Designing and assessing of an art-based intervention for undocumented migrants

Depósito de Investigación de la Universidad de Sevilla https://idus.us.es/ This is an Accepted Manuscript version of the following article, accepted for publication in Arts Health: Mateos-Fernández, R., & Saavedra, J. (2022). Designing and assessing of an art-based intervention for undocumented migrants. Arts & Health, 14(2), 119–132. https://doi.org/10.1080/17533015.2020.1866623 It is deposited under the terms of the Creative Commons Attribution- NonCommercial-NoDerivatives License http:/creativecommons.org/licenses/bync-nd/4.0/, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. 1 Designing and assessing of an art-based intervention for undocumented migrants Raquel Mateos-Fernándeza Javier Saavedra, PhDa aExperimental Psychology Department. University of Seville. C/ Camilo José Cela, s/n 41018-Seville. Spain Corresponding Author: Javier Saavedra [email protected] ORCID: 0000-0002-2328-7708 Tlf: 0034954557690 Experimental Psychology Department University of Seville C/ Camilo José Cela, s/n 41018-Seville Spain Declarations of interest: none CRediT author statement Mateos-Fernández: Writing- Original draft preparation, Investigation, Project Administration. Javier Saavedra: Writing- Reviewing and Editing, Methodology, Conceptualization, Data curation, Formal Analysis, Supervision, Validation. 2 Undocumented immigrants and refugees are more likely to suffer from psychosocial disorders. Some of the factors explaining this risk are the traumatic experiences they have during their migratory journey, migratory grief, the political, ethnic and religious persecution in their home countries, and the acculturation difficulties in a socio-political context of rejection in the host countries. This reality makes it necessary to introduce emergency psychological interventions in order to mitigate the negative effects of these factors. In this pilot study, an art-based intervention is described and assessed, with a sample of 11 undocumented immigrants who recently came to southern Spain on a small boat. The artbased intervention is assessed using a pre-post design and four questionnaires, which consist of The General Health Questionnaire, Beck’s Depression Inventory, the Barcelona Immigrant Stress Scale and Carol Ryff’s Psychological Well-Being Scale. Furthermore, five participants were interviewed before and after the intervention and a thematic analysis of the transcriptions was carried out. Results show a significant reduction of depressive symptoms with a large effect size. An increase of reflexive discourse and the feeling of belonging after the intervention was also observed. Keywords: undocumented immigrants; mental health; psychological disorders; art-based intervention. 3 The conditions for immigration are becoming ever more adverse (Ellermann, 2019), thus making it an important risk factor for mental health. The migratory journey can involve traumatic experiences and together with migratory grief can surpass the immigrants’ adaptive abilities and cause severe mental health problems. There are several types of grief coexisting in migration, including family and relatives, language, culture, homeland, social status, belonging to certain groups and contact with them, and risks for physical integrity. It is a complex kind of grief that, if handled incorrectly, can cause several psychological disorders. Once in the host country, acculturation implies such psychological challenges as the change in attitude and values, the acquisition of new social abilities and rules, changes in relationships and the adaptation to a different environment (Berry, 1997), in other words, a transformation of identity. The variables involved in the relationship between the migratory process and mental health make it impossible to establish simple causal relationships (Szaflarski et al., 2017; Saavedra, 2013). However, we can conclude that migrants, especially refugees and undocumented migrants who have experienced numerous losses, are the most vulnerable groups when it comes to suffering from several short- and long-term psychiatric illnesses (Hollander et al., 2016). In this context, the design of emergency psychosocial support programmes for migrants, especially refugees and undocumented migrants, is a fundamental issue in the host countries’ health policies. These programmes should be implemented within a few weeks of arriving in the host countries, with the aim of providing emotional support and preventing potential medium-term psychological disorders. Even though some pilot community-based interventions have been successfully implemented (Paloma et al., 2019), it is obvious that the psychological attention provided to this population is very deficient, even in such countries with highly advanced health systems. Art-based interventions (ABI) have recently been proposed as a therapeutic tool for refugees, children belonging to vulnerable ethnic minorities, 4 victims of disasters or domestic violence, etc., with the aims of exploring identity, re-building trust, sharing stories and healing wounds (Aktahr & Lovell, 2019). ABIs have proven to be efficient when used to treat multiple health problems, both physical and mental, in a wide variety of patients. Scientific evidence of their benefits can be found in studies carried out on people with all kinds of different illnesses, such as cancer, schizophrenia or post-traumatic stress disorder (Bungay et al., 2014; Fancourt et al., 2016; Saavedra et al., 2018a; Saavedra et al., 2018b; Slayton et al., 2010). Despite this scientific evidence, specific descriptions of interventions using ABIs with migrant or refugee populations are scarce. The few descriptions found coincide in the fact that ABIs are beneficial for migrant population. Among others, we can point out the following benefits: development of creative abilities, confrontation skills and problem-solving skills, promotion of communication, reduction of stress and anxiety, improvement of interpersonal relationships, support in the preservation of cultural identity and managing migratory grief. (Beauregard et al., 2017; Quinlan et al., 2016). There is a shortage of descriptions of ABIs with undocumented migrants, particularly in the first few months after their arrival to the host countries and using both a qualitative and quantitative methodology to assess its efficacy. The aim of this study is to describe and assess an emergency ABI in a community context with undocumented immigrants who recently arrived in Andalusia (Spain). Specifically, the ABI had the objective of promoting social contact, reducing anxiety levels and potential depressive symptoms, and making the expression of emotions and the processing of grief easier. In other words, we will explore the impact of the designed ABI on participants' stress, psychological well-being and depressive symptoms using a pre-post assessment design. 5 Method Participants The ABI was carried out with the assistance of the Movement for Peace, Disarmament and Freedom (MPDL) association in the city of Seville, in the framework of a programme for hosting immigrants in a vulnerable situation, aimed at assuring the coverage of basic accommodation and support needs for migrant people in a vulnerable situation due to physical deterioration and/or lack of support (family, social and economic). The programme is aimed at the Sub-Saharan male population that arrived illegally in Spain, with a non-determined age range, since users span from 16 to over 40 years old. This institution was informed about the intervention and the assessment’s procedure and approved the research project in accordance with ethical requirements. The inclusion criteria of the participants were to be undocumented immigrants who had arrived at the Andalusian coast in the last two months, to speak French or Spanish and live in some of the foster homes of the MPDL in the city of Seville. Participants should show that they had understood the aims of the intervention and, lastly, to sign the informed consent form. This study’s sample consists of a total of 11 people, male Sub-Saharan immigrants, ranging between 18 and 42 years old. The average age of the sample is estimated at 21.92. Regarding marital status, 2 out of 11 participants have a partner and 9 of them are single. We had 3 participants who had never received any formal education, a participant who attended primary school and 7 who attended secondary school. All of the participants arrived in Spain irregularly from Africa on small boats in the last month and a half, and most of them had traumatic experiences throughout the journey and in their homelands. Every one of them had a basic medical examination in the weeks following their arrival; they did not undergo, however, any psychological assessment or treatment. 6 Description of the intervention The first author designed the art-based intervention sessions. The second author supervised the development of the intervention. With the aim of reducing linguistic and cultural barriers, a French native speaker volunteer belonging to the Movement for Peace, Disarmament and Freedom participated as a mediator in the ABI. The intervention was carried out through 6 sessions between the months of May and June in 2018 in a room of a community centre in the city of Seville. Prior to the design and implementation of the intervention, a search for literature related to ABIs and health was carried out in order to compile activities and techniques that could be useful in our work context. We concluded that the ABI should be offered to undocumented migrants a few weeks after their arrival in Spain, and it should have a minimal economic cost. In other words, it should be considered an emergency intervention. Regarding the location, we decided to avoid places with a clinical or institutional connotation like hospitals. We chose a community space, open for all citizens, to hold the ABI. The activities we wanted to carry out had to be as simple as possible, so that potential cultural and linguistic barriers could be reduced, and minimal cost guaranteed. Every activity had to give the participants the opportunity to express emotions and share their experiences, without them feeling pressured at any time. In other words, migrants had to have control all the time. We thought it was appropriate to use such content as original music and songs from their native countries, as a source material to work with, in order to reduce cultural barriers (Lenette & Sunderland, 2016). As can be seen in Table 1, drawing (for instance, drawing a self-portrait), dance and music (musical improvisation) were the most used artistic practices. Writing (e.g. writing a thankyou and/or goodbye letter) and some relaxation techniques were also used. The materials 7 required for carrying out the activities were very basic, including paper, pencils and colouring pens, a laptop, speakers, connection to the internet, mats and balloons. The following musical instruments were used for one session: a cajón (Peruvian box-shaped percussion instrument), a djembe, a ukulele, Cuban maracas, egg shakers, a panpipe and a violin. [Insert table 1] The activities carried out were equally simple and easy to understand (see supplementary pictures 1, 2, 3 and 4). As an example, we shall briefly outline two of these. For the second activity of session 1, paper and felt-tip pens were given to each participant and they were asked to draw a self-portrait. They were told to try to reflect how they felt about themselves and that they could use whatever style, colours or drawing techniques they needed in order to do this. To finish the activity, they sat in a circle and each individual showed their drawing and explained why they drew it in that way and how they felt when they were drawing. In session 5 (migratory grief) participants sat on the floor forming a circle, and they placed a set of instruments in the centre. First, they gave the participants 10 minutes to try out and explore the different instruments. Then, they dedicated 20 minutes to improvisation; one participant started playing a percussion instrument at a steady and free rhythm, and then the rest of the participants gradually began joining in one by one or in small groups. Afterwards, each one of them was asked to choose an instrument and to try to improvise expressing how they felt by playing one of the songs chosen by them for session 2 (family) and 4 (migratory journey). Individual work was interspersed with shared activities, as well as with non-verbal and verbal ones (talking as a group). This way, participants could integrate bodily experiences and mind experiences, making it so that all experiences, in many cases traumatic, could be drawn upon 8 and shared in public narratives (Rubesin, 2016). One person participating in the intervention stated: Extract 1. Participant 5 (post-test). “I loved drawing and even more so when it came to drawing symbolic things. Explaining it to others afterwards was sometimes difficult, but it was also always fun and positive because it was a way of expressing ourselves and talking about ourselves, it was something that I think we all needed at the time, to talk about ourselves and be heard”. Quantitative analysis Due to the lack of control groups and because of the novelty and the size of the sample our intervention should be considered a pilot study. A mixed quantitative and qualitative pretest/post-test analysis was employed to asses the intervention. The quantitative analysis was carried out with four psychometric instruments filled in before and after the intervention, all of them in French. The first one was Goldberg’s General Health Questionnaire (GHQ12), used for the assessment of psychosocial health and the detection of risks of psychosocial disorders. It is a self-administered questionnaire which consists of 12 items that must be answered by choosing one of the four possible options. The general dimension assessed by GHQ12 is self-perceived health. We can differentiate two factors: psychological well-being, and social functioning and confrontation. GHQ12’s internal consistency varies between .82 and .86 (Villa et al., 2013). The second instrument we used was an abridging of Beck’s Depression Inventory, with 13 items, aimed at assessing whether and to what degree there is depression. For each item of this self-administered scale, the participant must choose between the 4 possible sentences (0- 1-2-3). The abridged version of Beck’s Depression Inventory has an internal consistency index of 0.88 (Luty & O’Gara, 2006). 15 In the following extract, the participant refers to the importance of finding leisure and fun spaces. An observed effect of the ABI especially is the ‘liberation’ effect, as is shown by phrases used by the participants such as “release myself from all fears”, “liberate myself from my story, from this burden” or “we forget our worries”. This liberation effect can be understood as a decrease of repetitive and negative thoughts, which would result in a decrease in the physiologic response to stress. Extract 7. Participant 2: “Very good, to be honest. The workshop has been something very important in our lives and to us as immigrants who just arrived here, because, as I said before, there was no spare time there, you were locked up. So the workshop allows you to open yourself up, to talk. You think about things here, you talk to people and they listen to you, because when you talk to people, it is important that they listen to you […] We play music here, they give you a piece of paper, they tell you to draw or write down everything you want to, free yourself, it is some sort of liberation. The workshop allowed me to liberate myself in some way, so that I could move on afterwards, so that I could say what I feel inside and release myself from all the fears I have”. Some results from the qualitative analysis are understandable in the context of the previously outlined quantitative analysis. Depressive symptoms of Beck’s questionnaire decrease drastically with a large effect size in the post-test. Furthermore, despite not having obtained a statistically significant difference, the reduction of the effect size of general stress for the BISS scale is medium. These results are compatible with the ‘liberation’ effect, the decrease of ruminating thoughts and the change of perspective. Discussion We are going to focus the discussion on three psychosocial processes fostered by our artbased intervention: social network and expression of grief, construction of coherent narratives and “therapeutic attunement” (Kossak, 2009). Participation in the ABI has allowed migrants to create an emergency social network that is temporary but necessary. All the participants’ evaluations put an emphasis on the security and 16 trust they had developed within that space. In fact, some of them see all the people who participated in the ABI, professionals and migrants, as a second family. Thanks to the social network built, migrants have allowed themselves for the first time in many months to start a series of fundamental psychological tasks. The struggle for their lives during the migratory journey and the lack of a social support network have blocked any expression of emotional grief. The ABI has let certain emotions flow, such as anger, sadness and helplessness. Moreover, interactions between participants during the ABI helped to restore a sense of emotional coherence, allowing for post-trauma construction (de Smet et al., 2019). Another fundamental task of the grief is creating coherent narratives of our experiences. Traumatic experiences block our ability to build narratives (Neimeyer, 2001). Firstly, participating in ABIs has let participants move beyond words and has allowed for a complexity in which contradictory experiences or emotions can coexist. Secondly, activities and interaction among participants have allowed to explore alternative narratives that give meaning to the participants’ experiences as well as making them communicable. Furthermore, when creating new narratives, participants could remember their motivations and imagine themselves in the future, which is a fundamental feature of a life narrative and a suitable identity. In this sense, creative practices such as drawing have proven to support the identity construction of immigrant students in the classroom (Beauregard et al., 2017). Ultimately, participants have been able to allow themselves to process and build on their grief in a secure context, control anxiety and stress symptoms, and take their time to explore more coherent and unified narratives of their experiences (Neimeyer, 2001). Various activities helped the participants to stop having obsessive thoughts and ruminations, which led to reduced stress levels. In this sense, several authors have highlighted the capacity of the arts to create flow experiences by allowing the person to focus on the present moment (Kossak, 2009; Saavedra, 2018a). In relation to the dance and musical improvisation activity, 17 one of the participants said “The atmosphere created was good and positive, we all had fun. I think it was good to play those games afterwards to forget about the stress and sadness”. The participants had experienced a lot of uncertainty and challenges throughout their migratory journey. The nature of some activities, such as that of musical improvisation, allowed the immigrants to face the uncertainty again and to tolerate it in a creative way. Based on the processes previously outlined, we can state that art-based intervention achieved moments of therapeutic attunement, at least during the development of some activities. Kossak (2009) has designated the term “therapeutic attunement” to refer to the individual and collective experience of being at one with other people and other ways of life in connection with everything that surrounds us, elicited by art-based practices. We believe that facing these psychological tasks may prevent medium- and long-term psychosocial disorders. In this sense, we have found a clear decrease of depressive symptoms in the post-test and the existence of a change of perspective and decrease of intrusive thoughts in our qualitative analysis. Psychological assistance to migrant people, especially refugees and undocumented immigrants, is a big challenge for the host countries in terms of health policies. Due to its flexibility, low cost and cultural sensitivity, the implementation of art-based interventions could serve as a first buffer for stress and supporting the processing of migratory grief. Our study has limitations, the first one being that the sample was very small. Whilst we have included effect sizes in our analysis in order to compensate for the lack of statistical power and to detect important changes between the pre-test and the post-test, the necessity to replicate the intervention with bigger and more diverse samples is evident. We were not able to use a wait list control group or a different kind of treatment. Therefore, we cannot dismiss the fact that at least some of the intervention’s efficiency is a product of the passage of time. 18 Lastly, we employed questionnaires with a high degree of use in the occidental cultures; even though they were answered in French and the participants were individually assisted, we cannot dismiss problems in understanding the purpose of these instruments. Furthermore, we cannot rule out that the expression of the depressive experiences of our participants does not correspond exactly with the symptoms described by the items of Beck’s Depression Inventory. These problems may explain the low internal consistency in some aspects of the questionnaire. In conclusion, the quantitative and qualitative results point towards the same direction. The study suggests that our art-based intervention has decreased depressive symptoms and stress, redirecting the narratives of the participants towards the future and increasing the sense of community, while allowing them to express their emotions and promoting a more reflexive style of processing their grief. In order to deepen our results, it would be necessary to increase the number and diversity of the sample, include control groups, and carry out a long-term follow-up of the participants using qualitative and quantitative methods. These results and others should lead us to the creation of a guide for the design of psychosocial interventions based on the Arts with the migrant and refugee population. Declaration of interest statement There are no financial conflicts of interest to disclose. 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For Peer Review Only Table 1.Design of the intervention based on creative practices: sessions, objectives and activities Session number Objectives Activities Session 1. “Introduction” Individual introduction of each one of the participants -Group introduction dynamics. -Drawing a self-portrait with the intention to reflect their emotions. Exhibition in front of the group. S2. “My family’s song” Express and share feelings, explore feelings of loss -Choosing a song which reminds of the family: each one of them is listened to. Commentary on why was it chosen and which feelings do they evoke. S3. “Let’s dance!” Express oneself through dancing and movement, handle stress and foster relaxation -Games with balloons and music, in groups and in pairs. -Songs to make everybody dance forming a circle -Relaxation activity, an adequate musical selection was reproduced and a progressive muscular relaxation exercise was carried out. S4. “My journey’s music” Share with the group the reasons for their emigration and the experiences they have been through -Choosing a song or a sound that reminds them or that represents their migratory journey, explaining its meaning and sharing the experiences they wanted. S5. “Migratory grief” Offer basic information about migratory grief, as well as coping tools -Brief introduction about grief. -Musical improvisation with different selected rhythms and songs by the participants themselves, on which everyone improvised using the selected instruments. S6. “My future” Share future expectations with the group and think about the next steps to take in life -Drawing how and where they used to see themselves in 5 years and explaining it to the rest of the group -Writing a thank you and/or goodbye letter to their families and/or their home countries -Thank you letter to this host country Page 21 of 27 URL: http://mc.manuscriptcentral.com/rahe Arts & Health 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only Tabla 2.Quantitative results and contrasts between pre-test and post-test (W de Wilcoxon and Hedge’s G). Pretest (sd) Postest (sd) Z p G de Hedge GHQ12 Total 8.667 (5.989) 7.196 (3.824) -.511 .609 0.233 Well-Being 4.833 (3.099) 4.25 (2.301) -.551 .582 0.316 Social functioning 3.833 (3.588) 3.666 (1.922) -.119 .905 <.001 BECK Total 5.272 (3.196) 2.5455 (2.423) -2.102 .036 0.924 RYFF Total 81.727 (6.958) 85.636 (11.386) -.801 .423 0.398 Autonomy 12.909 (3.048) 13.363 (2.579) -.358 .720 0.154 Control of the environment 13.909 (1.868) 15.09 (2.981) -1.425 .154 0.456 Personal development 14.545 (1.752) 15.636 (2.873) -1.073 .283 0.441 Positive relationships 12.636 (3.264) 12.909 (3.884) -.051 .959 0.073 Self-acceptance 14 (3.098) 14,363 (4.588) -.419 .675 0.089 Personal growth 13.727 (2.053) 14.272 (2.195) -.538 .590 0.226 BISS Total 28.916 (10.022) 24.417 (12.702) -1.099 .272 0.378 Nostalgia 4.833 (1.946) 4.250 (2.005) -.718 .473 0.284 Acculturation 4.166 (2.208) 3.500 (2.393) -.671 .502 0.278 Discrimination 1.916 (1.621) 1.92 (2.644) -1.065 .287 0.001 General stress 1.750 (1.055) 1.083 (1.443) -1.496 .135 0.507 Page 22 of 27 URL: http://mc.manuscriptcentral.com/rahe Arts & Health 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review Only Table 3. Categories and sub-categories for the interviews (pre-test and post-test) Categories/subcategories Definition Extract Health 1.-Physical health Positive or negative physical health status (for example, existence or absence of pain) Well, I feel my body well, I have no nausea or frequent headaches. 2.-Psychological health The participant’s (positive or negative) psychological health status, such as sadness, attention, stress, depression or anxiety Now that I’m here, my head is resting, and I focus on anything else. 3.-Traumatic experiences Events in the individual’s life that threaten or pose a danger to their mental health or physical integrity We went into the sea and 3 hours later, the Zodiac got drilled. The water came in and we started sinking down, sinking down. Protagonists of the stories 4.-Family members Every person the individual has any kinship with I used to live with my family: my father, my mother and my older brother. 5.-Friends Every person with whom the participant has any relationship based on friendship or attachment And the Ebola disease, which also came and took a lot of my friends… 6.-Partners in the migratory journey Every person the participant knows or travels with during the migratory journey I stayed there with another brother who helped us. Scenarios 7.Life at their homeland The participants’ life places in their home countries In my village, it is very difficult to go out and find money to feed the family, and I am the oldest brother; so I feel responsible. 8.Migratory journey Places related to the participants’ migratory journey, since their departure from their homeland to their arrival in Spain After going through Mali, I arrived in Mauritania and I entered Morocco. Emotions and reflections 9.Reasons for emigration Personal circumstances or reasons why the interviewee takes the decision of leaving his country Once, he decided to divorce from my mother because he did not want that I went on with my studies […]. All of this was part of what moved me to leave the country. 10.Personal reflections The individual’s self-analysis of events or situations from his past or present life It is like a new life, because it was a little bit complicated where we were, but here, when you talk, everybody listens to you, people are open-minded. 11.Feelings and emotions Moods, both positive and negative, that the individual experiences or has experienced I love my mother. Sometimes I call her and she doesn’t want to talk with me because each time I call her she starts to cry. Page 23 of 27 URL: http://mc.manuscriptcentral.com/rahe Arts & Health 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60