Assessment of the use of expressive activities in psychosocial rehabilitation: an analysis on rehabilitative and therapeutic effectiveness through utilisation of combined musical and theatrical activities "the musical", to promote significant changes in the expressed psychopathology of mental patients hospitalised in a psychiatric Residential Community, through use of Bowlby’s attachment theory.

Giovanni Curcio, PhD*

Enrico Conti, MD**

* Supervising Psychologist Psychosocial Rehabilitation Program Coo.S.S.E.L

**Neuropsychiatrist, Psychotherapist, President Coo.S.S.E.L Co-operative

Abstract

The purpose of this study is to explore and assess the efficacy and the utility of the use of expressive and creative activities in psychosocial rehabilitation, as measured across a (n =135) day period, in which (n = 11) women with a mean age of 51 years, hospitalised in a psychiatric residential setting, with a diagnosis of schizophrenia or schizoaffective disorder, were intensely involved in a theatrical and musical experience, better defined as a "musical". A before and after research design was used with multiple baseline measurement at four intervals: beginning activity, interval, 135 days and 30 days after conclusion for follow-up purposes. The study aimed to assess the level and intensity of involvement in the activity and evaluate its utility in influencing negative symptoms associated with chronic illness, assess its potential for producing significant and lasting changes in psychopathology, and the bettering of personal and social functioning globally. A statistical analysis of the results was voluntarily placed in second order due to the limited sample size. We preferred giving preference to a description of the study through observation of users and provider’s behaviour and the study’s measurement findings. The conclusions underline the importance of the therapeutic and rehabilitative relationship in influencing outcome. Bowlby’s attachment theory is used to analyze the study’s findings.

Introduction

The cure and treatment of individuals with a long history of mental disturbance, personal and social failure, as can be represented by a diagnosis of schizophrenia or other debilitating psychic disease is a continuous challenge for many clinicians of mental health. The treatment of individuals suffering from a severe form of psychopathology that invests deeply the personal, social, emotional and cognitive spheres is a source of frustration and dissatisfaction for both the provider and user. The current belief suggests the road that leads to therapeutic and rehabilitative success is long and arduous, and demands coherence and consistency in the relationship between both parts.

Use of expressive activities in the field of psychiatric and psychosocial rehabilitation is widely diffused. Activities like music therapy, artistic therapies, dance and movement therapy, poetical therapy, drama therapy, etc, is sufficiently used in the daily work of rehabilitation and aims to improve within the therapeutic relationship the physical, emotional, cognitive and social needs of individuals of all ages. Studies demonstrate an efficiency in promoting a general well-being in health and an improvement in overall motivation, through involvement in a curative relationship, and its opportunity to serve as an expressive valve for unexpressed feelings in hospitalised persons.

The effectiveness of music therapy, for example, was investigated and studied with various disabilities; these included, for example: infantile autism (Wager, 2000), schizophrenia (Zhang, 1997), the dementia (Korb, 1997), acute cerebral damage (Nayak, 2000), Parkinson’s disease (Packages, 2000), Alzheimer’s disease (Aldridge, 1998), disturbances of attachment (Brotons, 1996) and depression (Suzuki, 1998). In all the studies analyzed, in which it was used as a therapeutic intervention demonstrated a highly meaningful clinical effectiveness (Koger, Chapin, Brotons, 1999). It was widely used in promoting improvements in personal self-esteem, in promoting positive changes in mood, in helping persons regain control of their life situations, to interact appropriately and socially, to improve concentration, in building potentiality to resolve personal problems, to develop capacities of relaxation and to increase awareness of self and external knowledge.

Dance or movement therapy aims through a direct expression of body movement to improve the emotional, cognitive and physical states of the individual, and is also thought to be an efficient and effective therapeutic intervention with many mental, physical and psychological disturbances. In one study, (Packages et al. 2000), the use of singing in chorus along with vocal and rhythmic exercises and free body and physical movement with patients diagnosed with Parkinson’s disease, demonstrated an improvement in emotional functioning, daily living and the quality of life in a generalized manner. Other studies, thought valid, have seen improvements in social interaction, in mood and in the frequency of participation in groups, of persons with traumatic cerebral damage and in the better emotional state of persons suffering from schizophrenia (Nayak et al. 2000).

Farkas (1993) has warned however, that rehabilitation is not limited to the use of activities better defined as expressive therapies. He alerts all, to not forget that rehabilitation is more focused on the acquisition of specific roles and in the structured use of specific techniques to help users to choose the roles they want and to improve theirs abilities to conform themselves to these, in order to increase society’s acceptance of them. Hogarty (1993) mentions that the strategies of rehabilitation need to aim at the disability and the handicaps and must always be coordinated with therapeutic interventions in order to reduce the disability. She continues saying, that a plan for rehabilitation targeted at disability and handicaps areas, must, first of all, identify the optimal treatment strategies. It is improbable that rehabilitation of disability and of handicaps in schizophrenic patients can be successful without having tried aspecific, optimal and continuous attempts to resolve the primary disabilites.

In our study, we have hypothesized that expressive musical activities can maximise hidden or latent potentials of individuals to better elaborate their life and all aspects that regard it, including it’s being an important aide in rendering them more aware of their disability to develop better cognitive and emotional corrective strategies.

The musical, comprises a number of independent expressive components within the same activity: dance and body movement, music and singing and acting. It is rare to find in the scientific literature its employment in the field of psychosocial rehabilitation for therapeutic purposes. Mostly all scientific references pay a specific attention to the singular use of one or other component activity, with one substantial and formal exception being, that the musical comedy, in itself, is not as consolidated as may be music therapy and/o dance or movement therapy. We have intentionally wanted to study and investigate its use as a therapeutic tool in the work of psychosocial rehabilitation, above all to improve collaboration and increase interpersonal involvement in difficult users, and to better create a rehabilitation treatment plan.

The treatment of persons suffering from schizophrenia poses significant problems to the providers of psychosocial rehabilitation; specifically, the urgency and the need to promptly intervene, at times, as well as the nature of the users’ defensive psychological structure, makes treatment and therapy a long and difficult process, in which creative potential, latent in every person, unable to be utilised. Persons with serious psychic disturbance, in general, are not particularly interested in their own personal adaptation and can retain treatment or psychotherapy unnecessary. Some however are aware that unfavorable environmental conditions, such as social and physical conditions, can constitute an important handicap to improvement, and bettering these can diminish a sense of loss (Dembo, 1974). Schizophrenic users tend to have little introspective awareness into their own illness, neurocognitive deficiencies, limited adherence to treatment and a negative view of their progressive stance (Pines, Cassano, Dell’Osso, Amador 2001).

An expressive activity, as is a musical, is an attempt to facilitate a process of change in personal suffering and to encourage the development of role interdependence and dependency with others. Psychosocial rehabilitation can succeed when individuals realize the flexibility and the competences to enter comfortably into a variety of dependent relationships (Kerr & Meyerson, 1987).

The schizophrenic users are well-known to be resistant and difficult to involve in many types of therapeutic activity, expressive or creative. Recent studies have formulated that crucial and significant aspects of the providers of treatments can also be responsible in speeding up or in rendering the therapeutic process and the final outcome of therapy, a failure experience. In recent years, there has been an increase in the exposure of users to rehabilitative activity; this is probably due to a greater attention and value towards rehabilitation activities in general (Viganò, 1998). Some programs of psychosocial rehabilitation, for users with depressive disturbance and dementia, have evidenced that behavioural therapies based on the concepts of problem-solving, using pleasureable events, have been able to improve the symptoms of depression both in the users and/or in the caregivers; the improvement was maintained for six months (Draper, 1999).

In past years, accumulated research information suggests that psychotherapy and other types of psychological and expressive intervention is able to produce long-lasting improvements in behavioural functioning and is also capable of bringing about changes in cerebral functioning A leading study of 1999 conducted by Bateman and Fonagy, for example, has pointed out that seriously disturbed users in partial hospitalisation (these patients were affected by borderline personality disorder), involvement in an intensive psychotherapy program was able to produce changes in suicide potential, in self-destruction behaviours, in lesser need of protective shelter and diminished expressed psychiatric symptoms. Another study, led by Ciechanowski et al., demonstrated that the lack of collaboration in the doctor-patient relationship, of patients placed in a self-management diabetes program, was connected to multiple medical complications of the diabetes. These and other contributions suggest that psychotherapy principles are essential in all types of provider-user relationships, and that the therapeutic alliance is as important in psychopharmacology as it is in psychotherapy (Krupnick et al.) in determining the final therapeutic results of intervention.

In our investigation, we have assumed that provider-user ingredients are greatly responsible for determining if therapeutic change could occur (Frank, 1961). Some studies have confirmed that personal characteristics of the caregiver or therapist associated with good working and therapeutic alliance are: less self-directed hostility, a perception of greater social support and a highly comfortableness with intimacy in interpersonal relationships (Dunkle, Friedlander, 1999).

On the opposite side of the change paradigm, is the resistance to change or simply, the non-collaboration of the user (Miller & Rollnick, 1991). This resistance to change occurs when the user perceives the caregiver as a formal object, cold and not involved (Laing, 1965; Adams, 1993; Carling, 1995), hindering the process and the fluidity of the therapeutic and rehabilitative relationship, at all levels of competences; instrumental, interpersonal and intrapersonal, and a tendency to develop dysfunctional schemes of interaction that can become chronic through time (Spivak, 1987), arousing in the user attitudes and values attributable to his/her past that can damage the working alliance (Orford, 1986).

The lack of collaboration is typically schizophrenic, however, many of whom obtain improvements recover. Some studies have demonstrated that 70% of persons with a diagnosis of schizophrenia is non-cooperative with pharmacological treatments and many demonstrate series difficulty in establishing a therapeutic alliance due to unusual and dysfunctional behaviours (Laing, 1965; Spiro et al., 1993; Nehls, 1999), in addition, to the repetitiveness and circularity of inadequate interpersonal relations with other persons (Spivak, 1987).

Not all workers of psychosocial rehabilitation, on the other hand, are capable of connecting themselves empathetically with users who are highly disorganized and/or desocialised, often because of a selectivity aimed to exclude difficult and frustrating users. Little have the patience, the competence and the formal training necessary to construct an essentially intimate relationship important for the rehabilitative process and its success (Sullivan, 1962). Many clinicians assert that the establishment of an intimate relationship with persons suffering a serious mental illness, like schizophrenia, is essential and it’s absence can influence therapeutic success (Fromm-Reichmann, 1950). However, if the rehabilitative process is to be successful with persons in which harbours a deep sense of failure in behaving and in living, could this not depend on the "expectation" of hope that is built and transferred through a good therapeutic alliance, apt to stimulate dynamics of creative and motivational relationship based on collaboration and the expectation that the future could be better? (Landeen & Seeman, 2000). Authors like Landeen and Seeman assert through a study on "hope" in schizophrenic, that it’s absence is capable of influencing users ability to establish and to maintain good relations based on reality and to inhibit motivation, in general.

Benevolent therapeutic relations and positive role models, certainly can serve to speed up hope as an emotional aspect, and in turn increase participation adherence to cure programs and the desire to become involved with others. Schizophrenia as a disease is capable of undermining a sense of reality and destroying hope as an expectation towards establishing good relations with others. Therefore, working to construct strategies that can re-establish or help acquire a sense of positive relational reciprocity, a sense of personal competence, the awareness that things could go better and a sense of value in life, is not purely accidental (Miller, 1986). Schizophrenic users because of relational and cognitive disturbance have a poor disease outcome (Pini, Cassano, Dell’Orso and Amador, 2001) and consequently motivation highly degraded.

The present study begins with an understanding of Bowlby’s theoretical premises on attachment to evaluate the usefulness of expressive activities of a musical type in the field of psychosocial rehabilitation and, secondarily, if these activities are capable of effectively and positively influencing the dynamics in the provider-user relationship, the development of the therapeutic process and the expressed psychopatological symptomatology. In particular, under observation is an expressive activity, which in our case is, the musical comedy. Other theoretical and clinical considerations that will be made with respect to the provider-user relationship, the expressed symptomatology and the therapeutic process, are consequential to the investigation.

But how can we demonstrate if the musical comedy is a valid expressive activity to be used in rehabilitation? We have intentionally wanted to consider Bowlby’s theories on attachment to help us understand and make observations on the user group of study as well as on the staff workers involved in the preparation and putting on scene and/or stage. We assumed that the effectiveness of this activity could be confirmed if the user group of study involved themselves with satisfaction and had developed a pleasant collaboration in attending the preparations of rehearsal, maintained a high level of frequency participation throughout the 135 days of rehearsal activity and developed a good working relationship with the staff workers who directed the musical comedy; all of which was tested through measurement of the individual presences and the daily total minutes of constant working engagement as a measure of individual adherence to the musical comedy. The departure point was to determine individual styles of attachment of the study group and demonstrate that users with a difficult and resistant style of attachment mode could be engaged with success over time, and lead to reduction and management of their negative symptomatology, at least for the period in which the users participated in the musical rehearsals, and an improvement in social and personal living within the Residential Community.

In its essence Bowlby’s theory on attachment declares that attachment search is a primary human motivation. The affective ties between individuals and schemes of interaction between children and theirs caregivers produce internal cognitive models that serve as a calibrator guiding interpersonal expectations and behaviour towards mature modes of relating. Stable and consistently predictable caregivers tend to encourage the development of valid interiore Ego models which inturn fosters the belief that other persons are worth trusting and are a reliable source of nutriment. Unstable and inconsistent unpredictable caregivers in infancy tend to produce dysfunctional inner cognitive models and as a consequence insecure and anxious models of attachment throughout the life cycle (Bowlby, 1979, 1988).

The same Bowlby (1973) distinguishes two spheres of influence in the construction of the personality. The first sphere is constructed by external and environmental influences and refers to the presence or the absence of a reliably trusted figure that is able to supply a secure base in every phase of the vital life cycle. The second sphere, is defined by inner influences of the organism and refers to the personal capacity or incapacity to recognize a reliably trusted figure and to collaborate with it so as to establish a mutually gratifying relationship

Some investigators have determined that there are four main categories of attachment in adults: secure, dismissing, preoccupied and fearful (Bartholomew and Horowitz, 1991), and two orthogonal dimensions (the idea that a person is worthy to receive care and the idea that others can be worthy of trust in giving care), that in combination produce the four models of attachment. Studies on persons with or without serious psychiatric disturbance demonstrate that attachment states of the mind are associated with different approaches in interpersonal relating (Dozier, 1990), and that individual differences in therapist attachment styles or of the caregivers is capable of influencing the establishment of the therapeutic relationship (Dozier, Cue, Barnett, 1994).

Our study has tried to evaluate and observe the quality and the characteristics of the provider-user relationship as an aspect that could determine user participation in the musical comedy, and their relative engagement across time. Bowlby (1988) considered the development of a therapeutic alliance a prerequisite for involvement in the exploration process and eventual restructuring of behaviour.

The concept of therapeutic alliance finds its birth in Freud’s article on "Dynamics of the Transference" as an element of the paradox resolution encountered in therapeutic practice and theory (1912). Freud described (1910) the transference as a tie that could prevent a patient’s escape through the neurosis, but also observed that the transference could constitute resistance to the course of the analysis. How was it possible that the transference responsible for the motivation of the patient at the same time could hinder success towards mental health? The answer can be observed in the fact that the transference or the therapeutic alliance, according to Freud, was composed of different types of attachment that can help or deny the development of a primary relationship. We remember quite well that Freud, opportunely, also speaks about the necessity of a strong patient attachment to the curing doctor for success of the analysis (1915).

Today we are more than convinced that the therapeutic alliance constitutes an important and fundamental stepstone for the development of any therapeutic relationship. Many studies of research have widely explored the variables and the characteristics of the therapist in influencing the outcome of the quality of the alliance in psychotherapy (Hersoug, Hoglend, Monsen, Havik, 2001), confirming what Freud has written many years ago.

In our study, we are engaged in observing the creative potentiality stimulated and strengthened by the musical comedy. We have also assumed, that users with an insecure and difficult way of relating can be engaged with success in a musical comedy, despite the absence of specific expressive competences (the users were not singers, neither actors nor dancers), as well as having problems in interpersonal relating and specific cognitive difficulties.

Methods

Participants

The study was carried out in a Residential Therapeutic Community for mentally disable managed by the Social Co-operative Coo.S.S.E.L - Non profit Organisation in Reggio Calabria, from the month of November 2002 to April month 2003.

The Residential Therapeutic Community is an "alternative" residential structure divided in two modules accommodating approximately n = 38 female users with diverse diagnoses: dementia, mental insufficiency, autism, schizophrenia, schizoaffective disturbance, mood disturbance, personality disorders, Alzheimer’s disease, etc. The average age of the users of the Residential Community is approximately 62 years. The average age of (n = the 11) users selected for the study is approximately 51 years. The users were selected to participate in the musical comedy study according to age, for diagnosis (according to DSM-IV criteria) and by freely determined personal inclination and/or motivation. The (n = 11) women selected have a diagnosis of schizophrenia or schizoaffective disturbance common to them all. None of them has specific musical or theatrical competences. Some of the women had participated in the first musical comedy carried out in 2002. The (n = 11) women have consented to participate after thorough explanations on the activity comedy and the project. All the users of the Residential Community, including those participating in the musical comedy, are involved in a psychosocial rehabilitation program based on the Spivak Model.

The two rehab workers responsible for the musical comedy have demonstrated a high inclination and personal motivation to include in the daily programming of psychosocial rehabilitation a musical and theatrical activity. Neither of the two workers has specific competences or precise qualifications relating to the musical comedy, but are transported by a desire to investigate new forms of communication necessary in order to stimulate the expressiveness and the creativeness of users of psychosocial rehabilitation. We have established that the two educators demonstrate an attachment style defined as "secure" tested through concepts from a relationship questionnaire.

The activities of the musical comedy were subdivided by work group; all the users of the Residential Community has participated in the project, with the exclusion of those not in a position to participate for medical reasons. The work groups had in common the development of tasks finalize toward the musical. The work group activities defined were: the artistic group with tasks to realize the scenery and scenography; the dressmaking and sewing group with tasks of mending and creating the costumes; the newspaper group had the task of drawing up the scripts of the musical comedy and publicity aspects; the chorus group was teach the music and the cognitive group had the task to help users to memorize and recite their roles in the musical comedy. All the activities of the musical comedy (the rehearsals and the activity groups) had begun at the same time in the month of November 2002 and was concluded in April 2003.

The activity groups were programmed on a five day schedule, with morning and afternoon shifts. All the users of the Residential Community were involved in at least one of the activities of the musical comedy with various workers, while the users in the study group (n = 9) participated in some activities with various rehab workers, but with the same two rehab workers for the "rehearsals" of the musical comedy throughout the entire period.

The "rehearsals" was considered the musical comedys’ main activity, and the primary aim of our study. It was always carried out with the same two workers in charge of the musical. At the beginning of every rehearsal, daily attendance of each user was taken (total number of daily attendance to rehearsals sessions for single user), as well as the total daily minutes of participation in the rehearsals for each user, and the observed ruptures (the number of separations or breaches from the rehearsals per day for each user). The rehearsals lasted approximately (n = 120) minutes per day for a total amount of approximately (n = 10) hours per five days of rehearsals; and a total time of approximately 270 hours of rehearsals in the 135 days of activity period. The study endured a Christmas pause of approximately 20 days before resumption in the month of January 2003. They has been no calculation of the total hours of user engagement in other aspects of the musical comedy (for example, scenography, chorus, recitation, newspaper group, etc). We presume, in any case, that the total hours of participation in other activities was similar to involvement in the rehearsals of the musical comedy. They has been no consideration of neither the absences, nor of the time of engagement in other activities, nor observations made on the quality of the participation between worker-users in activities not pertinent to the rehearsals.

The "rehearsals" of the musical consisted in uniting the users, usually in the morning, in particular the users of the study (only a part of the users present during the rehearsals were involved in the study), in practicing their parts. During the daily rehearsals, of 120 minutes approximately, the users were engaged in the practice of the music and choreography of the musical and in the recitation and the singing of the parts for each user. In the afternoon, the users were usually participants to other aspects of the musical comedy, for example, in the chorus, the design and painting of the scenery, etc.

The attachment styles assumed for each of the 11 women is subdivided as follows : n = 7 users have demonstrated a style of attachment considered "preoccupied"; n = 2 users "fearful"; n = 2 users with an attachment style "dismissing". According to Bowlby (1973), adults with an attachment style defined as "secure" have interiorized a positive sense of personal esteem, they trust that others will be available and supportive; they are independent, they search for and expect that others will give them support. Persons with a "preoccupied" style of attachment are dependent on others for personal confirmation, acceptance and approval. Individuals who are "fearful" see others as unavailable and incapable of giving care; they perceive themselvesas unloveable eventhough they desire nearness. Individuals with a "dismissing" style distance themselves from others and develop strategies in which they become excessively independent; they are emotionally apathetic and do not trust others (Bartholomew and Horowitz 1991).

It is assumed that persons with attachment styles defined as "preoccupied" and "fearful" will have meaningful difficulties in establishing a collaborative working relationship with the educators, while the attachment styles of individuals defined as "dismissing" will be incompatible with a good working collaboration and relationship (Von Korff, Gruman, Schaefer, Curry, Wagner, 1997). The "secure" attachment style of the two rehab workers should arouse positive cognitive schemata and compensate for the insecure state of the user fostering the probable establishment of a good therapeutic alliance.

Bowlby (1973) has made known that persons with personality disturbances have a "disabled" capability, and donot succeed in recognizing appropriate and/or desirous figures with whom to establish rewarding relationships. If they meet this type of figure, the "disablity" makes them assume inappropriate behaviours described as: anxious clinging, excessive demanding or out of proportions to age or situation reference norms, disengaged separation and/or provocative independence. It is, therefore, hypothesized that these "disablements" will arise again in the course of work with the two educators.

Measurement

Seven (n = 7) days before beginning the rehearsals and all other activities referable to the musical comedy, the users within the project were subjected to intervals of psychometric testing in order to establish the baseline measures of departure. The study group was involved in a "before and after" research design, in which the group was compared with itself across time on a series of measurements. The reduced sample has not allowed use of a wider research design that would allow consideration of statistical analysis of outcome. A second baseline measurement was obtained before the Christmas break and a control measurement before resumption of the musical activities following the holiday break; a third baseline measurement was taken at the end of the musical comedy (135 days); and a fourth measurement after 30 days following conclusion. Two (n = 2) women selected to participate in the musical and initially involved in the study were discharged from the Residential Community, therefore, it was not possible to carry out a second measurement or include them in the project. Thus, the number of women effectively involved in the measurement baseline are 9.

The assessment scales used for the measurement baseline were as follows:

DI. SA. - Acquaviva Version, was used as an instrument to gather clinical information in a standard manner. This instrument reveals the type of relationship with the service model (admission, agreed interruptions, transfers to other services, abandonments/discharges etc); inquires into the following areas: types of cohabitation, work, constructive activities and economic conditions, autonomy in daily life, social and family functioning, life attitudes and physiological aspects, sanitary management from the last compilation, summary scales (social functioning, "psychotic symptomatology of a positive type, "neurotic and/or psychotic" symptomatology of a negative type. Problems in comprehension, memory and orientation).

Global Assessment of Functioning Scales, (GAF), is a scale of approximately 90 items used to estimate global psychosocial functioning and symptomatic level.

Brief Psychiatric Rating Scales, (BSRS), a scale of brief psychiatric assessment, consists of 24 items that measure the state of actual psychopathology, including disturbances in thought processes, deliriums and hallucinations.

TAT, (Thematic Apperception Test), test of thematic apperception, was used as a personal story telling measure to test motivation, emotions, feelings, complexes, conflicts of the personality and a cognitive mental representation of Self.

Relationship Scales Questionnaire, a questionnaire of 30 items, measures the four different categories of attachment.

Questionnaire S.T.A.I., (State trait anxiety inventory) Form Y 1 is a self-administered scale that assesses the state of anxiety or personal preoccupation; in this study the questions have been read to the users.

A series of paintings (following instructions for the human figure drawing) at the beginning of the study and re-administered during the Christmas break was used to have a measure of spontaneous creativity that could estimate psychological projective aspects.

Assessment Scale Spivak Model to measure socially competent behaviour in five living spaces (home, work, personal hygiene, family and peer relationships, social-recreation).

Results

During the innumerable rehearsals of the musical, all the users received psychological support for their participation. The beginning of every rehearsal was preceded by a phase, defined as spontaneous free movement and playfulness. All users were encouraged to playfully amuse themselves and to feel free to move about, to render their participation comfortable and less anxious, for approximately 15 minutes before beginning with the more formal aspects of the rehearsals. This served to sooth the users and to facilitate the inter-relational process, to accustom them in remaining within the group without excessive anxiety and conflict, to reduce the cognitive vulnerabilities that can influence the ability to bear stress and to intensely learn how to work on a precise activity.

The tendency to escape or rupture (for example, leave the activity room to go to the toilet, due to fatigue or expressed psychopathology) from the rehearsal room was remarkably higher when the anxiety and the interpersonal restlessness was felt as unmanageable, by both users and rehab workers. The group processes was facilitated by a good assiduousness to the rehearsals of the musical, by allowing a tolerant permissiveness that did not emphasize too strongly repetitive learning of the parts, a freedom of movement supported by a good communicative relationship, complete respect for the expressed psychopathology and acceptance of personal, social and emotional limits; all without losing sight of our expectations and desired progresses in learning, for example, the choreographies, the acing role parts etc.

The users received during the rehearsals of the musical comedy, feedback on their behaviour, their emotional and affective inner feelings, and were helped to develop strategies to deal with difficulties in attention, concentration and the tendency to isolate themselves. The group cohesion was reinforced by allowing users to freely express their positive or negative behaviours; the users were left to move about permissively whenever they felt the need to do so, group adherence to the rehearsals was reinforced by keeping motivation and expectations high and in line with personal behaviour.

Initially some difficulty in relational distance was encountered. The users were not accustomed to remaining together in an intense manner in the same context for extended time. The initial baseline measurement, in fact, demonstrated that all users had meaningful difficulty in social involvement and engagement. An impediment in social functioning was confirmed for 9 of the women in the study. The style of attachment for all the women involved in the study, was hypothesized, in any case, that significant difficulty would have been encountered in spontaneous behaviour, since all 9 women had a style of attachment defined as difficult. None of them was described as "secure" in their style of attachment, according to Bowlby’s definition.

An assessment of expressed psychopathology, negative and positive symptoms, and the state of anxiety has evidenced a range of impediments that went from moderate to severe-moderate on the B.P.R.S. as for the DI.SA., and a moderate level of impediment in social functioning for all the users of the study, according to the G.A.F.. The level of anxiety, insecurity and nervousness was moderately high (S.T.A.I.). Globally the users presented a wide range of symptoms including: delusions, noticeable depressive symptoms, high levels of anxiety, somatic worries, signs of disorientation, emotional and social isolation, tension, non-collaboration, distractibility, motor hyperactivity, motor retardation, euphoric mood and hallucinations. In specific, initial baseline measurement, (B.P.R.S.) witnessed significant signs as follows: (n = 8) users have evidenced delusions; (n = 9) users have manifested signs of tension and anxiety; (n = 6) users showed depression symptoms and (n = 9) users had somatic worries; (n = 2) users had unstable mood; (n = 6) users signs of mental disorganization, confirmed also by T.A.T. story narrative; (n = 6) users showed non-collaborative behaviours; (n = 6) users evidenced marked self-guilt; (n = 5) users with marked, but not continuous apathetic affect; (n = 9) users with signs of distractibility; (n = 7) users showed disturbances in emotional isolation; (n = 1) users with hallucinations; (n = 2) users with disorientation; (n = 3) users with motor hyperactivity; (n = 1) users with motor retardation; (n = 1) users with euphoric mood.

The Scale of neurotic and psychotic "negative" type symptoms (DI.SA.), like anxiety, depression, obsessions, apathy and emotional closure, at baseline measurement has evidenced moderate to severe symptom intensity. In particular, (n = 8) users have demonstrated a flattening of affective mood and emotional closure for a good part of the time, but not continuous; (n = 6) users have demonstrated signs of serious neurotic symptoms, continuous or nearly, that renders daily life limited and unpleasant ( as for example, frequent obsessive rituali, without serious medical risks); (n = 7) users have manifested an extended depressed mood, insonnia and occasional attacks of panic, not always evident to the others; (n = 2) with serious symptoms of worry for health related thoughts, like serious depression with motor retardation, insonnia and anorexia.

The Scale of psychotic "positive" symptoms (DI.SA.), has put in evidence the following: (n = 6) users showed some difficulty in the interpretation of reality because of delusions and/or hallucinations; (n = 7) users with obvious difficulties in communication and comprehension of various situations or evident signs of incoherent speech.

The Scale of intellectual capability (DI.SA.), forsees a glimpse of (n = 4) users with a sure slowness in comprehension; (n = 3) users with slight or occasional problems of comprehension; (n = 2) users with discreet intellectual problems.

Assessment of social functioning (DI.SA.) forsees all users (n = 9) in the study with marked difficulties in social, occupational and/or scolastic functioning, in more than one area, (as for example: avoidance of friends and job neglect, disturbed behaviours with others and little constructive activity.).

The Spivak Model assessment scale foresees a a group of individuals (n = 9) with discreet manual and instrumental ability, but not constant or continuous, in life spaces like, living area, work, personal hygiene, relationships with others and family and social-recreational, even though, some of them need greater support than others (as for example: success in waking up in time, carrying out simple domestic jobs, arriving on time for group activities, participation in the therapeutic activities, desirous of contact with family members, care of personal aspect). Slightly more difficulty is evident for interpersonal, intrapersonal and/or psychic behaviours.

Nine (n=9) women have totalized a relatively high global percentage number for presences in musical comedy rehearsals (89% on 135 days of rehearsals) without distinction for attachment style or expressed psychopathology. While the total number of ruptures for the group of users was higher at the beginning of group rehearsals (83% on 120 minutes of rehearsals per day), to then become stabilized after 15 days into rehearsals. Organizational factors could have played an important and crucial role, in influencing adherence to the rehearsals and the tendency to flee from them, (for example, users left alone without support or a precise cognition of what they were expected to do). Singularly, users with an attachment style defined as "dismissed" have totalled the greater number of ruptures from the rehearsals, while adherence remained good, given the opportunity allowed to freely move about, along with the secure attitude of the two rehab workers who compensated for the tendency to flee. In other words, users ruptured often from the rehearsals, but returned with the same ease; this behaviour slightly decreased over time.

Adherence to rehearsals remained stable and high after the first 15 days and continued until the Christmas pause; the number of total ruptures decreased from the beginning of the rehearsals until the break (25% of ruptures rather than 83% at begin). The total minutes of engagement in the rehearsals of the musical, for the group, were approximately 98 minutes per 120 minutes available, that is to say, users remained involved for approximately 81% of the time during rehearsals, once the tendency to flee was stabilized. The ruptures increased once activities were resumed after the Christmas pause, but, with lower frequency with respect to the beginning of the study (58% rather than 83% at initial start). The role of acquired learning in the first phase of the study and the more precise organization of the rehearsal activity, reinforced by a positive relationship with the two rehab workers and confirmed by stable, fluid and less disorganized group processes facilitated the emergence of those group factors like: acceptance, cohesion, adherence and hope.

Specifically, the (n = 7) users with an attachment style defined as "preoccupied" had a high total percentage of presences to the rehearsals and altogether a low percentage of ruptures. The (n = 2) users with a defined "fearful" attachment style and (n = 1) users with a "dismissing" attachment style, altogether had the highest number of ruptures with regards to the user group defined as "preoccupied", even though adherence to rehearsals improved over time for all users. Clearly an overall improvement in adherence was seen for three women, in the first phase of baseline measurement, before the Christmas break. The users with an attachment style defined as "dismissing" confirmed themselves as difficult to engage, but demonstrated good adhesion to the rehearsals when the rehab workers showed a tolerable permissiveness and worked with them on intervention strategies to help compensate users.

The second baseline measurement, shortly before the Christmas break, approximately after 60 days of rehearsals, foresaw a group of users altogether improved for: anxiety symptoms, tension, absent-minded, apathy and emotional closure, signs of mental disorganization, emotional isolation, somatic worries (B.P.R.S.). Improvement was also seen in the "negative" and "positive" symptoms (DI.SA.) such as: emotional flattening, apathy, obsessions, rituals and reality testing and communication; meaningfully lower was the perceived level of the anxiety, insecurity, somatic worry and the depressive symptoms. No change was found in symptoms such as: guilt, hallucinations and or delusions (B.P.R.S.); no improvement was noticed but neither worse were the instrumental and manual competences of the Spivak Model, while, the interpersonal and intrapersonal competencies evidenced a moderate improvement.

Shortly before resumption of the rehearsals, after the Christmas pause, a control measurement was effected (B.P.R.S., DI.SA., S.T.A.I., G.A.F.). The symptomatic improvements found in the first baseline measurement remained stable, despite a light tendency return towards emotional flattening, somatic worry, return of rituals and obsessions. It is somewhat difficult to assertain if the slight symptomatic regression is due to the break in the rehearsals, given the intensity of engagement, and/or to the Christmas pause for fatigue, better defined as post holiday syndrome; All together, group intensity and motivation for rehearsals was high and the length of time devoted to the rehearsal activity was considerable.

At 135 days from the beginning of the rehearsals (musical end) to approximately 70 days after the control was carried out, a third measurement was taken. Globally, measurement parameters remained unchanged with respect to control before the Christmas pause. A slight tendency towards increase in the level of tension, somatic anxiety and worry was noticed for all users (B.P.R.S., S.T.A.I.). It is possible that the tension accumulated by the intensity of the activity engagement, (without forgetting that the musical was publicly put on scene and/or stage in the final end of the study) expressed itself as a symptom of equilibrium and compensation or return to the state of homeostasis. We should not underestimate the fact that statistically there is a tendency towards improvement through absorption in the use of a multiple baseline measurement paradigm; for this reason the stability of the parameters be influenced by this factor.

A measurement of final outcome, beyond 30 days from the end of the musical, witnessed a slight return of the following symptoms: flat affect, emotional closure, apathy, anxiety, rituals and obsessions, distractibility, while positively correlated was non-collaboration (B.P.R.S.). All the users have evidenced a greater tendency towards collaboration, towards social involvement and more meaningfully available in their attitude towards the rehab worker as a figure, beyond 30 days from the musical end. Many users have continued to softly and spontaneously hum the music and words of the musical performance during the normal daily routine, for many days. An important, but not significant decline was witnessed in anti-social behaviour, restlessness and impediment in overall social functioning. Delusional symptoms, hallucinations and sense of guilt, remained invariant, while a narrative of emotional and cognitive feelings seemed better organized (T.A.T.).

Discussion

The initial hypothesis was to evaluate the effectiveness of an expressive activity like the "musical" in promoting personal, emotional or social changes in a group of users (for attachment style) living within a Residential Therapeutic Community; measure them and assertain validity of its use in the programming of psychosocial rehabilitation. Our initial hypothesis seems to confirm and demonstrate a reduction in frequency and intensity of negative symptoms (in persons with serious disturbances in personal, social and emotional spheres), changes in improved psychosocial functioning during the rehearsals of the musical and these were maintained for a longitudinal period of short duration. A tendency towards relapse of the negative symptomatology was witnessed once the intensity of the expressive activity ended, but a stable collaboration and a positive relational attitude was maintained with the two rehab workers in charge of directing the musical.

An intense expressive activity as is "the musical" seems capable of influencing positively social competences in persons with schizophrenia or schizoid-affective disturbance, but not capable of changing more structured disturbances of the personality like delusions and/or hallucinations; nor to worsen them. Instead, a positive influence of the musical was seen through improvements in obsessive behaviours, somatic rituals, anxiety, tension, worries, emotional closure, apathy, social and/or psychological isolation, communication and reality testing; all of which seem sensitive factors to group processes. "The musical" seems capable of improving neurocognitive processes like attention, concentration, verbal memory, visual awareness, orientation and psychomotor activity, but the stability of the parameters seems to indicate a need for intensity and a constant participation within such activities. Cessation of the participation seems to reduce more favourable aspect and suggests that the maintenance of the symptomatic progresses is tied to an intense, continuous and constant involvement over time.

Bowlby’s theory of attachment is an interpersonal theory of relations that proposes, that the quality of contact with primary caregiving figures influences how a person perceives and then later becomes involved in successive relations throughout life. This concept is transferable and applicable, in a generalized manner, to systems of health. Bowlby moreover, foresees in the development of a therapeutic alliance a necessary prerequirement to engage difficult users in a cure process and to restructure their models of attachment (Bordin, 1976), and consequently, to increase the ability to create a positive bond through which can be shared common objectives (as for example: rehabilitative objectives, acceptance of a program, involvement in instrumental tasks or within a relationship etc).

In our study, the hypothesis that users with "difficult" styles of attachment; (n = 7) users with a "preoccupied" style, (n = 2) users with a "fearful" style and (n = 2) users with a "dismissing" style, could be successfully engaged in an intense and uncommon expressive activity. The attachment styles of the users supposed an arduous task for the two rehab workers, and the consequent failure in being engaged would have negatively influenced users presence to the rehearsals, time of involvement and subsequently create an elevated number of ruptures in the rehearsals, and the improbability to modify the expressed negative symptoms. The "secure" attachment style assumed for the two rehab workers, characterized by an empathic ability to transmit confidence, affection, working stability, emotional intimacy, understanding and freedom from fear of abandonment, seems to have influenced positively the establishment of a therapeutic alliance and consolidated a concrete and meaningful adherence to the musical.

The perceptive feeling (users) that the rehearsals context was a secure, warm and affectionate atmosphere, despite the newness of the situation, along with its difficulties in learning, supported adherence. The personally secure attachment style of the two rehab workers tended to neutralize fear and maintain users well organized, decrease the number of ruptures and time away from the rehearsals. The establishment of a qualitative relationship between users and rehab workers developed an attachment of security and helped users to feel comfortable and meaningfully involved in the rehearsals and within all aspects of the musical.

This study nonetheless has some limits. It is difficult to understand and to establish with certainty various causal relationships and determine how much of the symptomatic and measured improvements in the musical is due to user participation and involvement in a rehabilitation program. We cannot exclude a certain propensity to have selected users more capable than others to be benefit from participation in the musical comedy. In addition, it is not sure if educators/rehab workers with a less "secure" style of attachment could obtain the same success as the two educators of the study. It would be interesting to study different styles of attachment in curative figures and their potential to influence the therapeutic alliance and work adherence.

Also, it is not clear how the other activities within the musical comedy (scenery, sewing, chorus, etc.) have influenced measurement results. It is necessary to study and measure hypothetical mediators of change (for example: social competences, cognitive capacity, the nature of the relation, age factors, users excluded from a rehabilitative program, users not selected to participate in the musical comedy, etc.), in order to determine which of the progress mechanisms has with relative certainty contributed to the improvements in global functioning.

It is important, in any case, to recognize that chronic and difficult users (including users with low mental functioning), are capable of modifying their emotional and cognitive behaviour and perception and work intensely on common objectives with meaningful success. A warm and non hostile interpersonal manner, along with a pervasively positive feeling of the musical comedy and its objectives (in the two educators), have been synonymous of a good quality working and therapeutic alliance, and also, a decisive factor in having assured greater probability in obtaining user group improvements. In addition, the users have communicated their satisfaction for participation in the musical.

In any event, "the musical" as an expressive therapeutic activity does not seem inferior in promoting personal, social and emotional changes in persons with serious and grave problems of living than other types of psychotherapy, but rather, seems to be worthy of consideration with difficult users, otherwise unengageable in classic and traditional psychotherapies or with non-expressive rehabilitative group activities. As we are all aware, dynamic psychotherapy or psychoanalysis is not well suited for highly disturbed patients; expressive musical activities can be an interesting alternative and supportive to an overall program of psychosocial rehabilitation. They are also pleasantly and amusingly reinforcing to both users and therapists. The positive and serene user attitude alongside the memory of having lived a constantly pleasant relational experience (30 days after conclusion), seems to suggest that attachment style can be modified through an intense expressive experience apt to stimulate users to interiorize positive aspects from their caregivers and modify cognitive patterns of Self (Fonagy, 1999; Beck, 1979).

This study also demonstrates that the use of expressive activities within a psychosocial rehabilitation and team approach to intervention, tends to create greater optimism and enthusiasm in rehab personal to effectively foster improvements with persons with diffuse disabilities, and less likely to experience a burn-out syndrome. It also stimulates staff members to work for long periods of time around an intense group project and gently encourages them to offer an altogether better service treatment plan.

Miller (1986) has defined "hope" as "a state characterized by an anticipatory and continuous feeling of well-being, personal improvement and/or liberation from the perception of entrapment. The anticipation can be founded on concrete evidence from the real world. Hope is the anticipation of a future based on a sense of mutuality with others, a sense of personal competence, and the ability to face up to personal or other problems, a psychological sense of well-being, a scope and meaning of life, as well as a sense of the possibility". A musical activity inserted within a psychosocial rehabilitation program seems capable of satisfying these basic requirements.

Recognitions

The authors wish to thank the Coo.S.S.E.L. Cooperative for the support demonstrated during the long programming of the study-project, and all the staff for their untiring and pertinacious participation in order to render the musical a success. In particular the authors wish to thank: Head of the musical, direction and elaboration of texts: Luneide Casciano e Caterina Vadalà; Coordinators: Angela Vadalà and Francesca Cammara; Newspaper and writing group: Mario Bova and Alessandra Perazzo; Scenery, technical assistance and lights group: Orazio Pensabene, Pietro Scopelliti, Aldo Carnevale, Emiddio Galimi; Photography group: Cristina Pafundi, Letizia Calabrò; Sewing group and costumes: Rosa Lupo, Quieto Concetta: Dictation group: Sandra Cutrupi, Franca Carnevale; Chorus group: Antonella Masottini, Rosy Anastasi, Carmela Barreca, Teresa Rovella, Alessandra Perazzo; Artistic and Graphical Arts group: Mariella Marino; Make-up: Teresa Rovella; Head of personnel: Mariella Surace.

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