Study Design

Given the research questions, we opted for an interpretative approach through the use of qualitative techniques (interviews with FCF’s specialized staff, a questionnaire with open-ended questions for Apascide’s specialists, and systematic observation of the process of constructing the puppets and drawings made by the participants), triangulating the instruments and the participants in the program (Hsieh & Shannon, 2005).

Content analysis has been chosen for the systematic interpretation and categorization of the qualitative data collected through verbal interactions obtained from the interviews. This approach involves the identification of thematic patterns, recurrent concepts, and underlying meanings in the participants’ responses. The inductive analysis undertaken allows themes to emerge naturally from the data. Coding and categorization of verbal information are performed to capture the essence of shared perceptions, opinions, and experiences. The aim of using this approach is to gain a comprehensive and in-depth understanding of the issues raised in the discussions and interviews. To maintain the anonymity of the participants, the following identification keys were used (see Table 1).

The data derived from the systematic observation of the puppet construction process, once categorized, were analyzed using IBM SPSS version 28 (IBM Corp., Armonk, NY, USA).

The use of different data collection techniques and instruments and the results produced are compared in such a way as to provide greater strength to the analysis and to enable the detection of possible differences. In this sense, some point differences were observed, which are discussed in detail in the attached tables, graphs, and non-parametric χ² analysis.

Instruments

An observational instrument was used to facilitate the systematic recording of the puppet construction process, which was reviewed and validated by FCF staff prior to implementation.

The art therapist who led the intervention received specific training in puppet-making with deafblind people, applying the observational instrument in interventions of similar characteristics, which is why it was not necessary to carry out a pretest-posttest.

In addition, interviews were conducted with FCF staff involved in puppet construction, and a questionnaire of open-ended questions was administered to Apascide staff (Table 2).

Procedure

Documentation of the different instruments was collected at different stages of the procedure (Table 2). The observational recording was applied to assess how puppet-making affects the perception of self and space in individuals with deafblindness and to observe changes in the participants’ relational skills.

The interviews and open-ended questionnaire aimed to investigate participants’ subjective experiences and impressions of the art therapy program (Gao, 2006) and included questions to identify experts’ and observers’ views on the impact of the puppet-making process on deafblind people’s ability to perceive their own corporeality and its position in space, their communicative effectiveness and interrelationship, and their personal subjective appraisals of the art therapy program. The data were compared to identify meaningful categories based on the research questions and analyzed further.

This study adheres to ethical standards that prioritize integrity, confidentiality and respect for all participants and stakeholders. In particular, it follows the American Educational Research Association (AERA), (2019) standards and the recommendations of the British Educational Research Association (BERA, 2019).

In addition, in order to achieve methodological consistency, a best practice protocol is adopted, in accordance with the Declaration of Helsinki (World Medical Association, 2008), in two phases:

1. Participants are informed about the nature, purpose and methodological procedure, and are asked to collaborate on a voluntary basis, explaining that they can withdraw from the program at any time.

2. They are asked for informed consent, which specifies the confidential treatment of the data, limits its disclosure to the academic sphere and establishes personal responsibility and a physical place for its safekeeping.

Participants

The study described above involves a control group (Apascide), which included 15 users (13 deafblind), and an experimental group (FCF), which included 11 users with deafblindness. The members of the control group did not receive the full art therapy intervention and only participated in a one-and-a-half hour puppet-making workshop, whereas the experimental group (FCF) received the full art therapy intervention, which included regular and personalized 45-minute sessions for 15 weeks, following an adapted methodology with body work, use of drawing, puppet-making, and puppet performance. The control and experimental groups were chosen based on the availability of time and space, with only FCF fulfilling this condition.

Category 1: Body and Space Perception

The creation of puppets allowed participants in the experimental group to explore and represent parts of the body in detail, enabling them to develop greater body and spatial awareness through the artistic activity, which had a positive impact on their self-expression and perception, as one specialist explains how a participant “showed a remarkable understanding of the different parts of the body when building her puppet” (P).

The puppet-making also helped participants to develop a better understanding of space by giving them a hands-on experience of how objects and body parts are positioned and move in space. For example, one participant explained that “the puppet was missing its feet to be complete and then I realised that I had gained a global view of the body, which is very difficult for a deafblind person” (P).

Meanwhile, the results show that the variability in the construction of the puppets among the participants was remarkable. Some showed a tendency “to include specific details while others focused on more general aspects” (MC5). These differences reflect the diverse ways in which deafblind people perceive and understand the body and space, “showing how individual sensory experiences shape perception and creativity” (A).

One of the highlights was how participants with visual residuals constructed puppets with more precise details, such as eyes and mouths, whereas those without visual residuals focused more on general shapes. This suggests that “residual visual ability influences how individuals represent body parts” (MC4).

Table 3 provides comparative data between the control and experimental groups on aspects related to the body characteristics of the constructed puppets and sensory impairment. In terms of the body of the puppets constructed, the control group seemed to have constructed more puppets with trunk, head, eyes, mouth, and hair/hat. Meanwhile, the experimental group had fewer instances of these features, suggesting a difference in preferences or approaches to puppet construction.

In terms of sensory impairment, it appears that the control group had more participants with visual or auditory impairment, whereas the experimental group had more participants without visual or auditory impairment. This may indicate a difference in the composition of the groups in terms of sensory impairment, which affects the final puppet construction outcome.

Results for Category 2: Non-verbal Communication

The art therapy program for deafblind people revealed the importance of non-verbal communication, especially through touch and body movements, as it “not only facilitated a better understanding and connection between the participants and the communication mediators, but also allowed for a more effective expression of ideas and emotions” (C).

Both groups show a variety of communication methods, with a slight emphasis on oral sign language for the control group and the alphabet for the experimental group, as shown in Figure 1.

Figure 1 - Ways of communicating.

Communication through touch was one of the most effective methods observed during the program; hence, it proved to be “an enriching activity that allowed us to have non-verbal communication with the residents. I really enjoyed being there. It’s communication by touch” (MC4). This approach allowed deafblind participants to overcome the communication barriers they face on a daily basis.

The use of body movements also played an important role in communication during the program. The communication mediators adapted their instructions and explanations through movements that the participants could perceive and understand, “this was decisive, as deafblindness is very limiting and the adaptation of communication has to be very precise” (I).

Sign language, adapted to the sensory abilities of the participants, was another prominent method. Some participants used the alphabet inside the palms of their hands to communicate, which facilitated a more direct and understandable interaction, “for us it may be a picture that is nothing. But for them it is something” (I). This statement again highlights the need to adapt communication methods to the sensory perceptions of deafblind participants.

In this sense, the communication mediators observed that non-verbal communication proved to be a powerful tool to connect with the participants, “the experience showed me something unexpected and that is that deafblind people have a greater awareness of the body of movement than I thought” (P). These observations suggest that despite difficulties, non-verbal communication can enrich mutual understanding and creative expression.

Despite the overall effectiveness of these methods, there were also significant challenges. The energy and effort required to communicate non-verbally can be exhausting for participants; thus, the art therapist noted that “signing requires energy. You need to move your arms and hands, plus a lot of flexibility” (A).

Category 3: Creativity and Originality

The evaluation of the program revealed notable differences in techniques and creativity between the control and experimental groups. The participants in the experimental group demonstrated an ability to reinterpret and modify the original designs, which was evidenced in the variety and uniqueness of their puppets; thus, it was observed that “the experimental group has more instances of puppets that deviate from the proposed models” (C). This analysis is based on the observation of the puppets constructed and the methodologies used during the construction process.

The methods used to guide the participants were crucial. Communication by touch and the adaptation of instructions to the specific sensory abilities of each individual were “essential for the success of the workshop” (C). This methodological adaptation allowed “even those with severe disabilities to actively participate and benefit from the art therapy” (I).

As shown in Table 4, the experimental group more frequently engaged in puppet-making through collaborative and sensory methods such as “doing it with them” (75.0%) and “explaining with movement/body” (80.0%), while the control group relied more on conventional approaches like “teaching by touch” (66.7%) and had the highest percentage in the “we did not know/no concrete way” category (100%). These differences illustrate the experimental group's greater engagement with adaptive and participatory techniques, which may have fostered their creative output.

In contrast, as shown in Figure 1, the control group showed a higher proportion of cases where a concrete way of making the puppet could not be determined, indicating a possible lack of methodological adaptation to the specific needs of the participants, “this might have limited the participants’ ability to explore and experiment with their creations” (I).

As for the level of cognitive functioning, both groups show a similar distribution among low, medium, and high levels, as shown in Figure 2.

Figure 2 - Comparison between the control and experimental groups with respect to level of cognitive functioning.

Looking at sensory impairment, Figure 3 shows that while the control group has more participants with visual or hearing impairment, the experimental group has more participants without visual or hearing impairment. This may indicate a difference in the composition of the groups in terms of sensory impairment.

Figure 3 - Type and degree of sensory disability.

Regarding the body of the constructed puppets, Table 5 shows that the control group seems to have constructed more puppets with more precise features such as trunk, head, eyes, mouth, hair/hat, and carried by the trunk than the experimental group, which “suggests a difference in preferences or approaches to puppet construction” (C).

Regarding the selection and use of materials, the qualitative data show how the experimental group showed “a greater variety in the use of materials, exploring different textures and shapes, with a particular emphasis on explaining with movement/body” (IC1).

With regard to creativity and originality, the experimental group “presented a greater variety in the type of puppets constructed than the control group, which stuck to the established model” (A).

The results of the χ² test are presented in Table 5. There is a significant relationship between the body of the constructed puppets and the groups (χ² = 26.733, level of significance = 0.031), suggesting significant differences in the characteristics of the puppets’ bodies between the two groups. A marginally significant relationship was found between the way the puppet was made and the groups (χ² = 13.615, level of significance = 0.058), suggesting possible differences in the teaching methods used in puppet-making between the groups. No significant differences were found either between the type of puppet constructed and the groups (χ² = 5.639, level of significance = 0.131) (Figure 3) or between the level of cognitive functioning and the groups (χ² = 0.450, level of significance = 0.930).

Category 4: Complementary Behavior and Interpersonal Relationships

The art therapy sessions proved to be a catalyst for improving social interaction among the deafblind participants. Although not all areas showed significant improvements, an increase in participants’ ability to focus and relate to others was observed, as shown in Table 6. This category encompasses aspects such as patience, attention, and social relationships, which were assessed through direct observation and reflections of the communication mediators.

Although no significant relationships were found in any of the areas, there was an improvement in participants’ ability to focus on activities and relate to others, which is one of the most striking findings. The puppet building and interaction during the sessions provided an environment where participants could develop and strengthen these skills, and the activity “also served as a means for them to interact and relate more effectively” (MC1).

The need-to-adapt activities and approach to meet the individual needs of participants were a recurring theme. The mediators’ ability to customize art therapy sessions to the abilities and limitations of each participant was crucial to foster an inclusive and supportive environment, in this sense, “tailoring activities to participants’ specific interests and abilities helped to maintain their interest and participation” (MC5).

Despite the observed improvements, challenges in communication and patience persisted in some cases who showed difficulties in “staying focused and patient during activities” (MC3).