Art Therapy

Journal of the American Art Therapy Association

ISSN: 0742-1656 (Print) 2159-9394 (Online) Journal homepage: https://www.tandfonline.com/loi/uart20

Art Therapy in Dementia Care: Toward

Neurologically Informed, Evidence-Based Practice

Elena Guseva

To cite this article: Elena Guseva (2019): Art Therapy in Dementia Care: Toward Neurologically
Informed, Evidence-Based Practice, Art Therapy, DOI: 10.1080/07421656.2019.1564613

To link to this article: https://doi.org/10.1080/07421656.2019.1564613

Published online: 19 Feb 2019.

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 Art Therapy: Journal of the American Art Therapy Association, 0(0) pp. 1–4, # AATA, Inc. 2019

Art Therapy in Dementia Care: Toward Neurologically

Informed, Evidence-Based Practice

Elena Guseva

Abstract and cerebrovascular events (Ballard & Howard, 2006).

Patients taking second-generation antipsychotics (i.e.,
Art therapy appears to be well positioned to assist people developed after the introduction of antipsychotic medica-
with dementia in improving their psychological well-being tions in the mid-20th century) demonstrate 1.5 to 1.7
and quality of life because of its ability to address times the risk of mortality and cerebrovascular events
neuropsychiatric symptoms and to circumvent declining (Steinberg & Lyketsos, 2012). In its criteria for safe
cognitive and verbal capacities. However, despite increased medication, the American Geriatrics Society recommends
interest in nonpharmacological approaches to the care of that antipsychotics not be used to treat NPS “unless
people with Alzheimer’s disease and dementia, art therapy nonpharmacological options have failed” and the patient
research in this area is still greatly needed. Neurologically is a “threat to self or others” (cited in Steinberg &
informed art therapy offers the potential to overcome Lyketsos, 2012, p. 900).
historical limitations in the direction of evidence- With the prospect of finding a cure for dementia
based practice. still uncertain and the fact that people may live with the
disease for many years, the diagnosis can be akin to a
An estimated 5.7 million people of all ages in the long-term sentence (Zeisel, 2009). Thus, care providers
United States are living with Alzheimer’s disease (AD), increasingly support the view that pharmacological treat-
accounting for a total national cost of $277 billion for ments should be used only as a second line of approach
their care (Alzheimer’s Association, 2018). By 2050, this and be replaced by nonpharmacological options when-
number is predicted to reach 13.8 million people, ever possible (Douglas, James, & Ballard, 2004). Given
increasing the total costs to more than $1.1 trillion. this argument, art therapy appears well positioned to
Over the course of the disease, 80% of people with assist people with dementia in the goal of improving
dementia experience neuropsychiatric symptoms (NPS), their psychological well-being and quality of life, particu-
larly as a means of communication that can circumvent
which raise their risk for increased caregiver burden,
declining cognitive and verbal capacities. However,
poorer prognosis, earlier institutionalization, and higher
strong evidence of art therapy’s effectiveness for the
costs of care (Cerejeira, Lagarto, & Mukaetova-Ladinska,
diverse dementia population has not yet been established,
2012; Selbæk, Engedal, & Bergh, 2013). NPS are
despite interest in nonpharmacological approaches to
among the known factors that accelerate progression of
treating the growing prevalence of dementia.
the disease (Lyketsos et al., 2006; Peters et al., 2015) Over the last two decades, art therapy increasingly
and create problems not only for the person with has been used for support and therapeutic care in various
dementia and his or her caregivers, but also in relation health-care settings (Ehresman, 2014; Stewart, 2004).
to the clinical management of the disease (Ballard, Proponents have argued that art therapy can enhance the
Corbett, Chitramohan, & Aarsland, 2009). lives of people with dementia by improving sustained
First-line management of NPS associated with attention, self-esteem, personal satisfaction and morale,
dementia includes the prescription of neuroleptics, which calm, and sociability (Gross, Danilova, Vandehey, &
is a pharmacological intervention often used as a Diekhoff, 2015). Art therapists claim that the process of
“chemical restraint” to sedate and subdue patients creating art offers unique opportunities for sensory
(Hughes & Lapane, 2011). Patients with AD who are stimulation, social interaction, and creative expression
treated with antipsychotics have been found to experi- (Stewart, 2004). Art making has been described as a
ence increased adverse effects that include Parkinsonism, vehicle for nonverbal communication that gives people
edema, chest infections, accelerated cognitive decline, with dementia a means to be understood and to have
their emotions validated by others (Camartin, 2012).
Elena Guseva is an art therapist and research assistant at Fortunately, it appears that the potential benefits of
Donald Berman Maimonides Geriatric Centre, Centre for
Research in Aging, in Montreal, Quebec and in doctoral art therapy are being recognized by many medical profes-
studies at McGill University. Correspondence concerning sionals who train for and work with the dementia popu-
this viewpoint should be addressed to the author at lation, such as neurologists, geriatricians, and family
elena.guseva@mail.mcgill.ca physicians. Educational, community building, and
1
2 ART THERAPY IN DEMENTIA CARE

health-care programs commonly provide opportunities self-esteem in a small sample of participants who were
for art making for people with dementia in long-term randomly assigned to either 4 weeks of art therapy or a
and health-care institutions. In the public policy domain, wait list control group.
Americans for the Arts, the Arts and Health Alliance, The need for rigorous study designs such as those
and the Society for the Arts in Dementia Care are a few just cited is recognized as vital in determining the effect-
of the nonprofit organizations working to increase public iveness of art therapy interventions—an observation that
awareness of the value of art in healing. Medical schools has been noted persistently in the literature (Chancellor
are introducing arts in medicine programs all over the et al., 2014; Huet, Springham, & Evans, 2014; Kapitan,
world. In geriatric neurology a chapter on creative arts 2014; Potts et al., 2014). Kapitan (2010) stated that
therapies has been included in a required training text- randomized controlled trials of sufficient scope are neces-
book (Potts, Miller, Prickett, Cevasco, & Duncan, sary for the development of an evidence-based model of
2014). Geriatric neurologists learn that art therapy is art therapy. Although evidence-based practice is at the
useful in helping to ease the effects of disability and core of the discipline, epistemological debates persist
degenerative disease and can play an important role in about evidence, art, and evidence that is discoverable in
person-centered dementia care. One implication for pro- art. More than 20 years ago, Tibbetts (1995) argued that
viders of geriatric health care is that the positive effects an overly narrow focus on either clinical or artistic
of art therapy (e.g., enhanced communication and social- claims, as well as a lack of support for art therapists who
ization, facilitated decision making, improved mood and wanted to examine the efficacy of art in the clinical set-
emotional expression, and promotion of well-being) can ting, would be highly limiting and could consign the art
lead to substantial cost savings (Potts et al., 2014). therapist to second-class status in mental health care.
Despite new or growing interest in the use of art This argument might still hold today when we examine
therapy as a nonpharmacological option for treating the current state of art therapy research on dementia
dementia, current research evidence limits the extent to interventions.
which science can inform practice. Based on systematic To date, within the field of creative art therapies,
reviews of the literature (Beard, 2012; Chancellor, music therapy seems to offer the most compelling exam-
Duncan, & Chatterjee, 2014; Cowl & Gaugler, 2014; ples of research and evidence-based practice with demen-
Maujean, Pepping, & Kendall, 2014), only a few pub- tia and the Alzheimer’s population. To validate their
lished case studies and small clinical trials have examined work with dementia patients, music therapists have
the effects of art therapy on the dementia population. embraced neurobiological research concerning human
For example, Mimica and Kalinic (2011) concluded that responses to music (de l’Etoile, & Lagasse, 2013). In the
art therapy for a patient with moderate AD was benefi- last 10 years music neuroscience has established itself as a
cial for reducing stress-related behaviors. Art therapy also discrete field of inquiry, with musically supported cogni-
was found to improve NPS in an individual with severe tive rehabilitation being of particular interest to dementia
dementia (Peisah, Lawrence, & Reutens, 2011). Most research (O’Kelly, 2016).
recently, Tucknott-Cohern and Ehresman (2016) Insights into the neurobiological mechanisms
described the healing benefits of 17 weeks of art therapy involved in emotional processing, and of neuropsychi-
in a clinical case study of an individual with late- atric symptoms in particular, have captured the research
stage dementia. interests of art therapists as well. Among those who are
Among studies of arts-based programs designed for advancing the field in this area are Hass-Cohen, Stewart,
people with dementia, Kinney and Rentz (2005) exam- King, Belkofer, Lusebrink, and Findlay, all of whom
ined the Alzheimer’s Association program called have written extensively on art therapy practice that inte-
Memories in MakingV R . They reported improved psycho- grates findings from neurobiology and relational neuro-
logical well-being of participants, including significantly science. Emerging research that consolidates the
higher levels of pleasure, interest, sustained attention, knowledge accumulated by art therapy and neurobiology
and self-esteem compared to other structured activities at (Belkofer, Van Hecke, & Konopka, 2014; Elkis-
an adult day center. Rusted, Sheppard, and Waller Abuhoff, Goldblatt, Gaydos, & Convery, 2013; Kruk,
(2006) compared effects of 40 weekly sessions of art Aravich, Deaver, & DeBeus, 2014) suggests that inter-
therapy with weekly recreation activity and found that disciplinary endeavors are helpful in the field without
art therapy program participants experienced gains in changing what Schaverien (1995) called the “esoteric
sociability, physical involvement, calmness, and men- essence” of art therapy (p. 25).
tal acuity. In an exploration of the intimate relationship
In one of the few studies with an active control con- between art and neuropsychoanalysis, Oppenheim
dition, people with AD who participated in an art ther- (2005) quoted from Freud’s 1910 paper on Leonardo de
apy intervention were found to be more engaged and Vinci, writing that “instincts and their transformations
less apathetic to their surroundings than those in the are at the limit of what is discernible by psycho-analy-
control group (Hattori, Hattori, Hokao, Mizushima, & sis,” at which point the discipline “gives place to bio-
Mase, 2011). An efficacy study by Kim (2013) found a logical research” (cited in Oppenheim, 2005, p. 1).
reduction in negative mood and anxiety and increased There is no doubt that scientific insights regarding the
 GUSEVA 3

brain, art, and dementia can provide art therapists with of the American Art Therapy Association, 31(2), 61–68. doi:
a deeper understanding of the therapeutic effects of art 10.1080/07421656.2014.903821
on health. Such knowledge can provide the field with a
scientific base that hopefully encourages rigorous research Camartin, K. (2012). The use of art therapy with persons with
dementia. Canadian Art Therapy Association Journal, 25(2),
and evidence-based practice. In addition, the language of
7–15. doi:10.1080/08322473.2012.11415566
science can help facilitate a dialogue with other profes-
sional fields for the purpose of knowledge transfer, which Cerejeira, J., Lagarto, L., & Mukaetova-Ladinska, E. B.
is crucial in dementia care. Stewart (2004) wrote that (2012). Behavioral and psychological symptoms of
the purposeful blending of art therapy and neuroscience dementia. Frontiers in Neurology, 3, 73. doi:10.3389/
could be the key to understanding the inner workings fneur.2012.00073
of dementia.
Effective and meaningful nonpharmacological inter- Chancellor, B., Duncan, A., & Chatterjee, A. (2014). Art
ventions are a major development in improving the well- therapy for Alzheimer's disease and other dementias. Journal
being and quality of life of people affected by dementia. of Alzheimer's Disease, 39(1), 1–11. doi:10.3233/JAD-131295
Despite its potential to deliver such intervention, art Cowl, A. L., & Gaugler, J. E. (2014). Efficacy of creative arts
therapy has achieved only limited acceptance thus far, therapy in treatment of Alzheimer’s disease and dementia: A
due to many factors, including an underdeveloped systematic literature review. Activities, Adaptation, and Aging,
research culture that still exists today. Neurologically 38(4), 281–330. doi:10.1080/01924788.2014.966547
informed art therapy could be a good first step in the
direction of evidence-based practice. Bridging the gap de l’Etoile, S., & Lagasse, A. B. (2013). Music therapy and
between art therapy and neuroscience potentially can neuroscience from parallel histories to converging pathways.
resolve questions regarding the appropriate role of scien- Music Therapy Perspectives, 31(1), 6–14. doi:10.1093/mtp/
tific evidence in art practice as well as engagement in art 31.1.6
practice for scientific research. Ultimately, such positive
Douglas, S., James, I., & Ballard, C. (2004). Non-pharmacological
changes can potentially propel art therapy from the out- interventions in dementia. Advances in Psychiatric Treatment,
skirts of the mental health field to the front line of care, 10(3), 171–177. doi:10.1192/apt.10.3.171
where it rightfully belongs and is very much needed in
dementia care. Ehresman, C. (2014). From rendering to remembering: Art
therapy for people with Alzheimer's disease. International
Journal of Art Therapy, 19(1), 43–51. doi:10.1080/
ORCID 17454832.2013.819023

Elena Guseva http://orcid.org/0000-0002-4903-1508 Elkis-Abuhoff, D. L., Goldblatt, R. B., Gaydos, M., &
Convery, C. (2013). A pilot study to determine the
psychological effects of manipulation of therapeutic art
forms among patients with Parkinson's disease. International
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