapists also need to be contained and held within a supportive framework that helps them maintain their strength, process countertransference, offer emotional support and clarify professional matters.

Another critical factor is the multicultural composition of the Alyn framework. The hospital setting creates an opportunity to break down barriers between the different sectors and social groups in Israel and connect them directly. The students and staff members are Jewish, Christian and Muslim from religious and secular backgrounds who have diverse opinions and worldviews and reside in a country characterized by a politically charged and fragmented reality (Bruno and Massarwa discuss this issue in detail in the next chapter). The day-to-day school setting can generate complex situations that require careful consideration of how to addresstraditions, beliefs, values and national heritage, as well as direct and indirect responses to the political situation and military events in the country and the region affecting both the staff and the students.

The reality that half of the children at Alyn Hospital speak Arabic but the arts and animal-assisted therapy staff are Hebrew speakers with only a basic knowledge of the Arabic language also has a direct effect on the verbal component of communication during therapy. Other staff members are present in the room to assist the therapists with Arabic translation during group sessions. The presence of a third party in the therapeutic space, as well as the actual need to translate emotional expressions through an intermediary, have profound implications for the dynamic in the therapy room, and raise professional and ethical questions that will not be addressed in this chapter, but are certainly worthy of mention and further examination. In individual therapy sessions, the therapists typically refrain from the inclusion of a translator, thus relinquishing the opportunity for mothertongue expression and communication with the client.

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