The art of therapeutic recreation: a specialist works for inclusion in an inpatient treatment program by using his love of art.

Inclusion is the latest trend in parks and recreation, with professionals addressing methods for all consumers to become involved in their park and recreation district programs. The lessons in accomplishing this not-so-easy task come from many sources, including individuals who at the local level, make a difference every day for one patient at a time. This is the story of the relationship of Wayne Simonson, a recreation specialist at Western State Hospital (WSH) in Washington State with a client named Judith.

Wayne began working at this mental health hospital shortly after high school. His professional journey has included positions as a hospital attendant working in the fashion center, a recreation specialist (RS) in the ceramic shop and as a staff in the patient lounge. Wayne now works in the Center for Older Adult Services (COAS) on one of the eight wards housing an average of 30 consumers per ward.

Throughout both his career and his personal life, art serves as a mode of Wayne's self-expression. A self-proclaimed artist, he has often been asked by friends and colleagues to assist with their interior decorating and he has painted pictures, including a portrait of his mother. He was looking for a way to incorporate his love of art into his job at the hospital with COAS.

Wayne's responsibilities in COAS as an RS include providing group and one-to-one recreation programs for individuals 50 years old and above. He is creative in his methods to engage consumers who refuse group programs, often enabling an individual to eventually attend treatment classes.

He saw potential in Judith, even though she had previously had negative interactions with males. Wayne worked tirelessly to involve her in a group that he and another staff named Therapeutic Arts. "Judith was very distrusting due to her past abuse and did not want to be touched. It took many attempts to gain her trust so we could begin painting," states Wayne.

Wayne's earliest attempts to engage her were centered primarily toward gentle encouraging and empowering conversation during assigned program times, and attending Judith's treatment conferences. Judith's guardian reported that she had some college education with unconfirmed assumptions that some of her studies included artwork. Wayne asked frequent questions of Judith about her past interests and reviewed some of her personal photographs with her, in a reminiscence format where positive past experiences could be recalled.

This type of effort fosters the recapture of actual experiences which aide in developing treatment-based opportunities that the consumer is more apt to take part in. Judith's diagnosis includes paranoia which is exhibited through repetitive motions, negative statements of "... want to die ..." or agitation and pulling away from others, e.g. nursing staff who are helping Judith at meal times or assisting her with activities of daily living.

Judith's need for hands-on assistance is due to her physical disabilities of what appears to be rheumatoid arthritis. As a result, she requires assistance with bathing, dressing, eating, and therefore holding a paint brush or any other art medium that requires use of her hands. As the photos reflect, her hands are quite bent and knarled from this disease. Judith's physical diagnosis, coupled with her mental health diagnosis creates a challenge for any occupational or recreation therapist in selecting positive interventions for her.

Touch is a non-verbal form of communication and in mental health it is a critically cautious form of communication. Even a warm and caring form of touch may be invasive to one with long-standing mental health issues or to someone who may have been physically abused such as Judith. Different staff members had found that touching her without permission sometimes caused her to stand and pace a room or become agitated.

Wayne shared that he first needed "to gain verbal permission from Judith to touch her to get her to paint." Once that verbal permission was gained, Wayne supported Judith's elbow with his left hand and placed his right hand over hers. He has learned to respond to Judith's muscle movements in order to allow a greater autonomy in her own creativeness. If permission isn't provided by her, then Wayne will not have her paint that day. He isn't afraid to experiment with mediums, which has allowed him to move from felt pens, to water colors and sponges, and graduating to water color and pastels with Judith, thus broadening her creative experiences.

Wayne gave Judith the choice when deciding on color. Sometimes she only repeated the first color Wayne offered before the question of other color options was mentioned. As an example, if Wayne offered blue, purple or yellow, Judith might only repeat "blue, blue, blue" in the manner she would repeat words when agitated, in a conversation, or echoing others.

This is inconsistent, as there were times when she would say "blue and yellow," other color combinations, or firmly state one of the color options she is given by only stating "purple." Judith's paintings range in pastel blues, yellows and pinks, to oranges, reds, purples, greens and blacks. Her early paintings were quite abstract in string-like lines crossing over each other, or long broad sponge or brush lines. Many treatment staff, however, could start to see elements of animals, plants or trees in her drawings.

It was as thoughts of possibilities arose, that Wayne's ideas evolved in the use of therapeutic recreation's most critical elements ... prompts, ergo the importance of trust and touch. Clearly he was already using voice prompts. Now he positioned Judith in an upright position, using hand prompts by gently placing his right hand over Judith's right (dominant) hand while she moved across the canvas. He supported her elbow through the motions she is making with a brush.

Wayne can now gently ask her the colors she wants to work with, naming two or three at a time so as not to confuse her with too many choices. Brush in her hand, Wayne then places his hand over Judith's. To each motion and direction Judith makes with her hand Wayne follows, aiding in steadying her movements. He continues with each change of motion she makes ... repetitive, dabbing or stroking with the brush. Strokes are bolder and more defined during the past year.

It is evident Judith trusts Wayne's touch and his words of guidance with the awareness of her right to refuse. Wayne reports this level of trust to be resultant of "prais[ing] Judith's work many times daily and to get other staff and peers to praise her work." In addition, mental health technician (MHT) Kathy notes, "When you tell Judith to go find Wayne for art group, she'll say 'yes' and go find him."

At the conclusion of Therapeutic Arts sessions Wayne independently reviews Judith's pictures, adding trunks to trees, and further defining background components such as hills or mountains. Wayne also encourages Judith to sign her paintings upon completion. Usually her signature is done hand over hand.

The treatment team believes the real signature is the opening of Judith's heart to a calmer woman, who has gained an improved trust with the staff who works with her daily. Bruce, an MHT, feels "she seems to be more calm and at peace." Similarly, Valerie has "heard her speak words," Rather than responding negatively about "going to die, going to die," Valerie adds "she is sitting more instead of pacing."

Diane, a certified occupational therapy assistant has observed Judith to "join in exercise classes by ambulating closer to the group to hear the music, then standing when the group is asked to stand, or to do leg lifts when the group is asked to do so." Diane believes this success may be due to a "structured routine that occurs five days a week at the same time, and gives her a sense of security."

Wayne adds that it is important "to display her [Judith's] work where she could [can] see them being praised and discussed." Several of her pieces are matted and placed behind plexi-glass on the walls of her room. He believes that by having "her permission to sell her art work gives [Judith] both a monetary value, and offers self value."

This last practice is also offered to other patients in Therapeutic Arts with their work being matted, framed and displayed in the building where staff and visitors may view and purchase items.

Many considerations are necessary when providing inclusive opportunities--whether in a community environment or in an institutional setting. It is essential to know the interests and capabilities of the consumer. This is accomplished through interviews or assessments of the consumer and/or the family or guardian that also include observation as well. In a clinical setting, observations are not limited to the recreation therapist, for other team members' verbal input or chart notes may reflect an individual's recreation and leisure interests.

With inclusion, it is also paramount that each of the participants in a program receives equal time from the leader. Further, the consumer requires as much autonomy as possible. Such autonomy engenders self-confidence and greater self-worth. In Wayne and Judith's situation, Wayne followed Judith's hand movements while she was drawing or painting, rather than leading her across the page. Foremost in any creative activity, the leader, recreation therapist/specialist, parent or teacher should maintain the integrity of the consumer's work.

Essentially, once the individual stops working on his or her project, it is finished. Inclusion in creative arts means acceptance of what is at both the beginning and the end of projects--accepting the consumer's choices. Inclusion is particularly being a part of a group, rather than an observer of a group as a means of establishing new and improved relationships.

Although this is just one of many instances where therapeutic art classes are occurring across the country, it shows the importance of patience and trust. Because of Wayne's actions, more staff can interact with Judith without her becoming agitated, which in turn improves her overall quality of life ... not just her paintings.

Wayne's repetitively engaging Judith in Therapeutic Arts resulted in further rewards. One morning a few months after Judith began Therapeutic Arts, an MHT was briefly called away from feeding Judith. She returned to see her eating independently. Judith is now increasing the use of her "pincher grip," too. While the action of feeding herself has not been sustained, it is hopeful that Judith will gain more independence as she begins to trust others.

Article and photos by Esther Freeman, CTRS, CPRP