Description of the Working Model and Clinical Examples

The special nature of the framework in which the arts and animal-assisted therapists work at Alyn Hospital calls upon them to deal with the complex conflict between internal and external content that can impede the creation of a therapeutic space in the classroom. Nevertheless, the therapy staff believe that art, music and animal-assisted therapy can contribute significantly to the students’ quality of life since with flexible and creative thinking the unique characteristics of the setting can be harnessed to enable effective work. They also believe that the integration of arts and animal-assisted therapies at Alyn Hospital does not only present a challenge but can bridge the gap between different languages and spaces.

The features of the therapeutic setting at this school prompted the team of arts and animal-assisted therapists to create a holistic working model to respond to emotional, social and community goals. The arts and animal-assisted therapies at Alyn Hospital aim to create a transitional space that allows for the transition between the inner and outer worlds, form a bridge between the individual and the group, between language and cultural divergencies and between the severe physical limitations and the healthy functioning parts of each individual. The overarching goal is to contain and sustain the duality of health and illness, which is the key to the healing power and the ability to foster hope of these therapies.

The arts and animal-assisted therapists’ therapeutic approach is well suited to the hospital’s primary therapeutic objective of the rehabilitation of children and teens and the provision of assistance to support better functioning. Therefore, the therapeutic working model centers around expression and support. The purpose of the therapeutic process is to create a safe, containing and supportive space, provide an opportunity for exploration and experimentation, relief and relaxation, the expression of internal emotional content, the expression of each student’s individuality and to enhance their sense of ability and self-worth. The core of the therapeutic work involves class groups since these sessions enable social learning, support and mutual feedback. Group therapy encourages interpersonal engagement, cooperation and social interactions between the students, awareness, their acknowledgment and sensitivity towards others, a sense of belonging and cohesion within the group, and the discovery of collective and shared issues among all group members. The working model at Alyn Hospital emerged from the facility’s defined mission. The model takes a holistic approach which relates to the client as a complete individual so that all physical, mental, emotional and social needs are met. The therapeutic space has clear yet flexible boundaries that allow for both separation and accessibility simultaneously.

The arts therapists work as part of the multidisciplinary team and strive to obtain maximal information about the level of each student’s medical, rehabilitative, educational, social, emotional and family-related functioning. Although their work focuses on the emotional components, it is conducted with an awareness of the goals and processes of other treatment plans. The working model is based on the view that the encounters between the different systems involved in these students’ health and well-being constitute an advantage and opportunity for teamwork and collaboration. The working model emphasizes collaborations and connections. It focuses on creating a space for discourse and sharing between the individual and the group, between professionals from different fields, between the interior and the exterior and between cultures. The pivotal tool for creating this space is the arts. The model views the challenges inherent to the system as opportunities for initiative and growth.

A Space for Collaboration

The working model at Alyn Hospital is based on the idea of the creation of a space for collaboration between the different therapists, the therapists and other professional staff, and the therapists and parents. The shared daily presence of art and music therapists at Alyn Hospital almost every day of the week facilitates a continuous and effective dialogue between the various partners.

Collaboration within the therapeutic team. It is important for the therapeutic team to collaborate and coordinate their work because their group therapy sessions take place in the same classrooms. The structure of the group sessions required modifications in the overall class schedule to allow for routine group supervision and staff meetings, and for each of the therapists to work in each class on a different day of the week. The staff meetings are planned on a weekly basis with the educational staff and are used to formulate collaborative work plans around common goals or content that each of the therapists works towards within the framework of his/her profession. The weekly supervision session acts as an anchor and framework for emotional support and clarification of professional issues.

Collaboration with the educational team. The educational staff is typically not present during the therapy sessions. This means there must be continual updating and coordination with the therapy team. To do so, the arts therapy team holds a weekly meeting with the educational staff during their work hours where the teachers discuss topics and content that arise in their classes, as well as issues concerning the social and emotional state of each student. The therapists present their perspectives on the classroom and the students and use information from the teachers to adjust their therapeutic goals. The art and music therapists’ previous work as teachers in the educational field gives them experience in engaging and discussing issues with the educational staff and also contributes to the level of cooperation and support between them.

For example, during one of the staff meetings, a teacher talked about a problem she had with two students. When she worked with the students individually, they showed they had understood the material, but when they were in the classroom, they were afraid of making mistakes and would not participate in class. Yael Kalfus, the arts therapist, suggested she would work on mistakes in her art therapy sessions. She presented the book “Beautiful Oops” (Saltzberg, 2010) to the class which describes a “mistake” on each page such as spilled gouache paints and crumpled paper, and how to make something new from each: the stain becomes a painting, the crumpled paper turns into a fuzzy sheep and so on. The students were excited about the creative ideas in the book and were then asked to experiment. Each chose a “mistake” from the art materials and turned it into a new artwork. Yael noticed that the new possibilities surprised them and enabled them to view a “mistake” from a new perspective. After the session, the students felt more relaxed and began to actively participate in classroom activities.

In another case, the teacher of the senior class asked the therapy team to help her develop and expand her students’ emotional vocabulary. The discussion between the teacher and the therapists led to the joint creation of a learning curriculum which integrates the arts and aims to develop emotional language and a concomitant development of self-awareness. Yael, the arts therapist, together with the teacher, devised a lesson plan in which stories and pictures were presented to the students in the classroom. These facilitated conversations about emotions and at a later stage led to creative work. The teachers and teaching assistants actively participated in these activities and presented personal examples of emotional sharing and containment. An activity using the book “Silly Billy” (Browne, 2006) allowed the students to talk about their fears and then make worry dolls. The book “Room on the Broom” (Donaldson & Scheffler, 2016) was used to shift the conversation to the subject of surprises. The students noted the various surprises that appeared on the witch’s path and spoke about their personal surprises. The class prepared boxes and each student picked a box and created a character that would pop out of the box by surprise. Before Tu BiShvat (a Jewish holiday; the New Year of the Trees), the students prepared a forest of emotions, and each student made a tree that represented one emotion such as a happy tree, a disappointed tree, a longing tree and so on. These activities gave the students and teachers an opportunity to discuss emotions in the classroom.

Tai Mann, the music therapist, organized combined meetings in the classrooms for students and the educational staff to provide the staff with ways to engage in emotional conversations with the students. Each session started with a routine where Tai strummed on the guitar, sang a song and addressed each student by asking how he or she was feeling. All the students were given the opportunity to play their feelings on the guitar, pick a card from the stack of emotion cards beside it and share their choice of emotion with the class. The students became accustomed to this morning ritual in which each of them was given the opportunity to express their emotions verbally and through music. The ritual helped them practice their listening skills and listen to each other patiently, and to enjoy being listened to. For some, the experience of being the center of attention was unfamiliar and often stressful. For many it was a chance to reveal themselves to others gradually and develop the ability to speak and share things with their friends and staff. After many years of this routine, the students’ progress has been striking. At the start, the morning routine was relatively short and the students used few words to express themselves in a concrete manner. Over time, the students’ vocabulary has expanded and their willingness to share has grown. At first, some of the students imitated each other and articulated the same emotions, but over time, and with the development of their empathic abilities, their capacity for self-expression has improved. This process has helped these students develop a sense of differentiation and find their true authentic selves. At a later stage, the themes formed the basis for inventing group songs, or alternatively one student would choose a song with the same theme and play it to the group. For example, one of the themes that emerged was rebellion; i.e., “I don’t want to!” This theme emerged when one student revealed that he did not want to take a blood test because it hurt. Another student said he did not like his physical therapy because it was hard for him. A conversation arose in the classroom about how hard it is to undergo unpleasant medical and therapeutic interventions, while also recognizing their importance to their health. Drumming on drums helped the students release their anger as they yelled, “I don’t want to!” Gradually the tension dissipated, and the expressions of anger progressively became moments of laughter and enjoyment. Tai played the song “I Don’t Want” (by Noga Geva) and after the students learned the words, they asked to hear it played in the following sessions. The song became their theme song that related to everything they had to do but did not want to do, and created a channel for dialogue between the students and the multidisciplinary team. The students were given a tool to directly express their difficulties and oppositions, and the team was able to validate and contain these situations and negotiate with the students as to how different activities and procedures would be performed. The musical expression helped reduce the level of tension between the parties.

Another issue that arose was the theme of missing a sick classmate who had been absent from school for a long time. One student strummed gently on the guitar and shared his longing with the class. Then more students expressed their longing for the same classmate, and the class composed a song together with the therapist, each writing one line of the lyrics. The song was recorded, and they were pleased to learn that it would be played to their friend upon his return. The presence of the educational staff in these sessions fostered a better level of understanding on their part and more empathy towards the students’ emotional worlds. It also significantly contributed to a more accepting and containing atmosphere in the classroom and provided the educational team with techniques for discussions about emotions which they could then apply daily in their work.

Collaboration with the paramedical team. The professionals who interact with the students at Alyn Hospital make it possible to provide integrated therapy. The arts therapists are cognizant of the medical-rehabilitative goals and can contribute directly or indirectly towards achieving them. Tai Mann, the music therapist, works in the rehabilitation day-care facility with the physical and occupational therapists. The music accompanies, supports and reiterates the motor-sensory exercises and helps reduce levels of stress and resistance. In the case study described below by Tai Mann, the emotional work also affected the physical aspects of the rehabilitation process. A 16-year-old boy suffered a head injury in a car accident. He was left with weakness in the left side of his body and speech difficulties. His parents described him as a talented and creative boy, loved by his family and friends and deeply connected to music. When the boy entered the music room for the first time accompanied by his father and some friends, he was brought inside in a wheelchair by his friend. The therapist could not see his face because he was bending over. Those accompanying him offered to remain in the room and sing his favorite songs. While listening to them, Tai observed the boy’s reaction. His body remained bent over, but she noticed that he was gently tapping his foot on the floor to the music. She realized that he had shared the experience with them. The boy continued to attend weekly sessions. During the initial sessions, he was interested in small instruments such as wind chimes and drums, which raised his upper left body and put him in a position to look forward. As the sessions progressed, he began to sit up straight and later, when he was already sitting upright, he began to take an interest in the larger instruments that were suddenly visible to him and chose to play the set of drums. It was very important for him to play with both hands at a consistent pace to produce a “good sound,” which was impressive and required him to make a great deal of effort. As he drummed, whether out of a love of music or to “make it sound like it should,” the therapist realized that he was unintentionally repeating his physical therapy exercises over time and with considerable effort, thus strengthening his weak hand. He later discovered the piano and began to compose songs. Some of the songs started from lyrics that he wrote, and others began with a tune he discovered while improvising on the piano. At the outset, he only played with his right hand, his healthy hand. When he felt that one of the songs was almost ready, he would add a musical accompaniment with his left hand. The music therapist was astounded by his effort to play with his weak hand, which could barely be lifted into position at the piano and required him to move each finger separately. This was a successful rehabilitative task for his occupational therapy exercises. He spent many sessions composing appropriate musical accompaniments for his songs. He also expressed the desire to sing while playing with both hands. Initially he sang monotonously and slowly, but his insistence on the quality of the performance prompted his speech therapist to take part in several sessions specifically dedicated to voice production and training. The content of the songs directly expressed the boy’s effort to produce the songs and deal with the rehabilitation process. The boy recovered and today functions independently. He continues to compose songs and play music, and recently returned to Alyn Hospital as a volunteer.

Collaboration with the parents. Some parents stay in the rehabilitation department with their hospitalized children, go with them to treatment and occasionally even stay with them during the therapy sessions because of the child’s physical or emotional dependence on them. Despite this complexity, the parent’s presence gives therapists the opportunity to observe the parent-child relationship and exchanges. It also provides an opportunity for family interventions and parent-child therapy sessions which can promote growth and change. The following case study shows how the presence of a mother alongside her three-year-old daughter contributed towards and promoted the therapeutic process.

Ayala (pseudonym), who was born approximately a year after her family immigrated to Israel, has a severe degenerative disease. She cannot move independently other than slight movements of her limbs, she breathes with a respirator and is fed through a feeding tube. In her first year at Alyn, Ayala did not speak, was grim and communicated with the staff solely through eye movements. When she wanted to say yes, she closed her eyes, and to respond no she rolled her eyes up. During the sessions with her parents, the staff learned that there was a significant gap between her level of communication at home and at school. At home she felt more at ease and spoke freely and fluently. Ayala was diagnosed with selective mutism, and it was decided that all the staff members who worked with her would focus on establishing a relationship of trust, and temporarily set aside any other rehabilitation goals. Despite her basic trust in her music therapist,

Ayala did not speak during the sessions. Concurrently, most of the songs that she chose were about sadness and anger. When her mother went with her to the sessions, she also avoided talking to her. During the multidisciplinary staff meetings, it was decided that the mother should take part in the music therapy sessions. A hammock and Ayala’s favorite games from home were brought to the therapy room. The goal was to recreate the same atmosphere as her home and transform the therapy room into a safe and enabling place that would serve as a transitional space between her home and the hospital. As early as the third session, Ayala began talking to her mother in the room and in the hall. Her mother told the music therapist which songs she listened to at home, and those songs were made part of the therapeutic process. Ayala grew up in a very warm and happy home and the selection of songs was upbeat and playful in contrast to her original choice of songs. In this way, the songs served as a bridge to creating a transitional space between her home and the hospital. Progressively, Ayala began speaking to the music therapist and later to the rest of the staff. She would only whisper with some of them, but with others she spoke loudly and confidently. Integrating her mother into the therapeutic process impacted therapy significantly.

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