Running head: ART THERAPY & DEMENTIA

ART THERAPY AND DEMENTIA: IMPROVING QUALITY OF LIFE

Submitted in Partial Fulfillment of the Requirements for the Degree of

BACHELOR OF ARTS

in

CLINICAL ART THERAPY

by

Elizabeth A. Follano

Long Island University, Post Campus

May 2016

_________

Author’s Signature Instructor’s Signature

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Abstract

The purpose of this research paper is to study and explore art as an intervention with

those afflicted with dementia and how the use of art therapy improves on their quality of

life. The research mainly focuses on the physical and cognitive limitations of dementia.

Specifically, the researcher examines how the disease affects the brain and how this

reflected on the individual’s art. The art therapy session of this paper supports art making

that can help these individuals by finding out their limitations and improving many

aspects that are associated with quality of life. The qualitative research within this piece

includes three case studies. The first that is examined is one that was conducted by the

author at Cold Springs Nursing and Rehabilitation Center in Cold Springs, NY. The

second is a historical case study done by art therapists in a home-based therapeutic

environment and the last is also a historical case study conducted in a nursing home in a

multi-dimensional group setting. The examiner focused on specific quality of life aspects

such as sensory stimulation, communication, and stimulation of reminiscence; though

these are only a few of a vast amount of limitations associated with quality of life. These

case studies have shown great improvements through the use of art therapy interventions

and proved how art therapy may be a great source when attempting to improve the

quality of life in those with dementia.

Keywords: art therapy, dementia, quality of life, Alzheimer’s Disease.

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TABLE OF CONTENTS

ABSTRACT……………………………………………………………………………….2

TABLE OF CONTENTS…………………………………………………………..…..3-5

I. INTRODUCTION……………………………………………………..…..6-36

A. DEMENTIA………………………………………………………...….6-8

STAGES OF DEMENTIA………………………………..….7-8

a. MILD COGNITIVE IMPAIRMENT………………….…..8

B. DEMENTIA AND THE BRAIN………………………………………9-11

1. DIAGNOSIS OF THE BRAIN……………………………..…9

2. AREAS OF THE BRAIN AFFECTED………………….10-11

C. EFFECTS OF DEMENTIA………………………………………….11-12

D. CAUSES OF DEMENTIA…………………………………………..12-13

E. TREATMENTS OF DEMENTIA……………………………………13-15

1. MEDICATIONS…………………………………………14-15

2. THERAPY…………………………………………………...15

F. STATISTICS OF DEMENTIA………………………………………16-17

1. MORTALITY RATE………………………………………...17

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G. ART THERAPY AND DEMENTIA…………….…………….…….18-33

1. ART AND THE BRAIN……………………………...….28-30

2. HOME-BASED ART THERAPY…………………….…30-31

3. FAMILY ART THERAPY……………………………....31-33

H. QUALITY OF LIFE………………………………………………....33-36

II. CASE STUDIES……………………………………………….................36-56

A. LYNN………………………………………………………………...37-44

1. CASE HISTORY……………………………………………………38

2. INTERVENTION……………………………………………..…38-39

3. OUTCOME………………………………………………………39-44

a. FIGURE 1……………………………………………………….41

b. FIGURE 2………………………………………………………42

c. FIGURE 3……………………………………………………...44

B. MR. M……………………………………………………………….44-51

1. CASE HISTORY……………………………………………….44-45

2. INTERVENTION………………………………………………45-46

3. OUTCOME…………………………………………………….46-51

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a. FIGURE 4………………………………………………………..48

b. FIGURE 5……………………………………………………….49

c. FIGURE 6……………………………………………………….50

C. MISS GEE…………………………………………………………...51-56

1. CASE HISTORY……………………………………………………52

2. INTERVENTION………………………………………………..52-53

3. OUTCOME……………………………………………………...53-56

a. FIGURE 7………………………………………………………54

b. FIGURE 8……………………………………………………....55

c. FIGURE 9……………………………………………………...56

D. CLOSING REMARKS ON CASE STUDIES……………………..56-59

E. SUGGESTIONS FOR FUTURE RESEARCH……………………59-60

III. REFERENCES…………………………………………………………61-64

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ART THERAPY AND DEMENTIA

Art Therapy and Dementia: Improving Quality of Life

This research explores and describes factors involved in dementia diagnosis,

prognosis, and treatment facilitators. Art therapy has been proven to be a rewarding

modality to use with people suffering from this disease. With the many causes of

dementias and types of diagnosis under this disease, it is hard to be sure what type of

treatments would work. This research paper explores the background to dementia, the

types of evaluations and treatments that are offered, and how art therapy can be a residing

factor in the treatment and evaluation process of dementia.

Literature Review

Dementia

According to the DSM-5 (2013), dementia has been known as a neurocognitive

disorder often in older adults. Dementia has impacted the quality of life in patients

because it slowly deteriorates their everyday functions such as motor skills, reminiscence,

communication, and daily living skills. Dash and Villemarette (2005) stated that early

warning signs of dementia are known to be the regularity of memory lapses and cognitive

oversights. This can make a patient suffering from this disorder feel hopeless and

isolated. Art therapy has been used to help those with dementia to enhance daily living.

This modality has also been known to help exercise the parts of the brain that have still

been functioning in the client and can improve their quality of life by providing sensory

stimulation, as well as self-expression (Stewart, 2004).

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Stages of Dementia

According to Stewart (2004), dementia has been defined in multiple stages of

advancement. Each stage has shown the progression of dementia and how the person can

become confused, paranoid, withdrawn, less receptive and expressive, and eventually

may have a decline in motor skills. All of these stages are known to happen from 3 to 12

years during the disorder's diagnosis, until those effected become completely incapable of

taking care of themselves (Stewart, 2004). As Stewart (2004) wrote, there are four

diseases that cause dementia and those include Alzheimer’s disease (AD), vascular

dementia, mixed dementia (which is a mix of Alzheimer’s and vascular dementia) and

diffuse Lewy body dementia. These forms of dementia have been known to be the

leading cause to 90% of dementia cases (Stewart, 2004).

There have been many studies behind the warning signs of dementia and the

outcomes of these studies have resulted in the three-category classification of aging to

cognitive function (Dash & Villemarette, 2005). These categories have included healthy

aging, normal aging, and pathologic aging. Healthy aging is referred to as those who have

minimal or no medical problems. Those with this type of aging may have to take few

prescription medications, or none at all, and can remain socially, physically and

intellectually active. The second category, normal aging, refers to those who are more

common to the course of an aging person. This type of aging may include those who are

diagnosed with many different chronic illnesses (such as diabetes or arthritis) and they

may have to take several types of medications. Those with normal aging could also have

a decrease in the intensity and frequency of daily activities that are leisurely or social in

which they previously enjoyed (Dash & Villemarette, 2005).

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It is hard to categorize an elder person as healthy or normal, because no one can

predict what will happen in the future. Those who have been categorized as normal could

possibly develop a pathologic illness later in life. Dash and Villemarette (2005) described

pathologic aging as individuals who have a greater change in their cognitive abilities than

those from the other categories. These people could have trouble achieving day-to-day

activities and have been known to develop dementia. Dash and Villemarette (2005) wrote

that it is important keep an eye on those characterized as “normal” because they have a

higher risk of developing pathological processes. In certain cases, there have been some

evidence that cognitive slowing has been an aspect of deficits in hearing and vision, very

common in elderly patients (Dash & Villemarette, 2005).

Mild Cognitive Impairment

Dash and Villemarette (2005) discussed a level of cognition known as mild

cognitive impairment (MCI). This has been described as a diagnosis used for those who

are between the normal and pathologic stages. This could be diagnosed when symptoms

of dementia may become more noticeable, but the symptoms may not necessarily

interfere with the ability to function. It is at this time when a patient is monitored more

and may even begin taking medications that are associated with slowing the progression

of dementia (Dash & Villemarette, 2005). One of these medications is known as Aricept;

although medications like this are known to prolong the early stages of the disease and

are unable to stop the progression of the disease completely. These medications may also

take time to take affect and that may not even help patients in time (Stewart, 2004).

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Dementia and the Brain

Dash and Villemarette (2005) stated, “AD [Alzheimer’s disease] is a disease

specifically of the brain. This means that although brain appearance and function are

distorted, the rest of the body appear normal,” (p. 73). First, there is a difference in the

brain substance between the folds on the surface of the brain (called gyri) that is much

less than compared to a normal brain. The spaces between the gyri are also grossly

enlarged (Dash & Villemarette, 2005). Second, the shrinkage of the brain (also known as

atrophy) is a common problem seen in AD patients.

Diagnosis of the Brain

According to Nazarko (2014), it is said to be impossible to accurately diagnose

people until postmortem when the brain could be autopsied, but it could be detected

through scans that can tell if the brain has shrunk; usually done with MRI scans. As said

before, shrinking of the brain is a common side effect of Alzheimer's disease (Dash &

Vollemarette, 2005; Nazarko, 2014). Stewart (2004) wrote that this has been seen outside

the neurons by a deposition of amyloid fluid; this fluid results in the formation of

plaques. On the inside of the neuron a physician may see neurofibrillary tangles. These

are known as cytoskeletal components that afflict the function of the neuron’s they are in.

Due to the increase in both of these issues (tangles and plaques), the number of synapses

decrease which results in Alzheimer’s disease. The most known affected

neurotransmitters due to this decrease are those associated with learning and memory

(Stewart, 2004).

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Areas of the Brain Affected by Dementia

There have been specific areas of the brain that can be affected by Alzheimer’s

dementia, as well as with the other dementias, and they are the hippocampus, the

temporal and parietal lobes, and the ventral and dorsal pathways (Nazarko, 2014; Safar &

Press, 2011). When the brain is scanned, those with dementia have been described as

showing a shrunken hippocampus and cells that are cluttered with plaques and tangles.

The hippocampus includes two functions, which are the process that helps to make

memories (making senses of what is going on and to process memory from short to long

term memory) and it is involved in navigation and spatial memory (basically, your

natural GPS). Spatial memory and navigation tells you where you are, where you have

been before, how you get somewhere or got there, and how to get back from there

(Nazarko, 2014). The diminishing of these functions is normally associated with the first

known signs of dementia; when a person gets lost and frequently confused.

The temporal and parietal lobes have been described to also be affected, along

with the hippocampus, and this could be seen by the changes in language and the slowing

signs of intellect (Gretton & Ffytche, 2013). The functions of the parietal lobe is to

interpret language and words, interpreting touch, pain and temperature, interpreting

signals from vision, hearing, and sensory and motor stimuli from memory. It is known to

help people to sense size, shape, movement and where an object is; this is also known as

visual and spatial perception. The temporal lobe is said to assist people with

understanding language and to remember, and interpret, what is heard. It also helps to

organize the information that is processed by these processes (Nazarko, 2014). Often,

people with dementia begin showing signs because they give new words to objects or

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have a hard time communicating with people, and this is likely due to the issues involved

with these lobes.

Safar and Press (2011) described the ventral and dorsal pathways as another part

of the brain that dementia is known to affect. The ventral pathway has been found in the

occipital and temporal lobes and it is known to help to integrate form and color so that

someone can recognize the object they are looking at. The dorsal pathway is mostly

found in the parietal lobes and is used to frame what one is looking at; to see the scene as

a whole (Safar & Press, 2011). This can make orientation and even spatial recognition a

problem for those that have issues in these areas. They may try to grab a cup and

completely miss it, or accidentally tip it over, because they can’t figure out where exactly

it is in front of them (Gretton et al., 2013).

Effects of Dementia

Dementia has had significant impact on the brain and may cause information to be

processed differently. Because of this memory loss, an individual affected with this

disease has often felt lonely, lost and in despair. As Rusted, Sheppard and Waller (2006)

wrote, “significant individual differences in the way that dementia manifests itself has

complicated the development of comprehensive care strategy for clients using residential

or day center services,” (p. 517). Nazarko (2015) wrote that some people are known to be

so into their own worlds that they seem happy, but they could just not be connecting to

the reality around them. Others become unresponsive and even can be selectively or

completely mute as side effects to their overwhelming feelings and disabilities. Nazarko

(2015) wrote that their receptive abilities are known to be affected and some treatment

goals can be used to help these people with reality orientation. These treatment goals

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have been known to aim towards helping those with dementia to become more aware

with their surroundings.

Nazarko (2015) wrote that some examples known include asking the patient what

the date is, what time it is, or even if they know where they are at the time they are asked.

Camartin (2012) wrote, “reality orientation aims to “disrupt cognitive decline with

repetitive activities” that emphasize current times, dates, and facets of reality,” (p. 9).

Moments with dementia patients may involve reminding them about their environment or

facts about themselves that they may have forgotten. The underlying goal of reality

orientation is to relieve stress through reorientation. Though, this idea is often criticized

because it may remind the individual of their deterioration, and the therapy also has a

lack of empirical evidence to back it up (Camartin, 2012; Nazarko, 2015).

Camartin (2012) also wrote, “non-cognitive symptoms associated with dementia

include “agitation, aggression, mood disorders, and psychosis…sexual disinhibition,

eating problems and abnormal vocalizations,”” (p. 7). These other presenting factors of

dementia may make it hard for caregivers to understand why an individual may be acting

a particular way at first or how to help them with their symptoms so that they are

comfortable. As Camartin (2012) explains, these behavioral and psychological factors

could be a defining reason why most people with dementia are institutionalized. People

with dementia need around the clock care, can become bedridden, and could need help

with daily functions that are now limited, such as dressing or bathing (Camartin, 2012).

Causes of Dementia

Dash and Villemarette (2005) wrote that there are multiple known causes of

dementia, including Alzheimer’s disease, Lewy Body dementia, frontotemporal

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dementia, and vascular dementia. Other causes known have included various neurologic

and medical conditions. These conditions can be reversible and could include disruptions

in metabolism, depression, vitamin B12 deficiency, thyroid disorders, normal pressure

hydrocephalus, brain tumors, subdural hematoma, medication and drug effects, and

infections of the nervous system (Dash & Villemarette, 2005). Though these are known

as reversible dementias, they are not always reversible. Dash & Villemarette (2005)

talked about a study done by Clarfield that surveyed 5,620 cases of people who had

symptoms from reversible dementias. Through these studies Clarfield was able to support

the idea that even reversible dementia may not actually be reversible. Out of all of the

5,620 cases Clarfield studied, only 18 were actually cured. This has been known to cause

a later diagnosis of other dementias if it cannot be reversed (Dash & Villemarete, 2005).

Treatments of Dementia

There are multiple known treatments for slowing the progression dementia and

those include medications and specific types of therapies to help those affected with the

physical and developmental limitations (Dash & Villemarette, 2005; Stewart, 2004;

Woolhiser-Stallings, 2010). Some of these medications have worked to slow down the

progression of dementia. Therapies such as physical therapy, speech pathology,

counseling and art therapy have been part of treatment to assist with improving daily

living functions (Dash & Villemarette, 2005). At times, both types of treatments have

been codependent on one another to help the patient to feel comfortable and able to

improve daily (Dash & Villemarette, 2005).

Ehresman (2014) states that there are no known medical treatments that can stop

or even reverse the onset of dementia. Though medications can alleviate some symptoms

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of dementia, the mental decline continues. There is research being developed that may

support the idea of interventions, such as art therapy, that can slow progression of

dementia and even improve quality of life in patients (Ehresman, 2014). As Ehresman

writes, “interventions that can delay disease onset or progression by even a modest

amount will decrease the financial impact and global responsibility of caring for people

with AD,” (Ehresman, 2014, p. 43). Due to these findings, creative art therapies have

been seen to be beneficial to the factors of improving behavior and quality of life in

dementia patients. There is a movement currently to integrate the creative art therapies

into mainstream medicine and also into health care facilities, but despite its efficacy, they

are not commonly covered by public health care and insurance companies in North

America (Ehresman, 2014).

Medications

The well-known treatments for dementia have been medication. These

medications are known as acetylcholinesterase inhibitors (Dash & Villemarette, 2005).

Acetylcholine has been known as an important neurotransmitter for memory in the brain

and low levels of it have been associated with memory difficulties. The most popular and

well known medication is Aricept (donepezil), but others that are known to be used are

Excelon (Rivastigmine) and Reminyl (Galantamine) (Dash & Villemarette, 2005;

Stewart, 2004). All of these medications have been known to work in the brain to help

with the levels of acetylcholine, but Exelon may also help with the levels of

butyrylcholinesterase, another enzyme that is known to help break down acetylcholine

(Dash & Villemarette, 2005).

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If this enzyme is found in high levels in the brain, then it is seen as an indicator of

Alzheimer’s disease. “There is some speculation that this enzyme may be involved in

“plaque maturation,” which may make the plaque more capable of causing disease,”

(Dash & Villemarette, 2005, p. 96). The dosages of these drugs must be increased slowly

to ensure the medication is working and that the patient can withstand the side effects,

which are commonly known to be nausea, diarrhea and vomiting (Dash & Villemarette,

2005). By being cautious, medications such as these may be a helpful treatment for

patients with signs of dementia.

Therapy

According to Woolhiser-Stallings (2010), people with dementia have been known

to be incapable of understanding or keeping a conversation going with someone else.

This may be a possible reason why traditional therapy does not normally work with them.

The therapist could be unable to ask questions and get an actual answer since patients

with dementia are known to have impaired cognitive and verbal functions. Woolhiser-

Stallings (2010) wrote, “Dementia involves the development of multiple cognitive

deficits as a result of any underlying medical conditions…” (p. 136). Due to this,

therapies, such as creative art therapies, that don’t require such needs could be a perfect

modality to be used with dementia patients. They may not only have trouble with verbal

communication, but they may have trouble with comprehension of what is going on and

judgment. This may mean that freedom of choice is not always applicable for people with

these impairments. Art therapy and other expressive therapies are modalities that may

help by allowing patients freedom of choice in materials and allow them to feel like they

do have a sense of control over things in their lives (Woolhiser-Stallings, 2010).

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Statistics of Dementia

Dash and Villemarette (2005) wrote that mild cognitive impairment (MCI) has

been known to have a strong relationship to those who are later diagnosed with dementia.

They gave example with a study done by Tuokko that reported 47% of about 800 MCI

patients had developed Alzheimer’s disease in 5 years. This was compared to a similar

sized group of people with no cognitive impairment that only 15% became inflicted with

the disease (Dash & Villemarette, 2005). This statistical relationship may show how it is

beneficial to pay attention and keep an eye on those with mild cognitive impairment. If

they are monitored properly, the progression of dementia can be slower on these

individuals.

According to Dash and Villemarette (2005), Alzheimer’s disease was the most

common cause of dementia, accounting for 55% of dementia cases, 15% were due by

stroke, and 10 % were attributed to a combination of the two. Another 10% were caused

by Lewy Body disease and the other 5% are due to reversible causes, such as those stated

earlier. There have been more recent studies done on these statistics, like a study done by

Berlin-Institut für Bevölkerung und Entwicklung (2011). The study was based on the

distribution of the most common forms of dementia worldwide. It states that 65% of

dementia patients had Alzheimer's disease, 15% had vascular, 15% had mixed forms and

5% had other types of dementia disorders. According to Ehresaman (2014) though,

dementia currently affects approximately 35.6 million people worldwide and these rates

are expected to double every 20 years. This is a more recent development in the statistics

of dementia and baby boomers coming into the age of for onset of dementia could be a

defining factor for these rising statistics. Ehresaman (2012) also wrote, “the total

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estimated worldwide costs of dementia are $604 billion, with 70% of the costs occurring

in Western Europe and North America,” (p.43).

In 2004, a study showed that one of the top issues in public health was that life

expectancy has risen to 77 years in the United States. Alzheimer’s disease accounted for

50% of dementia in this time as well. 1 in 5 people, 75 to 84 years of age and almost half

of those 85 years or older, were then afflicted with dementia. That was over 4 million at

the time and they predicted that in 2010 nearly 6 million people would be diagnosed with

Alzheimer’s disease. The study even projected that by 2050 there will be more than 14

million (Stewart, 2004). Within the next couple of years there may be more studies done

on the percentage of dementia patients worldwide. If so, more statistics can show the

onset and progression of the disease, and show if these results in the studies above have

changed or if the theories were proven.

Mortality Rate

Mortality rate due to dementia is a pressing issue with these patients. The

estimated time between when the first symptoms appear and the time of death is known

to be approximately 5 to 10 years. Although the range that Dash and Villemarette (2005)

said has been seen, is between 2 to 20 years. This statistic was found because of early

diagnosis and the treatments that these people had undergone during their years with

dementia. Dash and Villemarette (2005) wrote, “longevity is influenced by gender, the

presence of other medical problems, early detection, and the rate of cognitive decline,”

(p.53). These are factors that may be monitored to help keep these patients comfortable

during the progression of dementia.

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Art Therapy and Dementia

Parsons (1998) wrote that the creative arts can be defined as a “mirror of one’s

creative energy,” (p. 3). As a therapy, Parsons (1998) wrote that art does not need to be

aesthetically pleasing; instead it just needs to provide an opportunity for expression.

Jones, Warren, and McElroy (2006) wrote that art therapy is known to be a widely used

psychological therapy for those with mental health problems in hospitals and day centers.

Art therapy with any population is known to be done in a safe and healing environment.

In group or one-on-one settings, creating a healing environment is an essential step to the

introduction of any art therapy program in an individual’s life. A healing environment is

said to be “…the actual environment itself where psychotherapy is done. This external

setting can have an important impact on healing by significantly reducing or increasing

stress as well as empowering the client in their own process,” (La Torre, 2006, p.262).

The basic premise of environment is that since the earliest of evolutionary times

humans had to be aware of their environments. Being attentive, sensitive, and responsive

to our environments is a instinct we are all born with and when it comes to the

environment art therapy is held in, it is said it is best when one feels comfortable and

capable of working and felling safe (La Torre, 2006). As La Torre (2006) explains, this is

an essential need for the psychotherapeutic environment. Stephenson (2013) also explains

how the art therapist should be a supportive factor for older adults and allow them to be

in an enriching environment that is “…respectful of participants’ wisdom and life

experience while also acknowledging their physical needs by adapting the space and tools

accordingly,” (p. 156).

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Creativity has usually been seen as something uncommon in elderly populations.

Hickson and Housley (1997) wrote that society tends to think of aging in a negative light

and has a belief that old age is a period of decline. This is proven to be an idea of

dementia too, the "idea of loss" (Stewart, 2004), and creativity also seems to take on this

idea; the idea that you can't be creative when you get old or that it is weird for people

who are elderly to be creative. This is not accurate as Hickson and Housley (1997)

describe because there are many elderly people who have produced their greatest works

during old age. Some examples they wrote about were Verdi, at age 85, when he

composed "Ave Maria" and Grandma Moses who had her first exhibition at the age of 80

(Hickson et al, 1997).

Often, common phrases arise when talking about a person with dementia, such as

“they are not there anymore” or “it’s like talking to someone I don’t know,” and these

reflect the idea that the person has been replaced by something unfamiliar and in a sense,

untrue (Camartin, 2012). Though, this is a social construction just like the idea of

creativity being lost with age. Hickson and Housley (1997) wrote that "creativity is not a

timebound act nor a function of chronological age," (p. 540) but society has caused it to

be seen this way. Although this is the case, the creative process has been proven to be an

outlet for the elderly population by helping them to express themselves, and it could have

a profound meaning to the creator because it offers a way to channel their responses to

the limits and uncertainties of their existence (Hickson et al, 1997). Jones et al. (2006)

wrote that due to the aging in the general population growing, there a greater need to

provide services for older people that are designed around the needs of these individuals.

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Baines (2007) described the art making process as being rewarding for the

elderly, especially with dementia. According to Baines (2007), “art therapy is no longer

an adjunct to psychotherapy but it is becoming important in enabling those living with

various kinds of dementia to remain creative,” (p. 6). Because of the problems with

communication, it is said that the importance of allowing those with dementia to just

make art is a more common practice in art therapy. Art therapy is described as the

process of making art and creating to make an image that can help someone express

something about their self (Baines, 2007).As Jones et al. (2006) wrote, “art therapy may

be an effective therapy to reduce the symptoms of these illnesses [mental illnesses, such

as dementia] which present in older people,” (p. 52). A qualitative study done by Kinney

and Rentz’s, in 2005, shows how art therapy may be more beneficial for dementia

patients than other structured activities because the participants showed significantly

more interest in the program, they sustained attention, had pleasure in the process, felt a

sense of self-esteem, and normalcy (Camartin, 2012).

Art therapy has assisted in allowing people with dementia to cope with the

differences of their age-related and cognitive changes. It is known as a cathartic process

and a creative experience that may give support during loss that is so closely associated

with dementia (Stephenson, 2006). Stewart (2004) wrote, “the popular notion of aging

includes failing vision, aches and pains, joint stiffness, loss of mobility, loss of friends

and family, loss of health, loss of self-esteem, loss of previous life roles – the word “loss”

comes up over and over,” (p.150). The idea of “loss” that is associated with old age

becomes the backbone of how people feel when growing older. With creative art

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therapies, such as art therapy, it could help people see clearly that they can still express

themselves and communicate even through a neurocognitive disorder.

Art therapy is known to help patients to engage in social relationships with the

therapist or even through group activities. It may also increase their motivation to try new

things and to learn and help them to express themselves. People with dementia have

shown an interest in art programs and have proven that it can sustain their attention, give

the patients pleasure, and even bring up their self-esteem by making an art product (Safar

& Press, 2011). Through certain directives, people have been known to get back in touch

with themselves and learn new techniques they may have never had the chance to learn

before they began showing signs of dementia. As Innes and Hatfield (2002) wrote,

“whether the therapist offers a highly structured art task or promotes spontaneous

expression, the image will always reflect the person’s internal experience through color,

metaphor, dialogue, and title,” (p. 21).

It has been known to be helpful for caregivers to realize that people who suffer

from dementia may be given the art program to help them to focus on the here and now;

to keep in touch with their reality, even if they forget its existence soon after and even

forget the art directive they did (Kamar, 1997). Dementia has been known to affect

individual’s behavior and psychological effects, other than reality orientation. Art therapy

is said to be helpful with these problems because art and creativity is a capacity that

continues even in those who are severely affected. It is said to provide patients with the

means of facilitating communication with those who are isolated and unable to

communicate with caregivers. Art therapy is known to be a feasible and implementable

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intervention for people in outpatient or even inpatient environments as well (Peisah,

Lawrence & Reutens, 2011).

Dementia patients have been known to go through other therapeutic processes

besides art therapy. With inpatient facilities, the facility may offer other programs they

can attend, such as music therapy and dance/movement therapy. All three of these

modalities can help the patients going through them to express themselves and to give

structure to the weaknesses they may experience. It can also help with the integration of

life experiences that they may not have experienced yet (Innes & Hatfield, 2002). These

modalities are also all known as the healing arts, expressive or creative arts therapies.

There are other therapies along with these that could be offered and most of the time,

with inpatient facilities, these modalities are mixed into a recreational setting. Though, in

some cases, they do not work with the patient in a clinical aspect and won't focus on how

the therapeutic process will aid in the patient's cognitive needs. These therapies could be

used with outpatient programs as well, as long as the facility or caregivers allow it.

Art therapy is known to be especially helpful, along with other creative therapies,

because it can allow the person to communicate nonverbally, it could be a form of

reminiscing, may help with sensory exploration and stimulation, and allow the person to

project a sense of self. The visual arts are said to be nonverbal because it pulls out

creative representations from the creator (Kahn-Denis, 1997). Though a person with

dementia may not be able to express their physical or psychological experiences

outwardly, they could have the ability to respond affectively and visually. Camartin

(2012) wrote, “providing a vehicle for non-verbal communication makes it possible for

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clients to break through the barrier of social isolation, built up tension and frustration and

a chance to be understood and have emotions validated by others,” (p.10).

As Couch (1997) wrote, art therapy is a known mean of communication. “…The

artwork can convey strengths and conflicts, developmental levels, and can serve as an aid

in assessment and diagnosis. The art therapist provides encouragement and support and

an opportunity to make choices and to safely explore art materials,” (Couch, 1997,

p.187). Any form of art may help to start the process of inner healing in a person who

participates in the process and may also increase a sense of achievement that can help

restore the idea of self-worth. This could be important for people with dementia because

it can help them with gaining more confidence in the art making process (Couch, 1997).

As Parsons (1998) wrote, “the activities offered in nursing homes are, many

times, activities that require a start and a finish with specific steps in between,” (p. 1).

This can be very confusing for the patients that are disoriented, like those with dementia,

and they may not be unable to follow instructions that are necessary to finishing the

activity (Parsons, 1998). Parsons (1998) wrote one should pay attention to the process of

creativity. The process may be more beneficial for those with dementia, as opposed to the

product. The goal of art therapy, written by Parsons (1998), is to create an outlet in

which the client can express themselves through art or thought. Innes and Hatfield (2002)

wrote that the focus of art therapy is for the individual’s existential needs and values, and

gives emphasis to the creative process as opposed to the product.

However, the end product of a client’s process can be a tool for self-reflection and

distancing for the client. “Distancing means to create both physical and psychological

space from one’s image for the purposes of gaining clarity and new perspective,” (Innes

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et al., 2002, p. 22). The nature of creating an end product that is tangible and concrete is a

distinction that art therapy favors over the other expressive therapies. The end product is

also known to help with residents who need memory retention of the experience, but even

if they do complete an end product, the client may not remember completing it in the first

place (Innes et al., 2002). According to Innes and Hatfield (2002) the treatment goal of

memory retention is known to be used with those who are experiencing short-term

memory loss.

As Camartin (2012) wrote, “art therapy also supports the exercise of choice and

control in what and how art pieces are created (i.e. Colour and theme), therefore

reinstating a sense of mastery, competence and independence,” (p. 10). Allowing access

to these choices is not only meaningful but is also a way to help the client remain in the

“here and now” and out of the realm of social constraints (Camartin, 2012). Kahn-Denis

(1997) writes that Lowenfeld has even stated that the creative process is flexible and may

give form to expressive feelings, thoughts and emotions, depending on their own level of

development. It is stated by Kahn-Denis (1997) that it is important for the person to

explore new art materials and find pleasure in the medium itself. This could help with

sensory stimulation; even if they may not make anything that is clear on the paper, they

got to experience the process (Kahn-Denis, 1997).

Improving mood has been known as an important backbone to art therapy and

many art therapists believe in its mood enhancing abilities. Petrillo and Winner (2005)

wrote about how art therapy can help improve people's feelings of depression, which is

very common with elderly clients. They state that art therapy is not only a diagnostic tool

but is also a means of reducing stress along with improving mood. Petrillo and Winner

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(2005) wrote "art therapy is meant to foster a relationship between client and therapist,

provide the individual with a means of nonverbal communication of unconscious

feelings, and allow the person to externalize and thereby resolve feelings," (p. 205).

Parsons (1998) wrote that the benefits provided by art therapy are the opportunity for

self-expression, the development of confidence, the exploration of materials, allowing

one to think, to embrace imagination, to socialize and communicate with caregivers and

other residents, and to be used as an emotional outlet.

Some emotions that elderly clients with dementia have been known to face are

loneliness and isolation. Caregivers and therapists are known to play a crucial role in

helping clients with these problems and allow them to feel understood and cared for

(Learner, S., 2011). Due to the capabilities of communicating through the art process, an

elderly client has been known to communicate their feelings and the process has been

known to allow them to expel them however they see fit. Petrillo et al. (2005) wrote that

this process can be extremely helpful in the healing process or improving quality of life

in those who suffer with dementia, as well as help them to communicate visually and at

times make sense to the confusion in their heads.

According to Byrne and MacKinley (2012), art therapy has shown to be a great

intervention for reversing emotions such as depression and loneliness in dementia

patients. The arts are a mode of expression for people and can transport them into another

level of being. “Sometimes, it is the person with dementia who responds deeply to one of

these modes – in a sense of a human ‘being,’” (Byrne et al., 2012, p.107). Often it is

known that a person will express the deepest things of their lives through symbol. “In our

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deepest times of need, in tragedy, in joy, in love, symbols can connect us with the

spiritual need and with our God,” (Byrne et al., 2012, p.107).

Another aspect of art therapy that has been known to be helpful for dementia

patients, and even the elderly, is its ability to help them achieve a sense of empowerment.

As Kapitan (2014) wrote, art therapy can help elderly with feeling a sense of

empowerment by having control over the art making process, what materials they use,

and what they decide their content will be. Kapitan (2014) also explains that an additional

known experience that happens from art therapy is overcoming feelings, such as

helplessness, because art helps this population express themselves freely and allows them

to disclose what is happening to them currently. Kapitan (2014) explains the art making

process as a "continuum of empowerment" and that elderly clients will likely go through

steps of progress or healing during this process.

Some other things that Kapitan (2014) wrote about that could occur due to art

therapy is connecting to strengths, proactive social behaviors, relationships that are

created due to the process, and a gaining of self-efficacy. These processes are known as

being achieved by creative and critical thinking, taking risks during the process, and

discovering new things about themselves while participating in the process. As written by

Byrne and MacKinley (2015), art therapy is well recognized as a modality that those with

dementia can participate in rather than being passive. Creativity is known to reinforce the

connections between the brain cells, especially those that are responsible for memory. It

is also known to help encourage emotional resilience and may promote positive outlooks

and well-being (Byrne et al., 2012). According to Ehresman (2014), art therapy’s benefits

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are beyond those of other social activities because of the emphasis on emotional

expression and the bonding of individuals of group settings or with the art therapist.

Malin and Rogers (2013) wrote about an art program that was conducted for

elderly patients with dementia and their caregivers. As said by these authors, it may be

important to include caregivers in the art therapy program because it can help them to

understand the demented individual better and in return they can learn how to

communicate with them and better care for them. The art therapists offered activities that

helped to find balance between challenge and achievability. In the beginning, the

sessions’ goals were to improve confidence and self-esteem by creating artwork that was

aesthetically pleasing to the participants (Malin & Rogers, 2013). By the end of their art

program with these participants, new friendships had formed along with team spirit. As

Malin and Rogers (2013) wrote, “dementia is associated with the need for support and

care rather the ability to give support or help others,” (p. 47). Fully, the program offered

the participants a sense of purpose, a change in the care provided to the dementia clients,

and improvements in capacity, concentration, learning, creativity, confidence,

environmental orientation, decision-making, intellectual stimulation, and physical efforts.

Although this is all a beneficial aspect to rehabilitation for dementia patients, art

therapy can also be very confusing for an individual with dementia (Kahn-Denis, 1997).

Art therapy can be a strange and confusing means that a person with dementia may

struggle to be expressive and understood in the midst of their confused state. At times, a

canvas or blank piece of paper could be very intimidating or too great a challenge

(Camartin, 2012). This could also, once again, be linked to the fact that elderly people see

art as “humiliating and infantilizing” and could not want anything to do with it because of

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this. Camartin (2012) explains this by giving example to some art therapist’s patients who

claimed they had no talent or skill and just didn’t like what they produced as an art

product. This is known as a time when an art therapist should be a more supportive role

for these clients and encourage them in their art making skills.

Though, as Innes and Hatfield (2002) wrote, sometimes art therapists may

have to decide on whether the art therapy process is beneficial for a client and whether or

not they should continue the therapeutic process with them. “Perhaps another modality,

such as music therapy or dance/movement therapy, or art therapy in collaboration with

another modality, would better meet the person’s needs and promote their remaining

strengths,” (Innes & Hatfield, 2002, p. 27). The appearance of a product may be a

deciding factor to whether or not an art therapist should continue to offer their services.

Due to the confusion, or inability to perform in a beneficial way, during the process, a

client may be suited without the therapeutic modality of art therapy.

Art and the Brain

Depending on the areas of the brain that are damaged by dementia, art has been

known to show the progression or even the effects that the disorder has on an individual.

For example, people who have right hemisphere damage may have problems with the

spatial arrangements in parts of an image (Safer & Press, 2011). Those with left

hemispheric problems have a tendency to oversimplify the elements in their drawings,

but can understand the spatial organization of those elements. Also, as Safar and Press

(2011) explain, linguistic information is produced in this hemisphere and this plays a role

in depicting symbolic features in art. Those with Alzheimer’s disease have been known to

produce work that shows the decline in their visuospatial and organizational skills.

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Those with Alzheimer’s disease also have shown a decline in motivation while

doing the artwork and could give up during the art making process. As time goes on, their

artwork can seem to become more and more simplistic (Safar & Press, 2011).

“Importantly, the progressive loss of visuospatial skills and less realistic depiction of

subject matter does not necessarily mean that artistic quality is lost,” (Persiah, Lawerence

& Reutens, 2011, p.1012). According to Ehresman (2014), due to the decline in brain

functioning, one would think that this would affect the creative functioning of the

individual, but thankfully that is not the case. People with dementia may have the

physical and mental capacities to create a product in art, but the art could show a change

over time.

As Ehresman (2014) wrote, “the presence of a dementia such as AD can affect a

variety of abilities, including creative functioning and art-making skills,” (p. 43).

Symptoms that occur due to dementia and the level of brain damage are things that an art

therapist may need to pay attention to so that the client can get the therapeutic help they

need for their cognitive level of functioning. It is said that artistic creativity can reinforce

synaptic connections in the brain by altering neuronal structure and function; this could

be exceptionally helpful with people who suffer from dementia (Ehresman, 2016).

There are multiple known case studies done with professional artists that are

going through the stages of dementia. Gretton and Ffytche (2013) explain that even

though art changes, it helps to show the perceptual and cognitive deficits that an artist

with dementia may show. These deficits could possibly enhance or diminish specific

aspects of their artwork. It has been seen that people who even have a talent in art will

have troubles as the disease takes over. As time goes on, it will show in their work what

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parts of the brain have been affected by the disease either by the diminishing of certain

details or even repressing into other beginning stages of the art making process (Gretton

et al., 2013).

Home-Based Art Therapy

Home-based art therapy is not very common for the elderly considering many are

put into nursing homes that will provide the therapy along with other recreational

activities. Not much research has been done on home-based art therapy, though the

research that has been collected shows the benefits of it for the elderly client receiving

the care and also for their significant others (Sezaki & Bloomgarden, 2000). Sezaki et al.

(2000) wrote that with home care likely the client will receive other therapeutic needs,

such as occupational therapy, physical therapy, and nursing care, but psychological

services at home are rare. When bringing art therapy into home-based treatment, Sezaki

et al. (2000) wrote that it is important to understand that this is a special environment that

has its own set of needs and is a unique structure that can affect the therapeutic process.

This is known as a different environment than the institutionalized environment.

Sezaki et al. (2000) wrote, “it is generally agreed that the home is the least

restrictive setting of all sites where the elderly live, allowing for diversity of treatments

and ideas,” (p. 283). A study done by Jones, Warren, and McElroy (2006) showed that a

majority of the clients they researched on in a home setting valued art therapy and

actually requested further sessions. Clients, along with caregivers, acknowledged that art

therapy as a supportive element was important. The clients in these studies also

“preferred experiencing art therapy in the home environment, as it was perceived as less

distracting,” (Jones et al., 2006). As stated by La Torre (2006), when being in an

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environment that art therapy is practiced in, one wants to be comfortable and feel safe,

and their own home may be a perfect place to let this happen because it is an environment

a client is known to be most comfortable and familiar with.

Family Art Therapy

When it comes to home-based art therapy, sessions may include other members of

a client’s family. The uniqueness of family art therapy is that, unlike group therapy, it is

known to work with people who have interacted with each other for many years.

Kwiatowska (2001) wrote that group art therapy deals with people who are placed

together to interact with one another due to their common diagnosis, but with family art

therapy the clients have already developed their own patterns of interactions as well as

systems of defense. One goal that is known to be a center in family art therapy is working

therapeutically with the family as a whole because it encourages them to participate in a

joint activity and allows the therapist to see how the family interacts with one another.

What problems arise during the art making may need to be addressed at the outcome of a

process (Kwiatowska, 2001). Though, family art therapy can become individualized to

allow a therapeutic relationship to develop between the therapist and each client

individually.

Family art therapy is known to have its challenges as well. When a therapist

would switch from individualized sessions to group sessions, the members of the family

would show an increase of anxiety and resistance to the process (Kwiatowska, 2001).

Kwiatowska (2001) wrote, “Both the patient and the parents resented the invasion of the

relationship which they had managed to establish separately, sometimes with great effort;

various members of the group, most frequently the patient, withdrew or became less

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responsive,” (p. 30). Family art therapy may not only be practiced with a client and their

parents, but is known to be practiced with caregivers, spouses, children, and other

familial relations in a client’s life. One goal that may be used in family art therapy as well

is to help clients solve the problems that led them to seek therapy, to open the clients up

to a greater perception of their lives, and to help support a change in the dysfunctional

patterns of behavior (Riley, 1990).

Some assessments that were created for family art therapy are the Family Art

Evaluation created by Hanna Kwiatkowska, the Kinetic Family Drawings (KFD) created

by Robert Burns and S. Kaufman, the Family Centered Circle Drawings (FCCD)

technique created by Robert Burns, and the Family Portraits and Murals Technique

created by Judith Rubin (Kerr, Hoshino, Sutherland, Parashak & McCarley, 2008). For

Kwiatkowska’s assessment, an 18-inch by 24-inch piece of paper is used to draw on with

crayons or oil pastels. Those who would be participating in the group would make six

types of drawings, all at separate times. One was a free picture, where the clients would

draw whatever came to mind; the second was a picture of the family, where the clients

would draw their entire family (including themselves) and to draw the whole person

when representing each individual; the third picture would be an abstract family portrait,

where the therapist would ask the clients to create an abstract family portrait and await

any further questions from the clients on what to add or how to go about making an

abstract portrait; the fourth would be a picture started by a scribble, where the clients

would find a symbol from a scribble and represent it; the fifth would be a joint family

scribble, where the clients would start out with a scribble again and then do a joint picture

with their family to see how the family works together; and the final drawing consists of

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another free drawing to assess how the family worked together through the art therapy

process (Kerr et al., 2008).

It is hard to say how well these types of assessments would work in a professional

setting (Kerr et al., 2008). These assessments, such as Kwiatkowska’s, are rather long and

may not be capable of being finished in just one session with a family. Instead, some of

these techniques should be used at separate times to get an overall sense of each

individual and how they interact together in a family setting. Sometimes these techniques

will be done repetitively as small exercises before starting a larger drawing/assessment

that takes a longer of time (Sezaki & Bloomgarden, 2000). “Systematic features such as

alliances, boundaries, roles, closeness, and disengagement often are made visible through

a concrete medium such as art; art therapy provides a venue whereby clients may actually

see through the lenses of other family members for the first time,” (Kerr et al., 2008,

p.42). As Kerr et al. (2008) wrote, if a therapist rushes through directives with their

clients, the things that may need attention with therapy may not be recognized or worked

on. The family needs the chance to work on any issues that may arise during an

assessment and they too need to recognize the problems and learn how to work on them

properly, and in a healthy way for all participants.

Quality of Life

Quality of life is an arising factor in psychology and its definition is still unclear

within many professions. Just some definitions described by professionals are "the ability

to engage in/enjoy social interaction, family and friends, communication, and leisure

activities," "enjoyment of life, life satisfaction, feeling that life is worth living, having life

choices, personal dignity, a sense of achievement, well-being (including spiritual well-

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being), and living a life free of worry," and "includes mental well-being, feeling in

control, being of sound mind, having mental independence, mental health, psychological

and well-being," (McKevitt, Redfern, La-Placa, & Wolfe, 2003, p. 867). A lot of these

definitions are rather comparable and include the idea of "well-being." McKevitt et al.

(2003) wrote that therapists are more likely to define quality of life as social well-being,

mental well-being and life satisfaction. However, many have said that quality of life is

considered to be ones overall happiness and remains a dominant concept in the idea

(McKevitt et al., 2003).

Rusted, Sheppard and Waller (2006) wrote that due to the deficits associated with

dementia and the psychological effects one might have (i.e. depression and anxiety),

quality if life may erode. Due to these known side effects to dementia, psychosocial

interventions are being used in an attempt to improve quality of life in such individuals

(Rusted et al., 2006). As Innes and Hatfield (2002) wrote, “attention to quality of life and

the autonomy, expressive liberation and connection that art restores to live affected by

dementia are prime considerations of the art therapist,” (p. 20). Related research to art

therapy with dementia patients has shown the benefits of it with sensory stimulation.

According to this research, sensory stimulation could give short-term benefits on

measures of behavior, speech, and mood during and after sessions (Rusted et al., 2006).

However the patients did not maintain these benefits when they had a follow up a month

later, but evidence has shown an improvement in emotional adaptation and sociability as

long as art programs are available to the individual.

As Stephenson (2013) wrote, “with a rapidly aging population, it will be

increasingly important to help make it possible for older adults to achieve a quality of life

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that maintains health and is meaningful for them,” (p. 151). Research on the creative arts

has shown that participating in them can improve well-being, physical health and self-

esteem. During old age, this contributes to well-being by maintaining and developing

symbolic expression, problem-solving skills, perception and motivation (Stephenson,

2013). Art therapy aimed at promoting wellness can help individuals realign their sense

of self, and this can help in embracing the wisdom that comes with the changes they will

experience in thinking, feeling and behaving in later life (Stephenson, 2013).

Baines (2007) wrote about a list that has been created to illustrate the

potential outcomes of art therapy, as well with other creative art therapies, with people in

this population. These outcomes include positive emotional responses, reduction in

agitation, greater social engagement/interaction, change in cognitive processes, increased

verbal fluency, functional improvements, increased food intake, weight gain, increased

mobility, greater physical strength and balance, improved mood and attention span, less

stress (as well as with caregivers), elevated quality of life, and a greater understanding of

the human condition. These are considered benefits of the art therapy process and seem to

be a clear representation of how art therapy can help with the dementia population

(Baines, 2007). As Stephenson (2013) wrote, “Art therapy holds a promise of promoting

quality of life for older adults that maintains health and is meaningful. By expanding our

understanding of aging and developing effective programs that utilize art therapy and

other innovative methods to meet the needs of older adults, societal mandate to improve

wellness and health promotion practices can be further realized,” (p. 157).

Research has shown that human beings are creative, no matter the age or culture.

It has also shown that the value of staying creative is important for maintaining ones

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well-being and quality of life (Baines, 2007). Quality of life can be improved through art

therapy by helping the patient to overcome the obstacles that dementia faces them with

by making art (Safar & Press, 2011). When one retires, the main focus of retirement is to

relax and explore things you didn't have the time to do before. Most people who retire

will take up classes such as dancing, learning a new instrument, recreation, or even

learning how to paint. When one is diagnosed with dementia it is hard to go out and make

these decisions on your own. Thus, it is a great thing to allow these people the chance to

experience something new and rewarding like art therapy. Aging and growing older

should be a time of enjoyment and bring out the creative aspects of their personalities. It

is certainly a time for rediscovering yourself and finding new activities that you can enjoy

(Stewart, 2004).

Case Studies

A case study is known to be a study of the unique. This could be a study of an

individual, a group of people, an institution, or a system (Simons, 2009). Simons (2009)

wrote, “it is through analysis and interpretation of how people think, feel and act that

many of the insights and understanding of the case are gained,” (p. 4). In art therapy, a

case study is known to be qualitative with the importance of monitoring the impact of the

self on the research process and the outcome of the process (Simons, 2009). Though

practices in art therapy case studies have been qualitative, research has shown major

changes in recent years to provide more evidence-based practices (Case & Dalley, 2014).

The case studies that follow are qualitative, in that they interpret the drawings of

individuals diagnosed with dementia.

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In the following section, the author will write about case studies that revolve

around key aspects that help improve quality of life with clients that are diagnosed with a

form of dementia and at different levels of cognitive impairment. The first case study that

is spoken about is one that was conducted by the author during an internship at a nursing

and rehabilitation facility. The two remaining case studies included involve two other

types of settings an art therapy process can be directed at and two individuals with

different levels of dementia and even physical impairments, found through further

research of the topic. These case studies help to show how art therapy can improve

aspects associated with quality of life, no matter what level of dementia a person has or

what setting they are involved in.

Conducted Case Study: Lynn

The site that this case study was done at was Cold Springs Rehabilitation Center

in Cold Springs, NY. This case study was conducted by the author on the third floor of

the Brookville building of the facility that houses clients with a severe case of dementia.

The art therapy sessions are done in a group setting under a locked dementia unit. Those

that are participating in the program are residents of the facility that have to wear wander

guards to be sure that they do not leave the floor. There are also alarms on every

wheelchair that alerts aids if a resident has gotten up from their seat and is at risk of

falling. The art therapy sessions are held in the dining room on the floor and residents are

divided into multiple tables that seat at most four people, with seats assigned daily by the

nursing home staff.

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Case History

The case study participant is given the alias Lynn for protection of privacy. She is

an 86-year-old female born on January 1, 1930. She is Caucasian and has a height of 5 ft.

and 8 in. The client is also wheelchair bound and is diagnosed with dementia, along with

anemia, GERD, hypothyodism, and diabetes. Lynn used to live with a friend of hers for

25 years, but was suggested for assisted living after a fall she experienced that harmed

her. Before her friend, she had lived with her parents until they passed; she never married

or had children. Lynn has received a bachelor’s degree and after receiving her degree she

worked at NBC marketing for some time before returning back to school for her LPN.

Lynn worked in a home for a short time before eventually retiring. There is no

additional information on when Lynn began showing signs of dementia or the date she

was diagnosed with it. Due to dementia, Lynn is incapable of telling anyone what she

wants and has impaired decision making. She also has an impaired ability to understand

others and is selectively mute. She can work in any medium of art as long as you give it

to her and she is aware that it is there. When she is comfortable with a person she will

likely be able to answer yes or no questions.

Intervention

The goal of the art therapy sessions are to attend and/or participate in the art

therapy activity. This is evidenced by active and passive participation by sensory

stimulation. Art therapy sessions will help the resident feel they are participating in an

activity and allows them to get the sensory stimulation they need, due to their dementia,

and allows them to achieve reality orientation (Stewart, 2004). The method of the art

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therapy sessions are that residents are free to use whatever media they want to use, or

what is accessible at the time.

A variety of media will be available for choosing, but likely the art therapist will

have to choose the media for the resident if decision making is limited. Specific protocols

that are used are those that help with reality orientation and give the resident sensory

stimulation. For sensory stimulation, directives geared towards freehand use of mediums

are used (Kahn-Denis, 1997). For reality orientation, directives geared towards the here

and now are used, such as seasonal projects (Kamar, 1997). For Lynn, art therapy is

mostly used for the sensory stimulation, since reality orientation is a hard cognitive

process for her now. Mostly all sessions with Lynn are done in the dining room where

other residents are present, but it is more in a one-on-one manner since they do not talk to

each other in a group aspect.

Outcome

The first protocol used with Lynn will be titled "Fall Leaves" and the goal of this

directive was to help the client with reality orientation. The session started off with the art

therapist stating what time of year it was and asking the clients to paint the leaves with

tempura colors that matched the season to add to a big tree that was prepared ahead of

time along with the leaves the clients painted on. The tempura paint was nothing new for

Lynn and she decided to use a sponge brush to paint her leaf in with. From the choice of

orange and yellow, Lynn stuck with orange and began painting in a slow manner, lightly

dabbing around the edges of the leaf cut out that was given to her.

With persuasion on continuing to fill up the whole leaf, Lynn eventually did fill it

up and finished the first leaf, and eventually filled up a few more before the session was

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over. Lynn was also persuaded to use other colors to explore the differences and to try

something new. Though at the end Lynn still seemed confused as to what the art therapist

was talking about when asking her about fall, she did seem to enjoy the process and kept

looking at her leaves that were sitting on the table before they were put up on the wall.

She was not able to get the reality orientation the art therapist was trying to get her to

achieve, but she was able to get sensory stimulation out of the directive.

For sensory stimulation, the art therapist decided to allow Lynn to work on a

freehand drawing. When given a controlled media, Lynn commonly creates a picture in

the same way, creating a picture that she has noted previously as being her "signs," seen

in Figure 1. At this point in the therapeutic relationship Lynn was beginning to make eye

contact, smiling, and saying hello. She was given a piece of paper and marker to draw

with and she began to draw in her normal repetitive manner. These "signs" are lines that

go down then across, then up and across, and continues in this manner before she goes

back and traces over what she has already done again. When Lynn was handed a new

color, she would just continue to trace over and make the same shapes, but the way her

work came out at the end showed depth. This depth was most likely not intentional. It

was during this protocol that Lynn had spoken one of her aphasia words, and this was

when she had looked at the marker in her hand and said "this is gookie." The outcome for

this process was that Lynn was able to get the sensory stimulation she needed and even

continued the piece of work after the art therapist was gone.

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Figure 1: Lynn's Freehand Picture

Another protocol that was used with Lynn was one titled "Watercolor and

Resistance;" her outcome is seen in Figure 2. The treatment goal of this process was to

challenge Lynn's repetitive behaviors. This directive includes drawing with a white oil

pastel first, which was used by the therapist to trace Lynn's hand and make some other

shapes for her since she wouldn't be able to see what she was doing, and then allowing

Lynn to take the watercolors she chose to paint with and go over the paper. The

watercolor is a less controlled medium and thus made it harder for Lynn to continue with

her repetitive behaviors. Though she began to make her normal "signs," she was unable

to control the watercolors from mixing.

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Figure 2: Lynn's Watercolor and Resistance Outcome

She also seemed surprised when sections of the paper would not take the color

and she tried to go over and over those sections until she finally realized it would not

work and gave up; these sections were the ones resisting the paint where the oil pastel

was placed. When the water colors began to mix, Lynn stopped what she was doing and

just watched them expand slowly. She stared at it before continuing on, seeming to accept

what was happening. It was clear through her movements that she was trying to control it,

but at the end of the whole session she was smiling. When asked if she enjoyed the

process she said "yes," and this was the first time she had said that to the therapist

conducting the intervention. The outcome of this protocol was that Lynn's repetitive

behaviors were challenged and she was able to work through those challenges in a

healthy way and thoroughly enjoyed the process.

The final protocol was used again for the goal of sensory stimulation. This too

was another freehand drawing but was done with a different controlled media. On this

Figure 3: Final freehand done by Lynn.

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day Lynn was by herself at a different table then she normally sat at. At her normal

assigned table, she is with two other residents who usually passively participate in the

process. Lynn was seated closer to the radio on this day and was the only one who

seemed to be alert and awake on the floor. On the radio, classical music was put on to

keep the calm atmosphere of the room persistent. Lynn was given a piece of paper and a

colored pencil to start making a freehand drawing, but this time was different from her

usual repetitive manners.

Lynn began drawing with a red colored pencil and as she began the piece she

drew two hill shapes. Eventually, as she was drawing, she even seemed to put in a ground

line which was done by slowly running the pencil across the bottom. After she was done

with the red pencil, she picked out a purple pencil from the bucket of colored pencils that

was placed in front of her. With this pencil she drew one purple line above the hill shapes

and the line seemed to follow the shape of the red lines beneath it. The outcome of this

drawing was much different from her previous works of art seen on the previous pages,

and this is shown in Figure 3. Lynn was able to work faster than normal and she changed

from her normal repetitive behaviors. It is unclear why she changed but it may have been

because she was more alert that day, or that she was closer to the music and could

actually hear it, or it even could have been that she was put into a new seat from her norm

and was seeing a different perspective than she normally does.

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Figure 3: Lynn's Final Freehand

Historical Case Study: Mr. M

This case study was done due to a non-profit community based agency that helps

disabled residents to stay in their home when receiving therapeutic and medical services.

The agency’s intention of doing this is to help to improve the resident’s quality of life

(Sezaki & Bloomgarden, 2000). This is a case study that was done by Shinya Sezaki and

Joan Bloomgarden and written about in their article in 2000 titled “Home-based Art

Therapy for Older Adults” found in the Journal of the American Art Therapy

Association.

Case History

The case study participant is given the alias Mr. M for his privacy. Mr. M was a

69-year-old man that was being cared for by his wife at their home and Mr. M was

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known to be diagnosed with Alzheimer’s Disease (AD). He stopped working as a

pharmacist 5 years before his sessions started and his wife had to leave her job to take

care of him. Mr. M had taken medication used to slow the progression of Alzheimer’s

(Aricept) for 6 months, but the medication did not improve his cognitive impairments.

Alzheimer’s was a known genetic predisposition in his family. Mr. M did not have any

physical limitations but AD had been a factor that affected his cognitive functioning. The

therapy sessions were done in a family setting, with Mr. M and his wife participating in

the activities.

Intervention

The art therapy sessions that the art therapist conducted with Mr. M and his wife

proceeded for 60-80 minutes weekly. The goals of these art therapy sessions were to

improve the relations between the couple and were not directly used to improve Mr. M's

symptoms associated with his form of dementia (Sezaki & Bloomgarden, 2000).

“Relationship-focused art therapy for individuals with dementia and their families

assumes that the psychological problems of neurocompromised patients, which stem

from estrangement, burden, and chronic sorrow, result from inappropriate family

interactions and dysfunctional coping methods,” (Sezaki & Bloomgarden, 2000, p.287).

Family art therapy interventions were being used to improve communication patterns

which were considered when the therapist was developing goals. These goals include

enhancing the clients’ quality of life through the process of the disease, to help the clients

understand the reality of the changed family situation and to help implement coping

skills, to facilitate communication by providing a nonverbal and visual tool, to provide

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the joy of creating artwork and encourage the client and family members to have a

meaningful and enriching activity (Sezaki & Bloomgarden, 2000).

Outcome

The therapist structured the art therapy sessions with two regularly scheduled

activities and at the end of each session would be one longer art project; this occurred

over a 10-month period of time. The two activities that the therapist would start with

were called “warm-up exercises,” since they were conducted in the beginning of the

sessions (Sezaki & Bloomgarden, 2000). These warm ups were conducted with the

clients to help them feel relaxed before starting the longer art project. “The activities

were Visual Conversation (VC) and Squiggle Game (SG); both were used for assessment

and treatment as well as relaxation and enjoyment” (Sezaki & Bloomgarden, 2000, p.

287). In the first activity, the Visual Conversation, the participants needed to pick up one

crayon or marker and begin to draw without speaking to one another. Both take turns in

responding to each other’s piece of the line drawing one at a time.

This continues to happen until the therapist tells them to stop the process. Those

with Alzheimer’s Disease do have a hard time following the rules; in this case Mr. M had

a hard time not asking what certain things in the drawing was, which went against the

rule of remaining quiet through the process (Sezaki & Bloomgarden, 2000). “However,

the activity is useful to assess the individual’s cognitive ability and ways of interacting

with others,” (Sezaki & Bloomgarden, 2000, p. 287). The Squiggle game is usually used

with children, but the technique is also used in various other populations with

modifications to make it work well with said populations (Sezaki & Bloomgarden, 2000).

The Squiggle game is started by the therapist, in which the therapist draws a squiggled

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line or form on the paper and tells the client(s) to convert the line or form into another

image. After the client finishes their drawing, they make a squiggle for the therapist to

make into a different drawing as well.

While the client is drawing, the therapist will frequently ask the client about their

picture. With the sessions that involved Mr. and Mrs. M, the therapist used this

therapeutic technique as drawing for communication between the two clients. Mr. M had

difficulty when making another photo out of the shapes that were drawn by his wife, but

was capable of drawing lines that related to the shape in general. When the drawing was

done the opposite way, Mr. M showed enjoyment in watching what his wife would make

from his shape and this was seen by his smiles and laughter during the process. “The

therapist introduced different media and various activities such as printing, rubbing,

magazine photo collage, making a town map, mandala art, play dough sculpture, etc.

Among them, play dough was the most useful media to provide enjoyment to the couple.

By using the back and forth modality of the VC project, they passed the dough to reform

the shape that was created by the other,” (Sezaki & Bloomgarden, 2000, p. 287).

During the first Visual Conversation session, both Mr. and Mrs. M drew a picture,

seen in Figure 4. Mr. M had started the drawing by making a purple wave line that went

vertical, seen on the left side of the image. After that, Mrs. M made a bold red line on the

bottom of the drawing. After she had done this, Mr. M repeatedly drew horizontal wave

lines instead of vertical, like he had started out with. Sezaki and Bloomgarden (2000)

wrote, “the picture allowed the therapist to understand Mr. M’s cognitive impairment and

provided a glimpse into the couple’s relationship,” (p. 287). Whenever Mrs. M drew a

spiral line, Mr. M would trace the spiral with his purple maker and then would copy it on

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the right side of the paper. The sun and small mountain were drawn together in the same

way. When imitating his wife, Mr. M did not appear confused during the process. In the

next session, Figure 5 was made and this was when Mr. M and his wife learned how they

can communicate through mutual drawings (Sezaki & Bloomgarden, 2000).

Figure 4: Mr. and Mrs. M's first Visual Conversation

When starting the drawing in Figure 5, Mr. M had drawn a long black shape that

was almost snake-like. After this, his wife made a design inside of his shape and he began

to imitate what she was doing again then after. When Mrs. M made zigzag lines, he made

many wavy lines and this is when she began to understand his ability to follow her to

complete the picture they began. At this point, Mrs. M had begun to test the way her

husband responded to her with art (Sezaki & Bloomgarden, 2000). By the time the sixth

session came around, both Mr. and Mrs. M had seemed to develop a way of

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communicating through this process, as well as collaborating on the Visual Conversation

pieces they made.

Figure 5: Mr. and Mrs. M's Second Visual Conversation

In the beginning of every session of visual conversation, Mr.M was always the

one to draw first, usually starting out with a large outline of an unknown shape, and then

the two would take turns from there, with Mr.M following his wife’s lead. During the

process of the sessions, Mrs. M began to become frustrated with the scribble drawings

she was making, and began to add more figurative drawings to the art like the drawing

shown in Figure 6 (Sezaki & Bloomgarden, 2000). Mr. M had started the drawing out,

making three red circles that Mrs. M imagined being a snowman. Mrs. M then drew the

snowman in with Mr. M without giving any verbal instruction to him.

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Figure 6: Mr. and Mrs. M's Scribble Drawing

“All art activities sought to enhance the clients’ potential for developing

communication skills, despite cognitive deterioration,” (Sezaki & Bloomgarden, 2000, p.

289). It is clear that through this process, and the sessions, the couple were able to

develop communication skills with one another that were pleasing. The therapist has

hoped that the outcome would allow Mr. M to become more in tune with his environment

by using communication skills that helped to prevent more deterioration from his

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diagnosis. This approach also helped Mrs. M who had a hard time communicating with

her husband due to the AD, which in the long run may have caused her to have some

mental health problems (Sezaki & Bloomgarden, 2000). Due to it being too painful for

Mrs. M, the reality of the cognitive disease was able to be seen and understood through

the art making process with her husband. When the initial session was done, Mrs. M had

actually written a letter to the therapist and agency that allowed them to receive the

treatment. In this letter, she stated how she had been depressed when she realized her

husband had limited cognitive abilities and the realization of being a wife to someone

with Alzheimer’s Disease. This letter actually validated what the therapist originally

thought would be a problem for Mrs. M and why it would be important for her to

participate in the program..

The reason that the Visual Conversation was good to use with Mr. M is that it

helped him to understand his wife. “The connections, such as one in the vertical wave on

the left edge (Figure 5), indicated that they started communicating with each other again

after they had lost the ability for meaningful verbal communication for several years,”

(Sezaki & Bloomgarden, 2000, p. 290). Their son, who participated in one session, told

his mother that he was surprised that he had successful communication with his father

through the art activity. These therapeutic gains occurred where the clients felt the most

comfortable and secure—at home.

Historical Case Study: Miss Gee

The art therapy sessions in this case study were held at a nursing center in the

suburbs of a Midwestern city. The nursing center had 200 beds and offered skilled and

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intermediate long term care, day care and vacation stay for older adults. This facility also

had a structured Alzheimer’s unit and the sessions were held in the basement activity

room, which was also used as a kitchen area. This case study was done by Sharon Jensen

in 1997 and is mentioned in one of her published articles.

Case History

This case study includes participants in a group therapy environment. The

participants vary in severity of Alzheimer’s disease and other related dementias, as well

as cognitively higher functioning individuals with physical limitations. Most participants

were residents permanently at the facility and ranged in age from 70 to 93. The maximum

number of participants for each group was 15, but only 6 to 10 actually participated. This

study will be focused on one individual given the alias Miss Gee for her privacy. This

woman is described as a small woman whose demeanor could best be described as

dependent and fearful. Miss Gee had full use of her motor skills but had a remarkable

response to movement; she was always very anxious when making any movement

because she was always afraid she was going to fall (Jensen, 1997).

Intervention

One limitation Miss Gee had was apraxia and due to this she has to constantly be

told when to sit, walk, or stand (Jensen, 1997), but she is commonly brought into the

sessions in a wheelchair and remains in it. Miss Gee also had osteoporosis and this

caused her back, neck and shoulders to be hunched over and her chin is constantly resting

on her chest. It was hard for Miss Gee to take direction and she would normally just

rewrite words she heard previous to starting her art pieces or make minimal drawings.

The art therapist used art therapy as an intervention to help Miss Gee work through her

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limitations and through her negative perceptions of herself. Art therapy was also used as

a reminiscing tool for Miss Gee.

Outcome

In order to help change the repetitive behaviors of just writing words on a piece of

paper, the art therapist tried to do collaborative pieces with the client. This resulted in the

client just writing the word of what she saw on the paper, like when the therapist drew a

face and asked the client to add to it, Miss Gee instead just wrote the word for the feature

that the art therapist drew. During one session, Miss Gee completed a picture of a tree in

response to the task of drawing a family tree (Figure 7). Miss Gee was able to respond

with limited reference to her family history, but she did recall her father’s name. She did

not remember her mother’s name and that was when the art therapist asked the client if

she recalled what her father called her mother, and she stated that he called her “darling”

which she then added to her picture.

During sessions after this, Miss Gee would come in and exclaim that she was too

old and couldn’t do the work, or that she wasn’t a good artist, and in return the art

therapist pointed out that she was not the oldest person in the group (there was another

woman in the group who was older that the therapist pointed out) and that she did not

have any great expectations for anyone in the group process when making art, but that

she was happy that the client could make it that day. Her response to this was to express

herself by moving her arms and legs vigorously and she seemed delighted to be able to

move freely and safely in the wheelchair she was in. After this day, every group that

followed, Miss Gee exercised and made art.

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Figure 7: Miss Gee's Family Tree

In one session, Miss Gee made her first completed artwork. It was a face; simple

and made from within a circle, but while she was in the concept of drawing a person, she

began to draw the whole body within the circle, shown in Figure 8; this is a form of

boundary confusion which is common with Alzheimer’s patients and is also a form of

regression (Jensen, 1997). On the top of the page, Miss Gee wrote “she was older than,”

showing that she was still focusing on the comment the art therapist made about her age.

In another drawing Miss Gee made, she attempted to make a house (Figure 9). She stated

that she had lived in the house as a child and she was able to name the town she lived in

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and tell the group things about what her and her brothers did as children. The drawing

clearly did not have to be very elaborate to stimulate reminiscence.

Figure 8: Miss Gee's Face

The therapist’s studies said that people with Alzheimer’s will continue to

deteriorate as it continues to affect their cognitive functioning (Jensen, 1997), but the art

therapist states that Miss Gee’s improvement in the process is inconsistent with the

literature findings that the therapist found. This may show that proper intervention will

both maximize self-esteem and functioning, but may also decrease dependence. This is

seen by the findings that Miss Gee was only active when she attended the art group and it

shows that the multisensory art experience appears to have been a successful intervention

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for her. It is still difficult to tell if the improvements Miss Gee had was due to her

increased individual attention to her needs, the stimulation she got with the new activity,

the variability of the course the disease had on her, or other outside variables.

Figure 9: Miss Gee's House

Concluding Remarks on Case Studies

As the case study examples have shown, some of the problems that these clients

were having were generally worked upon. Mr. M and his wife were finally able to

communicate with one another and understand each other through the art process, Lynn’s

final drawing in the time that was spent with her may suggest that art had an impact on

her repetitive behaviors and her overall well-being, and Miss G was able to finally

express herself through the art making process, as well as reminisce through the cognitive

limitations that the disease gave her. These achieved goals through the art process is

shown to help each individual client with their overall quality of life; being comfortable

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through the process and being able to create a satisfying product on their own or with

others.

Though at first most individuals are defiant to the art making process, some may

actually excel and feel comfortable in it. Sometimes those who do not want to make art,

eventually will with the guidance of the art therapist. This is seen in Miss Gee’s case,

when the art therapist assures her she is not judging her or anyone that was in the group

therapy process. When they do begin to make art and the art therapist begins to assess

their strong suits and their weaknesses, art therapy may be used to help challenge the

limitations that one might have or strengthen the things that they are good at to limit

frustrations during the process. Overall, by allowing the clients to be challenged and feel

comfortable during the process, art therapy can help improve many important factors

associated with quality of life.

Lynn should continue to use various types of materials to explore her abilities and

allow her to get the sensory stimulation she needs. Perhaps moving Lynn around and

allowing her to sit with new people or see a different perspective on the room will help

her with changing her repetitive behaviors and could possibly affect future artworks.

Even allowing her to hear music better as she goes through the art making process could

cause a change as well. It would be important to try these new things to see what may

have caused the changes in her last piece of artwork and if they can further be of help to

her repetitive behaviors.

Lynn is showing more alertness and energy each time she goes through the art

making process. She speaks more now before and after the process. She says "hello,"

"yes," "no," "good morning," and "thank you." Sometimes she mumbles incoherent

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things as well, but she is actually trying to communicate more and seems to recognize

those around her now. The art therapy process is showing some great improvements for

her cognitively and for her to get the proper amount of sensory stimulation she needs for

her level of dementia. Lynn seems to enjoy art therapy and continues to work on the

directives every time she receives them.

Mr. and Mrs. M should continue to do the exercises they are given daily. It may

be important to start including other family members in the process at times (like their

son who was included in one session) to help more of the family learn how to

communicate with Mr. M through his impairments. Art therapy seems to be helping Mrs.

M accept that she is caring for her husband who suffers from Alzheimer’s disease and is

improving her mood, which is associated with the depression she was getting from not

understanding the disease and its effects on her husband. To continue to work with these

clients, it would be wise to use directives that force the two to work together to make a

final product, much like the exercises that the therapist was already doing with them.

Quality of life is achieved through the completion of an art directive, gaining a sense of

understanding of one another, and being able to communicate with each other in a new

way. Mr. and Mrs. M may become more comfortable with the process as time goes on

and may be able to take on more challenging directives, so to challenge Mr. M’s

limitations due to Alzheimer’s. This will help the both of them learn how to work through

frustrations together and gain a better sense of each other’s strengths and weaknesses.

Miss Gee had only begun to really develop her artistry in the case study

presented. As time went on, she began to figure out how to express herself through the

mediums she used and through her artwork she learned to reminisce, even though her

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cognitive abilities were limited due to dementia. Not only was she able to access

memories that may have been forgotten, but she was able to feel empowered by

completing her art products and was able to communicate with the group and art therapist

through the final pieces. Allowing Miss Gee to continue freely drawing through the art

therapy directives may help her to learn her own sense of control and mastery of the

materials and may help her to increase quality of life through art. In time, it may also help

to allow her to also be given materials and directives that can challenge her limitations

and weaknesses, so she can gain an even better sense of empowerment through her work

and hopefully tap into more of her memories in the process.

Suggestions for Future Research

Through the use of art therapy, it is shown that this modality is a positive

experience for people in this population. Art therapy is said to be helpful with people who

suffer with dementia because it gives them a sense of empowerment, it can help with

communication, and it can also help with reminiscence, such as said in the literature

review section. All of these factors that are aided with art therapy are ones that are

closely connected with quality of life. As stated before, quality of life is what some

therapists would define as an overall sense of positive well-being, whether it is social,

mental or life satisfactory (McKevitt et al., 2003). Though, many have also said that it is

an overall happiness in one’s life.

A problem that normally arises with dementia patients is depression and other

limitations that cause the patient and even their surrounding caregivers to be affected.

When art therapy helps increase quality of life in a positive way, depression has been

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seen to decrease over the period of the process. Art can be greatly affected by the

damages that dementia creates in the brains of those affect by the disease (Ehresman,

2014). They will have many limitations due to this and thus it may be good to suggest

that people in this population work on more simplified directives; directives that are

easier to understand and follow directions for. Since dementia is widely spaced in its

severity, it is not easy to figure out what type of directive would work with an individual

until you can assess their weaknesses and strengths. The weaknesses that one can possess

due to dementia are those involving cognitive and physical limitations. Age and dementia

can cause problems in both of these areas and these weaknesses may have been seen in

the art products of individuals with this disease.

It takes time for the art therapist to understand the client’s needs, their goals, and

how art will help them through their therapeutic process. As stated in the literature

review, having dementia does not mean that overall creativity in the art process is

impossible for clients with the disease. Case studies and other research findings prove

that the creative process is not lost with the damages the brain withstands due to dementia

and that generally, no matter the severity of dementia, the client can make an art product

and be satisfied at the end of the sessions they go through. It is seen that testing the

limitations and challenging these individuals through certain directives can help them

with finding a sense of self again. Through all of these findings, it is seen that art therapy

may help improve dementia patient’s quality of life and well-being.

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