DRAWING FROM WITHIN.

ART THERAPY CAN SPEAK FOR--AND HEAL--YOUR RESIDENTS

What is art therapy? If you've ever had the urge to pick up a black marker and scribble across the page, or wished you could splash giant buckets of paint all over the floor a la Jackson Pollock, then you've experienced art therapy firsthand.

Art therapy is a mental health field in which clients use art to express themselves. Thoughts and feelings, metaphors and symbols often can be expressed more easily in a concrete and tangible work of art rather than through words alone. There are two differing schools of thought within the field that outline the course of treatment: art psychotherapy, in which theories of psychoanalysis, especially those of Freud and Jung, are blended into the making of art; and art as therapy, in which the art process itself is inherently healing. Most art therapists combine the two, using verbal therapy techniques along with the art process.

Silence is golden

Because of the mainly nonverbal process involved, art therapy is particularly useful for those who have difficulties expressing themselves with words. This is one reason why it is useful in working with older adults, especially those with cognitive impairments or brain damage. People who were born in the early part of the last century have little faith in "talk therapy" and even less in therapists. However, the use of art in the process helps distance the problem, feeling, or memory, puts it on the paper, and lets the metaphor of the artwork communicate.

Long-term art therapy can be used to calm someone with anxiety, bring relief from depression, tap into undamaged parts of the brain in an Alzheimer's patient, or help someone grieve. Other goals in working with this population include: increasing self-esteem to focus on the positive abilities of a client; promoting creativity to validate what he is still able to do; cognitive and physical stimulation; evaluation to assess changes in behavior, ability to follow directions, and make sense of a task; and encouraging social interaction and the establishment of relationships.

A case study

A 95-year-old widow, let's call her Mrs. Bloom, had been on the Health Care Unit of a CCRC for more than a year when she started art therapy. Mrs. Bloom grew up in the sunny South, becoming a physical education teacher and spending as much time as she could at the ocean before marrying a doctor and moving up north. Now she doesn't get outside much, never gets near the ocean, and can exercise only from the confines of her wheelchair.

Mrs. Bloom was referred to art therapy because of her depression and early dementia. The nurses were concerned that the days where she would pack up her belongings to "go home" might someday lead her outside of the building, which is an obvious safety issue. While her first sessions in art therapy produced crude, unexpressive imagery, her later imagery brought out a lifetime of memories, relived and revealed through her art.

Seeing how much her stories meant to her, we decided to have her start a "memory book," where she would draw a piece of her past every week in art therapy sessions. Early childhood memories, usually the most vividly remembered by this population, held special importance, and became a way to resolve past conflicts and bring up concealed feelings that she had held inside for decades.

Fill in the blanks

For several sessions, Mrs. Bloom had created images of stereotypical flowers that seemed to show her reluctance and defensiveness against opening up. In this session, we decided to try giving her a stimulus with which to start drawing, hoping to elicit a more personal response. We asked Mrs. Bloom to pick one of five pre-drawn figures to include in a setting. We then asked her to complete a few phrases about the picture, which resulted in this: "I am near the ocean. I want to swim, but it's chilly. I will try a little later. I feel like swimming, but I don't want to be cold. I need a little more sunshine. I wish I were not alone here. I secretly want to see my boyfriend. Never refer to me as a vulgar person with no clothes on." These few, simple sentences poignantly represent her need for sunshine, companionship, and the feel of the water. Her issues were becoming clearer, yet they remained in the safety of the "young girl" figure in the picture, and in the metaphor of the page.

"Blue party dress"

Several weeks later, we had begun to build a strong therapeutic alliance in our sessions. Mrs. Bloom's trust in the therapist and in the art therapy process began to grow. She now spoke more openly about the memories and feelings brought up by the art-making. Her image, "Blue party dress," is a picture of Mrs. Bloom at age 14 in a party dress. After making the figure, she revealed that throughout her life, she'd thought [apparently along with everyone else] that her sister was the prettier one and had therefore deserved the prettier dresses. In making this dress and finally giving herself the prettiest dress, Mrs. Bloom let out some of the anger she'd repressed over this lifelong jealousy, telling about a secret that she'd "never told anyone before." She was also opening up to the possibilities of art therapy, and became eager to come to our sessions each week.

"Summer pleasure"

On one particular day, we found Mrs. Bloom alone in her room, sobbing. She said that she wanted to leave "this place." After talking with her, it became apparent that she was longing for home, and felt like she had somehow been separated from her parents.

Rather than redirecting her, we validated her emotions by suggesting that she make a picture of a place where she'd most like to be. She painstakingly constructed a picture of the plantation house in her image, "Summer pleasure," depicting her grandfather's home. When she was finished, she had stopped crying, visibly calmed and soothed by her image. She explained that in the picture there is a golden sky because it is the time right before the sun sets, when she would be sitting on the porch, watching it set. With this, she seemed to not only want to return to this comfortable time of her life, but she brought to life the metaphor of the sun setting on her own life now that she was nearly 100 years old.

"Out swimming in the clouds"

Again, Mrs. Bloom was longing for the ocean. She said that she felt most at ease in the water, and that as a girl, she dreamed that she would one day swim the English Channel. Depressed by the fact that "they" wouldn't let her go to the pool any longer [because of hip fractures], Mrs. Bloom found a way to immerse herself in the water, as if swimming in heaven, in a collage. She titled her picture, "Out swimming in the clouds" because the collage image that she expanded on blurred the lines between water and sky. To Mrs. Bloom, swimming under or in the sky seemed to blend her most favorite elements together--her love of the outdoors, and her love of the water.

"Grandmother's garden"

On another day, Mrs. Bloom speaks as if she is a young girl and her therapist is her art teacher. "This garden was made for grandmother. She worked on it some when she was younger, but stopped when she got older. I think old people gave up earlier in those days, and were pampered by their family," she explained. The artwork brings her back to her childhood more often than not during the making of her memory book. The memory envelops her and allows her to feel what she did back then, if only for a fleeting moment or two.

The picture seems to speak to Mrs. Bloom's grief over not being with her family in her old age, and perhaps thinking about a place for final rest, in a garden, near a bench. In this way, we continued to speak, mainly through the symbolic language of the artwork, about the nearing end of her life. Thinking back to her grandmother and mother, Mrs. Bloom tried to make sense of where she was now, in relation to where they were at the end of their lives. An ounce of regret and longing for her own garden mixed with the proud feeling of having not "given up" and being an active rather than passive gardener in her own life. Even now, at 97, she continues to have a window garden in her room.

Two years later, Mrs. Bloom continues to work in both individual and group art therapy. In individual sessions, she gets one-on-one attention, an element that seems to be missing in most nursing home environments. She also gets an avid listener, a therapist, and a way to put into perspective all the things that go along with being alive for almost a century.

We now receive fewer calls from the nursing staff asking for a counselor to come and work with her when she is found crying in her room. She recognizes the art process as something special, where she can share whatever is on her mind that day, and feel validated about it. Group sessions offer clients a different point of view in that they see their peers in the same life struggles. Many are tickled about becoming an artist in their 80s or 90s, most seem grateful for a safe forum in which to discuss the emotions and thoughts of everyday life.

Benefits of art therapy in your facility

Art therapists are trained to provide clinical art therapy, but can also provide case management, assessment, development of treatment plans and goals, and staff in-services and education. Therapy can be particularly important for this population, because as a person ages, the problems he or she has in life age along with him or her. Their issues are the same as the ones we have--from family and marital conflict to abuse, depression, and anxiety. The difference seems to stem from the fact that older adults know that they have less time to face these issues. Thus, they look inward, ".... becoming less concerned with outer appearances and events and more absorbed in internal reflection" according to art therapist Susan Spaniol in an editorial in Art Therapy: Journal of the American Art Therapy Association. [1] They may finally have the time to look inside, perhaps at conflicts or emotions that they've held inside for decades. Art therapists can provide a non-threatening means for self-expression and self-explor ation through the art process.

Art therapists are masters-trained clinicians, and can be registered and certified by the Art Therapy Credentials Board (ATCB) after completing postgraduate supervised clinical hours and an exam. An art therapist can be hired contractually (for anywhere from an hour a week to full time, from $10 to $100 an hour, depending on experience and setting), as part of a clinical team (along with social workers, psychologists, nurses, and psychiatrists), or as part of a therapeutic recreation department.

The average salary for a full-time art therapist spans a wide range because of the vastly different settings in which art therapists work. Only a small proportion of art therapists currently works with older adults--only about 5 percent, according to the American Art Therapy Association Inc.'s 1998-1999 Membership Survey Report. But the expectation is that the field, like many other health care fields, will continue to expand as the baby boomers move into long term care.

Art therapy can be a cost-effective method of relieving some of the plagues of nursing facilities, including depression, hopelessness, and grief. The discipline offers something new to those with other mental health practitioners, and can easily be incorporated into a program.

For more information on art therapy or on how to find an art therapist in your area, you can contact the American Art Therapy Association at 888-290-0878, or visit its Web site http://www.arttherapy.org.

Rebecca C. Perry, MA, ATR is director of Art Therapy at Goodwin House West, a CCRC in Falls Church, Va. She is also president-elect of the Potomac Art Therapy

Reference:

(1.) Spaniol S. Art Therapy: Journal of the American Art Therapy Association 1997;14(3).