Effectiveness and Meaningfulness of Art Therapy as a tool for healthy aging: a systematic review protocol

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1 Effectiveness and Meaningfulness of Art Therapy as a tool for healthy aging: a systematic review protocol Dianne Gall 1 1. Masters of Clinical Science Candidate, Research Fellow, Joanna Briggs Institute Royal Adelaide Hospital, North Terrace, ADELAIDE SA 5000 Introduction I approach this research from a background of practising and exhibiting as a professional Contemporary Australian Artist with over 25 years of experience. Over this time, I have had many different points of view presented to me from a variety of people from different backgrounds, cultures and ages. One of the most common comments from people is, I was really good at art at school, I love to draw but I ve never taken it up, one day I hope to go to an Art Class. So it is with this thought in mind that I approached this work, looking into the available evidence of Art Therapy and its effects on the mind and soul. If expressing oneself in what I call the first language, meaning the first things we learn as human beings are in the visual language, our mothers face, colours, smells and sounds, we recognise our favourite toys from shape and colour. So, as this is the basis of human communication, it seems logical then, that this is a way of reaching into the mind, finding positive imagery and the sense of self at its very core. One of my most prominent memories is of an encounter at one of my art exhibition openings, I had produced some little paintings of a local icon, known locally as Balfours Frog Cakes. A woman approached me who would have been in her mid-eighties, and began to reminisce to me of what it was like in the late 1920 s when her mother took her and her brother once a month on a Saturday into town into the teahouse and bakery for a special treats. I could see this woman standing in front of me, turning into a little girl of five again, her eyes lit up and she was back there, she had such a peaceful happiness about her, and I felt so happy that I had bought joy to someone through my art. I know that many an individual and it is thus that I want to provide the evidence for the practice of Art Therapy to be more widely adopted so that more people could again find themselves have experienced this phenomenon. Background As a concept, Art Therapy has been around in an accepted capacity since the late 1930 s, involving work with mental health patients in America and the United Kingdom. Artist Mary Huntoon, was one of the first to be accepted for her practice and began art therapy sessions Page 305

2 with patients at the Menninger Clinic at Topeka in Kansas and called her work, Art Synthesis around In an increasing ageing population, together 2 with the positive effects of modern medicine on human longevity, it is conceivable that greater percentages of the world s population will be residing in aged care facilities without any particular disease other than the effects of the normal ageing process. As a possible delay mechanism for the onset of mental illness, depression, dementia and Alzheimer s disease, Art Therapy can mentally and socially stimulate residents 3. The elderly person gains a sense of improved wellbeing, greater confidence and in turn a physical improvement on health and quality of life. Art therapy can also provide the aged person with increased cognitive abilities, social skills, feelings of selfworth and a possible link with the past 3. Most children have a naïve talent for visual expression which is often lost as other verbal languages are learnt. Therefore, many adults feel they once had a talent in making art and would like to explore the possibility of learning to paint, draw, sculpt or perform other forms of visual expression. Self-expression provides a vehicle for the aged care patient to overcome a sense of apathy and hopelessness, rather than retreating inwards, the patient feels more encouraged to participate in the activities of living. Modern medical research has paved the way for populations to live longer, healthier lives. That is a wonderful thing in itself, however, what are people going to do with themselves as they age and can no longer be as physically active as they once were. What will occupy their daily routines as they grow old and their friends and family pass on? Perhaps the creative therapies can fill the void left by these life-changing issues? It has been suggested that creative modalities can improve problem solving abilities, self-esteem and general life satisfaction 4. Ravid-Horesh 5 asked the question, if art therapy enhances positive outcomes of the aged person s life review, allowing for self-acceptance, greater self-esteem and happy ageing. What cannot be expressed in words, cannot be articulated, perhaps are deep within a person s psyche can often be bought out with other forms of communication. The other issues with people living longer is the ability to support themselves financially, many will not have the funds to live as they once did, lowering their self esteem and the feeling of their place in the world. Mental Health is becoming more and more of a greater concern in the general ageing population and even the broader realisation that people are lowering their sense of one s humanity and of one s self, this may be loss through a loss of cognitive abilities from idleness and inactivity 6. There are thankfully an equally growing number of people, together with researchers interested in the aged to help with diverse and tailored approaches to therapy, providing important psychological support 7. This is a global issue, one of the human condition, so regardless of time, cultural background or differences, this review will wherever possible not restrict the search for information to language or region, date published or other boundary. Keywords Art Therapy; Aged Care;self esteem Page 306

3 Aims and Objectives The aim of this review is to determine from the available evidence the impact of the Art Therapy on physical and mental health outcomes of elderly people. Review Question/s What is the impact of Art Therapy participation on the individuals wellness and emotional needs? What is the experience and meaningfulness of the aged person and their participation either in group Art Therapy situations or in one on one situations? Inclusion Criteria Types of Participants Participants will be people aged 65 years or over with no evidence of dementia or other cognitive disabilities. They will either be in nursing home care, community care, day care, residential, low-care, supported living or the medical home. They may have no family or other emotional support and be suffering from increasing introspection. Types of Interventions The intervention of interest will be Art Therapy with the focus on the visual arts. All available techniques will be considered, including for example, art therapy sessions using a variety of tools, drawing, painting, computer manipulated imagery, photography and any other mode of visual expression. Art Therapy techniques examined will be those used in the group situation or with the individual aged person. Examined will also be who runs the art therapy program, is it an artist, professional art therapist, general therapist, is the therapy self-directed, how long will the sessions run for, what time period are sessions conducted over? Are these programs six months, twelve months etc how do the frail aged cope with half hour sessions or one hour sessions. Types of Studies Any quantitative and qualitative study designs will be considered for this review. Each study will be classified according to the JBI levels of evidence (Appendix I) and preference will be given to those higher in the hierarchy of evidence such as randomised controlled trials (RCTs). Studies that are long term follow up and observational cohorts will be included as will be Guidelines from professional associations. Types of Outcome Measures Quantitative outcomes will look at the measureable psychological and psychosocial outcomes and behavioural characteristics resulting from Art Therapy. Indicators will include measures of cognitive function, Quality of Life (QOL) scales, depression scales, frequency of participation in activities and art therapy assessment scales. What are the participants communicative skills, social interaction, and quality of social interaction, behavioural problems e.g. Page 307

4 stereotypic behaviour, and attention and concentration skills? Do they have an improved cognitive abilities, do they cope with stress and adverse events more easily. Qualitative outcomes will be subjective from the patient s point of view, how they react to what feelings and emotions they are experiencing from the therapy sessions. Does the reminiscing help or make them feel sad for what they ve lost, or happy for what they ve had in their past? Reason for exclusion Studies will be excluded if they are about the performing arts - music, dance and drama. Participants will be excluded if they are under 65 years of age, and if they have been diagnosed with dementia, Alzheimer s or other cognitive disorders. Editorials and opinion articles will be excluded. Search Strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: MEDLINE CINAHL (including Pre-CINAHL) EMBASE Cochrane Central Register of Controlled Trials (CENTRAL) JBI CSA Sociological abstracts Clinical Trials PsycINFO Current Contents AgeLine Informit ISI Web of Knowledge Health Source: Nursing/Academic Edition Scopus Page 308

5 WorldCat The search for unpublished studies will include: MEDNAR Proquest Dissertations and Theses, Index to Theses, The Networked Digital Library of Theses and Dissertations (NDLTD). Experts in the field will be consulted such as those registered with the Australian and New Zealand Art Therapy Associations (ANZATA), American Art Therapy Association (AATA, British Association of Art Therapy, as well as any other countries with credible associations, together with University lecturers, and Art Therapists. Additional searches will be conducted in specialist journals such as The Arts in Psychotherapy to eliminate any excluded citations in the databases. Initial keywords to be used are: Concept 1: Art Therapy, art psychotherapy, art therapists, therapeutic arts, artistic expression, visual expression Concept 2: Aged Care, aged, gerontology, elderly, healthy ageing, older adults Concept 3: self esteem, social interaction, well-being, quality of life, self concept, memory, hope, behavioural research Methodological Quality Critical Appraisal Quantitative and qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the appropriate standardised critical appraisal instruments from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI-SUMARI, Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data Extraction Quantitative and qualitative data will be extracted from papers included in the review using the appropriate standardised data extraction tool from JBI-SUMARI(Appendix III). Page 309

6 Data Synthesis For quantitative data all results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Qualitative research findings will be pooled were possible, using the JBI Qualitative Assessment and Review Instrument (JBI-QARI). This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings according to their quality, and categorising these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings. Potential Conflicts of Interest None Acknowledgements Zoe Jordan BA, MA Heather Gibb RN BA (Hons), PhD Page 310

7 References 1. Malchiodi, Cathy (2006) Art Therapy Sourcebook. 2 nd ed McGraw-Hill 2. Smith, K. (2004) Art Therapy with Older People. In: Evans, L., Garner, J. (eds.) Talking Over the Years. A Handbook of Dynamic Psychotherapy with Older Adults. Brunner- Routledge. Hove. 3. Basting, A. (2006). "Arts in Dementia Care: This is not the end...it's the end of this chapter." Generations 30(1): Flood, Meredith, Phillips, Kenneth D. (2007) Creativity in Older Adults: A Plethora of Possibilities. Issues in Mental Health Nursing 28:4, Ravid-Horesh, R.H. (2004) A temporary guest: The use of art therapy in life review with an elderly woman. The Arts in Psychotherapy 31(5): Gfeller, Kate. (1995) The status of music therapy research, in Music Therapy research: Quantitative and Qualitative Perspectives. 7. Dennes, Marilyn. Half Way Between Everything: Case Material for Art Therapy in Aged Care 2005 Bonza Street Press. 8. Gilroy, Andrea. Art Therapy, Research and Evidence-based Practice SAGE Publications 9. Kates, Naomi. (2007) Individual art therapy for elderly clients. Canadian Art Therapy Association Journal 21(1): Sezaki, Shinya, Bloomgarden Joan in Magniant, Rebecca C. Art therapy with older adults:a Sourcebook Charles C. Thomas 7. Block, Susan D. (2001) Psychological considerations, growth and transcendence at the end of life: The art of the possible. JAMA 285(22), Wikstrom, Britt-Maj (2003) Health Professionals' experience of paintings as a conversation instrument: A communication strategy at a nursing home in Sweden. 16 (3), Heenan, Deirdre. (2006) Art as therapy: an effective way of promoting positive mental health? Disability & Society 21(2), Kapitan, Lynn ed. (2009) Introduction to the special issue on Art Therapy's response to techno-digital culture. Art Therapy: Journal of the American Art Therapy Association 26(2), Betts,, Donna J. Betts (2006) Art therapy assessments and rating instruments: Do they measure up? The Arts in psychotherapy 33, Dychtwald, Ken. (1981) Humanistic services for the elderly. Journal of Humanistic Psychology 21, Schleppenback, John R. (2003) Living Longer, but for what? Legal neglect of cognitive treatments. Page 311

8 17. Eichelbaum, Elizabeth (2000) The use of art therapy to deal with low self-esteem among the aged: Selected case studies. The University of Tennessee, Knoxville Bell & Howell Information Learning Company Publ no AAT Callanan, Bernadette. (1994) Art therapy with the frail elderly. Journal of Long Term Home Health Care: The Pride Institute Journal, 13 (2), Noice, Helga; Noice, Tony. (2009) Arts intervention for older adults living in subsidized retirement homes. Aging, Neuropsychology, and Cognition. 16 (1) Smith, Marianne;Vorwald, Jo Benson;Reid, Audrey. (2007) H.E.A.L. model of adult day healthcare. 8(1), Wikstrom, Britt-Maj (2000) Visual art dialogues with elderly persons: effects on perceived life situation. Journal of Nursing Management 8, Jongenelis, K (2004) Prevalence and risk indicators of depression in elderly nursing home patients: The AGED study Journal of Affective Disorders 83 (2-3) Waller, Diane (1981) Becoming a profession Art Therapy in Great Britain Routledge Page 312

9 Appendix I: JBI Levels of Evidence Page 313

10 Appendix II: JBI Critical Appraisal Forms Experimental Appraisal Form A. Experimental Studies 1. Was the assignment to treatment groups truly random? Yes No Unclear 2. Were the participants blinded to treatment allocation? Yes No Unclear 3. Was the allocation to treatment groups concealed from the allocator? Yes No Unclear 4. Were the outcomes of people who withdrew described and included in the analysis? Yes No Unclear 5. Were those assessing outcomes blind to the treatment allocation? Yes No Unclear 6. Were the control and treatment groups comparable at entry? Yes No Unclear 7. Were groups treated identically other than for the named interventions? Yes No Unclear 8. Were outcomes measured in the same way for all groups? Yes No Unclear Page 314

11 9. Were outcome measured in a reliable way? Yes No Unclear 10. Was appropriate statistical analysis used? Yes No Unclear Include Yes Reason: No Page 315

12 JBI Critical Appraisal Checklist for Comparable Cohort/ Case Control Reviewer Date Author Year Record Number Yes No Unclear 1. Is sample representative of patients in the population as a whole? 2. Are the patients at a similar point in the course of their condition/illness? 3. Has bias been minimised in relation to selection of cases and of controls? 4. Are confounding factors identified and strategies to deal with them stated? 5. Are outcomes assessed using objective criteria? 6. Was follow up carried out over a sufficient time period? Page 316

13 7. Were the outcomes of people who withdrew described and included in the analysis? 8. Were outcomes measured in a reliable way? 9. Was appropriate statistical analysis used? Overall appraisal: Include Exclude Seek further info Comments (Including reason for exclusion) Page 317

14 JBI Critical Appraisal Checklist for Descriptive/ Case Series Reviewer Date Author Year Record Number Yes No Unclear 1. Was study based on a random or pseudo- random sample? 2. Were the criteria for inclusion in the sample clearly defined? 3. Were confounding factors identified and strategies to deal with them stated? 4. Were outcomes assessed using objective criteria? 5. If comparisons are being made, was there sufficient descriptions of the groups? 6. Was follow up carried out over a sufficient time period? Page 318

15 7. Were the outcomes of people who withdrew described and included in the analysis? 8. Were outcomes measured in a reliable way? 9. Was appropriate statistical analysis used? Overall appraisal: Include Exclude Seek further info Comments (Including reason for exclusion) Page 319

16 QARI Critical Appraisal Form Criteria Yes No Unclear 1) There is congruity between the stated philosophical perspective and the research methodology. 2) There is congruity between the research methodology and the research question or objectives. 3) There is congruity between the research methodology and the methods used to collect data. 4) There is congruity between the research methodology and the representation and analysis of data. 5) There is congruity between the research methodology and the interpretation of results. 6) There is a statement locating the researcher culturally or theoretically. 7) The influence of the researcher on the research, and viceversa, is addressed. 8) Participants, and their voices, are adequately represented. 9) The research is ethical according to current criteria or, for recent studies, there is evidence of ethical approval by an appropriate body. 10) Conclusions drawn in the research report do appear to flow from the analysis, or interpretation, of the data. TOTAL Reviewers Comments: Page 320

17 Appendix III: Data Extraction Form JBI Quantitative Data Extraction Form Author Record number Journal Year Reviewer Method Setting Participants Number of participants Group A Group B Interventions Intervention A Intervention B Page 321

18 Outcome measures Definition Other outcome measures Outcome description Scale/measure Results Dichotomous Data Outcome Treatment group Number/total number Control group Number/total number Continuous data Outcome Treatment group Mean & SD (number) Control group Mean & SD (number) Author s conclusions Page 322

19 Comments Page 323

20 Qualitative Data Extraction Instrument Author: Record Number: Journal: Year: Reviewer: Method Methodology Data Analysis Setting & Context Geographical Context Cultural Context Page 324

21 Participants: Number: Description: Interventions Page 325

22 Findings Narrative Description Qual of Evid. Rating 1,2,3 Page 326

23 Authors conclusion Reviewers conclusion Page 327