Published:
October 2022
Issue:
Vol.17, No.2
Word count:
7371
About the authors
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MMH (Art Therapy), BSocSc
Leticia is an early-career art therapist who is also working as a provisional psychologist with the Department of Education, Australia. She has worked in the NDIS as a provisional psychologist delivering therapy to people with a disability, and works with a diverse range of client presentations. Leticia graduated with a Master of Mental Health (Art Therapy) from the University of Queensland in 2021, following her undergraduate studies with first-class honours in psychology at the University of the Sunshine Coast. She works with individuals and groups to encourage self-discovery, trust, freedom of choice, authenticity and positive outcomes. Her primary interests are supporting young people from diverse backgrounds from a positive psychology perspective to encourage a growth mindset. Leticia adopts various therapeutic approaches such as psychodynamic art therapy, CBT, ACT, DBT and Gestalt therapy.
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DClinPsych, PhD, BSc (Psych)
Amy is an early-career researcher and lecturer in psychology. She is also a practising clinical psychologist and clinical supervisor to early-career psychologists. Amy is interested in diverse interventions that aim to improve coping skills and enhance psychological wellbeing. She has considerable clinical experience and knowledge in the areas of eating disorders, youth mental health, psychological assessment, evidence-based clinical interventions such as CBT, DBT, ACT and schema therapy, complex trauma and anxiety disorders. Her research work focuses primarily on the areas of disordered eating, youth mental health, clinical interventions, psychological assessment and emotional regulation.
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MA (Expressive Therapies), BEd, DipTeach, AthR
Jane began her career working in the multi-disciplinary team in the Child and Youth Mental Health Service at the Mater Children’s Hospital, Brisbane, working for 13 years with young people and their families. Jane was involved in the development and teaching of the art therapy strand in the Master of Mental Health Program at the University of Queensland, starting in 2004. Jane was the second art therapist Field Coordinator for the program for ten years and now supervises students completing their research courses in the program. Jane has a keen interest in group programs and has worked with various client populations within her private practice, including adult oncology, parents living with mental illness, adults at risk of homelessness and children from refugee backgrounds. Jane currently works at a school in Logan, QLD, within a trauma-informed practice facilitating individual therapy, group and class programs.
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MMH (Art Therapy), Grad Dip Ed, BArts, AThR
Katherine has a multifaceted career as a long-term HR professional and art therapist. She currently divides her time between her strategic HR role, her private art therapy practice and her academic role. She tutors and supervises second-year students in the University of Queensland’s Master of Mental Health (Art Therapy) program in arts-based independent research. Katherine’s primary interest is in supporting clients, either individually or in groups, to promote psychological wellbeing. Her previous experience includes working with young refugees and asylum seekers. Her art therapy work continues to adopt trauma-informed and mindfulness-based approaches with women and children coping with anxiety, depression, PTSD, grieving and life transitions, as well as work groups focused on improving resilience and well-being.
This work is published in JoCAT and is licensed under a CC BY-NC-ND-4.0 license.
A role for art therapy in buffering the effects of stress and reducing burnout amongst childcare workers: Results of a group art therapy intervention pilot study
Leticia Martin, Amy L. Burton, Jane O’Sullivan and Katherine Winlaw
Abstract
Childcare workers play important roles in our modern Western society, yet this population of workers experience high staff turnover due to work-related stress and increased rates of burnout. This study aimed to assess the perceived benefits of a six-week group art therapy intervention as an approach to reducing stress and burnout in a small sample of childcare workers. The intervention combined art-making and self-reflection in a small group. Use of the Copenhagen Burnout Inventory (CBI) and Professional Self-Care Scale (PSCS) measured stress, burnout and self-care before and after the intervention for comparison. Additional qualitative data collected from participants at the end assisted in richer understanding of their experiences. Results reveal the art therapy group effectively lowered participants’ stress and reduced personal burnout. Qualitative responses indicate participants found the group both enjoyable and beneficial. Suggestions for future research in this area are outlined.
Keywords
Burnout, stress, childcare workers, art therapy, self-care
Introduction
Childcare workers play an important role in modern Western society significantly contributing to the early education of children (Decker, et al., 2002). The popularity of childcare centres and the optimum number of childcare workers required to effectively run these centres has significantly increased in recent years (Rao & Li, 2009). A review was able to articulate that pay rates have remained low for many years and employees within childcare are predominantly women (98%) who are lacking support and often juggling multiple roles while maintaining work–life balance (Goelman, & Guo, 1998; McDonald et al., 2018; Šverko, et al., 2002).
Given the important role childcare workers play in our communities and their influence on the development of children, it is vital that they are healthy and well (Curbow, 1990; Li et al., 2013; Love et al., 2003; Sisson, et al., 2017; Tovar et al., 2017). It has not yet been identified whether art therapy can reduce stress and burnout among childcare workers; however, the present study aims to address this gap in the literature by proposing, trialling and evaluating group art therapy as a low-cost approach to reducing stress and burnout in childcare workers. This mixed-methods study examines a six-week art therapy intervention aimed at reducing work-related stress and burnout through increasing self-care in a group (n = 6) of childcare workers.
Literature review
Childcare workers and workplace stress and burnout
Research in the childcare sector has identified that up to 30% of workers with minimal training consider leaving the industry due to low wages, lowered public value, high job stress and demands (Jackson, 2020; McDonald et al., 2018). Those with higher qualifications (e.g., degree qualified) have an even higher chance of leaving in search of better working conditions (Phillips et al., 2016). Keeping workers within the sector has been acknowledged as a challenge as the industry grapples with how to attract and retain skilled employees (Thorpe et al., 2011). Lack of experienced workers adds to the strain on the existing staff, with some individuals working through breaks, not having days off, working overtime and staying back after hours to complete paperwork (Løvgren, 2016). One US-led study identified that the most common reason early educators left the sector is work-related burnout (Russell et al., 2020). Burnout is described as emotional fatigue, loss of perceived personal accomplishment, and depersonalisation of the sufferer (Seti, 2008). The World Health Organization (WHO, 2019) reports that burnout is a result of chronic workplace stress characterised by exhaustion, mental distance from the job and lessened professional efficacy. Burnout is common among the helping professions (human-service sector) as a direct result of working closely with people (Decker et al., 2002). In the case of childcare workers, burnout results from exposure to prolonged stressors without necessary supports in place (Løvgren, 2016). High stress in childcare workers leads to an increased incidence of sick leave or unexplained leave, lowered quality in work standard, withdrawal, depression, greater staff turnover, and a reduced quality of care provided to the children (Løvgren, 2016). Thus, childcare centre employees are distancing themselves from work (either in the short term by taking sick leave or in the longer term by leaving the profession) to cope with burnout (Russell et al., 2020). These longstanding issues have more recently been exacerbated by the ongoing impact of Covid-19 on workload stress and burnout experienced by childcare workers around the globe (Harry et al., 2022).
There is growing concern about the management of stress and burnout among the childcare profession due to the consistently high staff turnover related to job exhaustion, burnout, compassion fatigue and stress (Carson et al., 2010). Burnout disrupts stability of care and negatively impacts the overall quality of the early-childhood education delivered by these services (Decker et al., 2002). Given the high cost of childcare worker burnout, it is critical that resources are dedicated to developing methods for better stress management to address the prevalence and impact of workplace burnout among childcare workers (Carson et al., 2010).
Art therapy and group art therapy
The theoretical underpinnings of the present research project are based on the healing nature of art as therapy (Moon, 2017). Naumberg defines art in therapy as the focus of uncovering the unconscious and bringing to light thoughts and feelings (Rubin, 2009). Consequently, the therapeutic process for every individual is unique. Art therapy, as described by Edwards (2014), involves art creation within a supportive environment whereby one can explore and give meaning to difficult thoughts, feelings and emotions through a nonverbal portal. Art therapy has been found to be effective in treating a number of mental health issues and various populations have benefited from art therapy (Marangu, 2010; Stuckey & Nobel, 2010).
Studies have identified the many advantages of delivering therapy in groups (Hajek, 2001; Smolar, 2018). Yalom defines group therapy as the unique interaction between not only the therapist and client but between each group member, with the group acting as an additional tool of change (Vinogradov & Yalom, 1989). A meta-analysis revealed that group therapy was as effective as individual therapy when compared to waitlist group who did not receive any intervention (McRoberts et al., 1998). In fact, Burlingame et al. (2003) found that group psychotherapy was good for stress syndromes. The literature review also indicates that the group is more effective when ten or fewer sessions are attended by the client (Burlingame et al., 2003). Further, Glassman and Wright (1983) argue that the standard group size should be eight to twelve individuals; this aids in the dyadic transference and creates a beneficial variety of relationships within the group. They indicate that a larger group is more difficult to work with. Thus, the literature supports that a small group size (particularly in the case when there is only one group facilitator) and a duration of ten or fewer sessions is likely to lead to the best outcomes for participants (Burlingame et al., 2003; Glassman & Wright, 1983; Yalom, 1966).
Group art therapy has also demonstrated evidence of efficacy in promoting skills in the management of stress in the workplace (Huet, 2015). Group art therapy is described as an expressive therapy that takes place among the safety of a group (Malchiodi, 2012). Riley (2014) affirms that the goal of art therapy groups is to create different narratives around their challenges, resulting in novel approaches that allow productivity. The expression of art offers a unique way to express the thoughts, feelings, fears, insecurities, problems and experiences that cannot be expressed verbally (Malchiodi, 2012).
Group art therapy has been successful for different populations including healthcare workers, mothers of children with disabilities, and mental health workers (Belfiore, 1994; Huet, 2015; Lee, 2021). For example, a study that applied group art therapy for the prevention of burnout among medical health workers found that the group work was able to offer them a unique way to use language to tap into subconscious feelings related to work (Belfiore, 1994). Additionally, a review stated that group art therapy is cost-effective when compared to one-on-one psychotherapy (Uttley et al., 2015). In fact, the evidence from the literature indicates that the implementation of approaches that enhance employee mental health and resilience to stress and burnout is not only cost-effective, but brings about increases in job satisfaction, productivity, longer employment, lower absenteeism, and overall profit as employees are more engaged (Heckenberg et al., 2018). Further, there is evidence that shared work experiences in a safe place can produce a positive mutual relationship between employees and employer (Rose et al., 2010). Thus, an art therapy group intervention that provides a supportive environment may serve as a cost-effective, positive therapeutic approach to assist employees to manage work-related stress and prevent employee burnout.
Art therapy for stress and self-care in the workplace
Art therapy can be used to treat stress in the workplace (Huet, 2016; Reed et al., 2020; Slayton et al., 2010). Art therapy has been applied successfully as a self-care tool to increase resources and treat burnout among population groups such as those working in direct care: for example, oncology workers, hospice staff, nurses and doctors (Belfiore, 1994; Ho et al., 2021; Huet, 2016; Potash et al., 2014; Salzano et al., 2013). Nainis (2005) found that oncology nurses were experiencing a high rate in staff turnover due to suffering burnout, and sought to evaluate the potential role of art therapy in reducing the risk and impact of burnout. In the study, oncology nurses engaged in a collaborative art therapy ‘healing quilt’ project and it was found that the implementation of this program lowered staff turnover and increased patient satisfaction (Nainis, 2005).
Further evidence in favour of the role of art therapy comes from a study that harnessed creativity to promote self-awareness and improve self-care practices among hospice workers (Murrant et al., 2000). The intervention was aimed at increasing hospice workers’ self-awareness of stress, including how to prevent stress overload. The participants engaged in journaling, music and art therapy in a group therapy context. The participants reported that they felt happy when they connected their artwork to feelings and experiences Through the art, participants were able to release and experience the emotions associated with work, which helped them process their feelings. This study found the use of creative techniques was a powerful and emotive tool that precipitated an active role in self-care and enhanced team building. The benefit of art therapy was also demonstrated in a study that applied a five-week mindful-based art therapy intervention for the treatment of anxiety and stress in 77 university students (Beerse et al., 2020). Following the intervention, the university students displayed a reduction in psychological markers such as anxiety and stress, and biological markers such as salivary cortisol outcomes, when compared to pre-intervention measures. Thus, the data demonstrated a reduction in stress across both psychological and biological outcome measures.
A literature review on eleven art-based interventions for workplace stress by Huet highlights that “numerous interventions have been developed to address work-related stress, but evidence of their efficacy is sparse” (2015, p.66). Huet also indicates oncology staff are most vulnerable to burnout. It would therefore stand to reason that studies on art therapy and burnout prior to and since then have focused primarily on clinical and non-clinical oncology or palliative care staff, with limited recent studies on wider workplace populations and art therapy for burnout (Huet, 2015, 2016; Reed et al., 2020; Tjasunk & Soossaipillai, 2019). However, it was noted that most of the studies fostered therapist self-reported results and not participant outcome measures, used non-standardised surveys, and lacked appropriate description concerning the intervention. Huet (2015) concluded that there needed to be a greater interest in expanding the research to include robust studies that aid in the development of theories that assess the application of art therapy to lessen work-related stress. Thus, a study that addressed both qualitative and quantitative processes might address some of these earlier limitations (Huet, 2015).
Aims and hypotheses
Work-related stress and burnout have been established as primary factors in high turnover among childcare workers. The results of the above studies identify a role for creative-based therapies, such as art therapy, to play in the effective management of work-related stress and the potential to use this role to prevent burnout. However, art therapy has not yet been applied to childcare workers’ experiences of stress.
The goal of this study is to address this gap. The research aims to assess whether a brief art therapy group-based intervention can support the prevention of burnout and buffer the effects of stress among a small group of childcare workers.
Based on the existing literature on group therapy interventions, it was hypothesised that a six-week group art therapy intervention for childcare workers would lower overall scores measuring personal and client-related and work-related burnout. It was also hypothesised that the intervention would increase professional self-care scores for the childcare workers. Finally, it was also hypothesised that attendance at the sessions would lower self-reported stress levels.
Methodology
Design
The study utilised a quasi-experimental design and compared pre- and post-outcome measures for participants in a six-week art therapy intervention. The size of the groups and the duration of sessions were determined by balancing the recommended group therapy length based on the literature with the practical constraints of the busy childcare centres (Burlingame et al., 2003; Glassman & Wright, 1983; Yalom, 1966). The design is quasi-experimental as there was no control group and no random allocation. The research was based on a mixed method of investigation incorporating qualitative and quantitative data to measure the above-mentioned variables. Mixed methods were chosen to provide a broader approach to answer the research questions and counter any weakness associated with the use of just one method (Gerber, 2015; Halcomb, 2018; Johnson et al., 2007). This methodological choice also ensured a richer, more informed understanding of the intervention, including any problems encountered by participants. Ethical approval for project 2021/HE000810 was gained from the University of Queensland’s Ethics Committee on August 9, 2021, thus ensuring alignment with the guidelines of the ethical review process of the University of Queensland and the National Statement on Ethical Conduct in Human Research.
This project fulfilled the independent research requirements for the researchers in their second and final year of a Master of Mental Health (Art Therapy) program at the University of Queensland’s Medical School. The student researchers were not affiliated with the childcare centre; the only work completed was purely research. This was not a student placement; the student researchers approached the childcare centre management team independently.
Participants
Childcare workers employed at a large private childcare company located in various suburbs on Brisbane’s north side (metropolitan Queensland, Australia) received a flyer by email inviting them to participate in the treatment trial. A total of 20 childcare workers initially indicated their interest in participating; 14 of the 20 dropped out due to other commitments and time constraints. Therefore, a total of six participants took part in the intervention trial. The inclusion criteria were limited to individuals between the ages of 18 and 60 years old who were experiencing work-related stress and were willing to undertake an intervention consisting of a six-week program of group art therapy. Childcare centre staff who were not working directly with children were excluded. Two participants dropped out after two sessions and were excluded from the study. Therefore, at the conclusion, the study sample consisted of four female participants. Of the four participants, there were two full-time and two part-time employees. (See Table 1 for demographic details of the final sample.)
Note: CC = child care.
Table 1. Demographic details of the final sample (n = 4).
Measures and materials
Copenhagen Burnout Inventory (CBI)
The CBI was used to measure burnout (Kristensen et al., 2005). The CBI is a 19-item questionnaire that measures three sub-dimensions of burnout: personal, work-related and client-related. The personal burnout scale has six items measuring the amount of physical and psychological fatigue and exhaustion experienced by a person. The work-related burnout scale has seven items and measures the degree of physical and psychological fatigue associated with work. The client-related burnout scale has six items for the degree of physical and psychological fatigue experienced by people who work with clients (in the case of the present study, children). An example of a question is ‘‘How often do you feel worn out?” These three scales have shown good reliability and validity in studies undertaken in Danish and Australian samples with Cronbach’s alphas ranging from .79 to .94 (Kristensen et al., 2005; Winwood & Winefield, 2004). The scoring is on a 5-point scale ranging from 1 (always) to 5 (never/almost never). The scale labels are re-coded to the original format labels of 100 (always), 75, 50, 25 and 0 (never/almost never), so that higher scores indicate higher levels of burnout.
Professional Self-Care Scale (PSCS)
The PSCS was used to measure self-care (Dorociak et al., 2017). This scale is a 21-item scale that assesses five factors of self-care: professional support, professional development, life balance, cognitive awareness and daily balance. The PSCS has been used to measure other professionals’ experience of self-care in research (Rupert & Dorociak, 2019) and displays good validity, internal consistency and reliability, reporting Cronbach’s alphas that range from .7 to .83. The five factors are assessed using a 7-point Likert scale that ranges from 1 (never) to 7 (always). Scores range from 5–35 for professional support and professional development. They range from 4–28 for life balance and cognitive awareness, and range from 3–24 for daily balance. Higher scores indicate a healthy level of self-care in all five factors.
Self-reported stress scale
At the beginning and end of each session participants answered a question to rate how stressed they felt. Participants selected responses on a 5-point Likert scale (where 1= very much stressed, 2 = somewhat stressed, 3 = undecided about stress, 4 = not really stressed, and 5 = not at all stressed). The responses were reverse-scored, such that higher scores indicated higher stress, and lower scores indicated lower stress. The purpose of this measure was to determine whether there would be any change in stress over the course of each art therapy session. The scale was created by the project team and chosen to simplify the number of scales and assessments participants needed to complete.
Art materials
The art materials provided were rocks, magazines, glue, paint brushes, acrylic and watercolour paints, chalk and oil pastels, clay, Textas, coloured pencils, paper, and canvas.
Group therapy reflections
At the completion of the intervention, participants were asked to complete twelve open-response questions that aimed to collect qualitative data on the participants’ experience of the program. The questions were handed to each participant in a written format and once completed the forms were returned to the researcher. (See Table 2 for the questions.)
Table 2. Qualitative questions.
Procedure
The research was conducted in a training room at the Sesame Lane Childcare Service Centre. There were tables, chairs and space for art materials. (See Appendix A for a photograph.) The area was a quiet room that facilitated safety and privacy while meeting the needs of the group art therapy intervention. Permission was previously obtained to use the premises for this purpose. The program was conducted by a student art therapist. Each session was conducted in the same manner. A standard approach was used each week to ensure participants felt safe and were aware of what to expect. (See Appendix B for program plan.)
The intervention consisted of six weekly one-hour group art therapy sessions. A six-week program was chosen because it was the longest duration practically possible due to time constraints that would not diminish the robustness of the design. A six-week design offered a balance between the recommended ideal group therapy duration, based on the literature, as well as the practical constraints of the busy childcare centre and the research timeline (Burlingame et al., 2003; Glassman & Wright, 1983; Yalom, 1966). The art therapy was grounded in a humanistic person-centred approach. Psychoeducation was provided based on mindfulness research linked to stress management and wellbeing (Visnola et al., 2010). Each session concentrated on a different theme and was followed by a check-out and brief ‘homework’ (journal creation). During the sessions, the participants were encouraged to explore facets of life that were causing stress. (See Appendix C for photos of the artwork.) The CBI and PSCS data collection occurred at the beginning of Week 1 and the end of Week 6. Stress data was collected before and after each session. Answers to qualitative questions were collected at the end of the intervention, at Week 6. All questions were collected on paper.
Table 3. Weekly themes and descriptions.
Data analysis
The data were collected on paper forms. The quantitative data were manually entered into Statistical Package for the Social Sciences (SPSS, version 28) for analysis. The quantitative data were analysed using a paired samples t-test for comparing scores on the burnout and professional self-care measures between pre- and post-intervention. A significance level of .05 was sought for the data. Two participants dropped out after two sessions, so they were deleted from the sample. As per Braun and Clarke (2006), an inductive approach was utilised for thematic analysis of the qualitative data. After the researcher was familiar with the responses, initial codes were generated. A table was created using Excel with the codes and a description of each one. The definitions for each code were cross-checked with another colleague. The coding for the qualitative data was done by first one person then was taken on by another to cross-check and final themes and groupings were agreed upon.
Results
Burnout
The scores on the CBI at pre- and post-intervention are summarised in Table 4. The results show that the group experienced a decrease in personal burnout scores; a two-tailed, paired samples t-test revealed a statistically significant reduction on the CBI personal subscale between pre- and post-intervention. There were no significant differences observed for work-related or client-related burnout between pre- and post-intervention, p > .05.
Notes: CI = confidence interval; LL = lower limit; UL = upper limit. An alpha level of .05* was used to determine significance.
Table 4. Contrast of pre- and post-measures for the Copenhagen Burnout Inventory (CBI).
Self-care
Table 5 summarises the scores on the PSCS at pre- and post-intervention. The results of the two-tailed paired samples t-tests for the PSCS sub-scales reveal no significant changes in scores between pre- and post-intervention (all p’s >.05). Results from a one-tailed t-test reveal a significant reduction between pre- and post-intervention scores on the PSCS professional development subscale (p = <.05). A one-tailed t-test indicates a directional one-way relationship with how participants perceived professional development.
Notes: CI = confidence interval; LL = lower limit; UL = upper limit; Prof = professional; Cog = cognitive.
Table 5. Contrast of pre- and post-measures for the Professional Self-Care Scale.
Self-reported stress
The results from the single stress question posed directly before and after each session reveal a significant reduction in self-reported stress levels for Weeks 2, 3, 5 and 6 (p’s <.05). (See Table 6 and Figure 1 for details.) There was not a significant reduction in the stress levels reported in Weeks 1 and 4 (p’s >.05). On average the overall post-intervention scores were 1.98 points higher than their pre-intervention scores indicating an overall reduction in stress levels over the course of the one-hour art therapy sessions across the six-week group program.
Notes: CI = confidence interval; LL = lower limit; UL = upper limit. An alpha level of .05* was used to determine significance.
Table 6. Weekly and total pre- and post-intervention scores on the Self-reported Stress Scores.
Figure 1. Graph of weekly pre- and post-intervention stress scores.
Table 7. Themes and quotes from answers to qualitative questions at the end of the intervention.
Qualitative analysis
Overall, the participants’ responses indicate that they were surprised how well the intervention worked and most of them reported that they were sceptical about the efficacy of the program at the outset. Participants stated that they felt the intervention was helpful for processing feelings and made them feel more relaxed. Participants’ responses indicate that they thought that the program was effective reducing the risk for burnout, increasing self-care, and reducing immediate feelings of stress. All participants reported that they wanted the intervention to go for longer than six weeks. Participants’ responses also indicate that they observed a difference in the way they interacted with others at work and at home following participation in the art therapy program.
Discussion
The aim of the six-week art therapy intervention was to reduce stress and burnout through increasing self-care practices and enhancing coping mechanisms for stress among childcare workers. It was hypothesised that the intervention for childcare workers would lower overall scores for personal and client- and work-related burnout. It was also predicted that the art therapy intervention would increase professional self-care scores for the childcare workers and that, immediately following each session, participants would report reduced stress when compared to the beginning of the session.
The current study found that the art therapy group intervention was able to reduce personal burnout scores in childcare workers. Additionally, group participants reported significantly reduced stress levels at the end of four out of the six weeks. Overall, there was a significant reduction in stress levels over the course of the program.
The intervention was not able to increase self-care as measured by the PSCS. The qualitative data reveal a deeper insight into the benefits of the intervention, highlighting, despite initial scepticism, that the participants thought art therapy was helpful. Participants found the intervention facilitated the processing of feelings and emotions and shifted self-perceptions. The program promoted safety, therapeutic alliance, and positive interactions with friends and family. The efficacy of gathering quantitative and qualitative measures is substantiated in the results, as the efficacy of the results demonstrated weakness in the quantitative data that could be explored in greater detail by the mixed methods.
The hypothesis that the six-week art therapy intervention for childcare workers would lower overall scores for group participants for personal and client- and work-related burnout is partially supported. Results demonstrate that there was a significant reduction in the personal burnout scores between pre- and post-intervention. This finding is consistent with a similar art therapy intervention on hospice workers’ experience of burnout (Salzano et al., 2013). Thus, the art therapy intervention impacted how the childcare workers appraise burnout in their personal lives.
During the process of art-making the individual takes themself on a journey of self-discovery that helps increase self-esteem and overcome emotional impasses (Franklin, 1992). This exchange was reflected by one of the study participants, who said, “Art has totally made my mindset more positive and forgiving of my flaws.” Lee et al. (2018) found that a greater level of positive feelings for an individual produced a more engaged workforce. When workers are engaged in positive reflections this can act as a buffer to stress and improve health (Bono et al., 2013). Thus, participants were engaged in a positive reflection through the art that changed their perceptions of personal burnout.
Contrary to expectations, work-related burnout scores remained consistent, with no significant difference between pre- and post-intervention. Research has identified that within psychotherapy the optimal number of sessions for symptomatic changes is approximately four to eight sessions (Nordmo et al., 2020). Perhaps if the duration of the intervention had been nine or more weeks, we would have been able to replicate the findings of Visnola et al. (2010), who successfully targeted the effects of stress and anxiety on employees with a nine-week art therapy intervention, observing a significant decrease in work-related stress. Thus, future investigation of this type would benefit from at least nine sessions to allow for a greater time for the effects of therapy to impact appraisal of work-related burnout.
It is also noteworthy how high the scores for personal and work-related burnout were among our research group when compared to other studies (Kristensen et al., 2005; Milfont et al., 2007). Further, while the pre-intervention personal burnout scores reduced significantly over the six sessions, it must be noted that the post-intervention scores were still considerably higher than community norms (Kristensen et al., 2005). Given the severity of scores for personal and work-related burnout in this sample, a longer intervention period might be required to provide adequate support and skills to childcare workers to reduce their burnout scores.
Interestingly, in comparison to work-related and personal scores, the client (child) related pre-intervention burnout scores were already quite low and very close to the average normative scores reported in the CBI (Kristensen et al., 2005). The CBI inventory highlights that a lower score in the client sphere indicates that the individual does not attribute burnout to working with children (Kristensen et al., 2005). In accordance with the results of this study, previous studies looking at midwives’ appraisal of burnout correspondingly found that the midwives’ client burnout scores were much lower than their personal and work scores (Henriksen & Lukasse, 2016; Jordan et al., 2013). Studies involving childcare workers similarly found that caregiving was not the stressor (Faulkner et al., 2016). Thus, much like the above-mentioned research, it is not the perception of contact time with the clients (children) that is adding to the stress of workers.
It was further hypothesised that the art therapy intervention would increase professional self-care scores. The results of this study found that there were no significant changes in the self-care scores between pre- and post-intervention; however, the qualitative data reveal that participants perceived that they had increased their self-care practices because of engaging with the art therapy – that included meditation, time with loved ones, self-check-ins, self-indulgent times and time spent journaling while creating art. One participant commented, “I now allow myself time for self-care.”
Research found that self-care can also come about through self-compassion (Coaston, 2017). Within the qualitative data, self-compassion increased for one of the participants. She said, “I gave myself more credit and forgave myself.” Perhaps the measure “self-care” was not appropriate for measuring this construct. The Professional Self-Care Scale (PSCS) is intended to measure psychologists’ levels of self-care (Dorociak et al., 2017). At the core, self-care practices strengthen one’s ability to undergo various stressful situations, and create resilience through meaning-making and self-discovery that enhance those insights in one’s personal and professional lives (Bressi & Vaden, 2016). These processes happened during the intervention, with one participant saying, “[Art therapy] has allowed me time to explore and express my emotions, as there were times I could not open and talk about my feelings, some sessions were intense with the emotions and meanings behind the artwork.” However, the PSCS was not able to capture this change in participants.
Finally, it was hypothesised that immediately following each group art therapy session, participants would report reduced experiences of stress when compared to the beginning of the session. As predicted, there was an overall reduction in stress following the group art therapy sessions. Looking at the before and after session scores for each week, a significant reduction in stress was observed for Weeks 2, 3, 5 and 6. The scores indicate that the stress levels went right down to “Not at all stressed” following the interventions in Weeks 5 and 6, when the participants felt comfortable with art therapy and the other group members. There was not a significant reduction in Weeks 1 and 4; however, it must be noted that the before-session stress scores in Weeks 1 and 4 were not as elevated as in Weeks 2, 3, 5 and 6.
A probable cause for under-reporting scores in Week 1 was stigma surrounding reporting stress-related concerns in the workplace. Research has identified that often participants do not want to be labelled weak or be judged by co-workers; thus, they will under-report stress levels (Klinefelter et al., 2020). One of the participants said, “The biggest challenge of the program for me was the start of the program when we were meeting everyone.” It holds that once safety was established in the sessions, the participants felt comfortable to report actual stress levels. This was identified during the first discussion session as each participant came to an understanding that they were not alone in feeling highly stressed. During Week 4 it was identified that it was scheduled close to a public holiday. Research has found that a scheduled holiday will greatly lessen job stress; thus, the data might have reflected this (Westman & Etzion, 2001).
Further, across all six sessions the post-intervention stress scores were less than the pre-intervention stress scores. This finding is consistent with a similar study that measured participants’ cortisol levels directly after an art therapy intervention (Visnola et al., 2010). In accordance with the results of this study, a robust experiment conducted by Visnola et al. (2010) revealed significantly lower stress and cortisol levels following each of the nine sessions of group art therapy. Thus, much like other research (Huss & Sarid, 2014; Karpaviciute & Parkinson, 2015), our study has been able to demonstrate a measurable reduction in stress levels arising from the group intervention. This is a promising result and further research is required to validate this finding.
The most common theme that the qualitative data revealed was that art therapy was helpful and was ideal for processing feelings and emotions. Such a sentiment was exemplified in the Week 3 body scans as participants were able to self-identify how stressed they were after work and relate it to how that may influence interactions with loved ones.
The artworks in Figure 2 indicate that most of the participants felt stress in the head, stomach and feet. It was the exercise that increased anxiety and was discussed in the session. The body scan gave them a moment to be introspective, with one participant saying, “Coming to terms with my inner thoughts, emotions and feelings was a challenge.” Participants felt that body scans precipitated shifts in self-perception that had the effect of producing positive feelings and interactions with friends and family. One participant reported, “My moods are lifted with my family and my interactions are now calm and bubbly after art therapy.” Another said, “I was more patient and in the moment with my children, enjoying them more.” The participants stated that even without the verbal processing, the art itself was a means of processing feelings. This is in alignment with other qualitative research that identifies the healing nature of art (Belfiore, 1994).
As the intervention progressed there was a shared trust and growth among the members that facilitated the way for individuals to have moments of vulnerability. For example, one participant had an emotional reaction to the body scan and all the participants commented on her artwork, highlighting the colours, strengths and differing perspectives. The artwork gave participants a focus for encouragement and a means to communicate that was not overly uncomfortable.
Figure 2. Body scans from Week 3.
There are other factors to note, such as that the art therapy had a team-building effect that enhanced social connection and made the individuals feel less alone with their problems. As a participant noted, “I so enjoyed this group. After a few sessions we all supported each other in a different way. It is nothing like what we do at work.” Specifically, they all seemed to display a sincere need for connection with each other, that gave them a sense of belonging. This finding is consistent with that of Mejias et al. (2014) who identified that group art therapy enhanced a sense of belonging. With that sense of belonging and safety, each participant journeyed through the art to uncover a hidden aspect of their self each week. The participants were able to work through the art and to process thoughts and feelings while discussing it in safety. Thus, self-directed insights led to a change in a previously held schema that was able to benefit the whole group. This contributed to feelings of belonging, validation and self-worth that lead to self-care.
As observed by Klein (1973), art has the potential to be transportive in a discovery of previously uncovered thoughts, feelings, expressions and attitudes. One participant noted that it was acceptable to “allow myself time for self-care”. Observations of the artwork for Week 4 emphasise that participants felt that they had the autonomy to increase positive feelings through self-care practices, e.g., saying “no”, spending time in the gym, creating art, journaling, walking in nature or practising self-belief. (See Figure 3 below.)
Figure 3. Artwork that includes self-care.
Limitations and future directions
A limitation of this research was lack of experimental rigour, primarily related to the quasi-experimental design, the size of the group, the lack of a control group and the choice of measures. The research requires experimental rigour, and future investigation would benefit from random allocation and a control group. Conducting the intervention during work time influenced the final number of participants. Examining ways to increase the interest in participation in the workplace and the sample size would add to the power of the study.
Designers of future studies are advised to use an alternative measure of self-care that is more suited to the childcare worker population such as the Health-Promoting Lifestyle Profile II measure, which could capture changes in self-care. It is a more sensitive scale that has been used extensively throughout various populations (Walker et al., 1988).
A further limitation was not collecting pre- and post-intervention data on overall personal stress levels as well as depression and anxiety scores using a validated measure such as the Depression Anxiety Stress Scales (DASS-21; Lovibond & Lovibond, 1995). It would have been interesting to determine whether scores on a measure of psychological distress reduced over the course of the art therapy intervention. Therefore, future studies are encouraged to collect pre- and post-intervention measurements of stress and psychological distress.
Conclusion
Overall, the data provide mixed-methods evidence that a brief art therapy program effectively reduced stress and personal burnout in a small sample of childcare workers suffering from work-related stress. While art therapy did not reduce work-related or child-related burnout, the qualitative data confirm that it was beneficial in helping participants process emotions and feelings, and induced a feeling of belonging and safety that led to various shared personal insights. Although sceptical at first, all participants noted that they thought art therapy helped them to shift perceptions that stimulated positive interactions with workmates, friends and family. Ultimately, this research justified the use of mixed methods as it revealed the emotions and feelings of the participants that was not captured by a quantitative measure. It also provided insight into the benefits of art therapy in supporting a reduction in work-related stress and safeguarding against workers developing burnout in the childcare workforce. While this study yielded promising findings, further investigation is required to confirm the benefits of art therapy for reducing stress among childcare workers and other helping professionals.
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Appendix A. Art therapy space
Appendix B. Program plan
A standard approach will be used each week to ensure participants feel safe and are clearly aware of what to expect. General outline for each weekly session will include:
Introduction – emphasising confidentiality.
Brief mindfulness exercise or guided visualisation.
Check-in – seeing how everyone is feeling coming into therapy and a review of anything they wanted to talk about from the previous session – and quick pre-session stress scale.
Art therapy intervention and individual reflections.
Mindful breathing.
Check-out and quick stress scale.
Take-home ideas for ‘homework’ and comments.