Art interventions as cognitive rehabilitation therapy for dementia patients

Art Interventions for Dementia Patients

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Creative Aging

Art Intervention Processes for Dementia Patients

Art Interventions for Dementia Patients

Vignette

There are few phrases that I dislike more than 'It is what it is'. I believe people that make use of this phrase are stating that whatever the concern, it is not worthy of thought; it is their under-mannered way of naturalizing the consequences of misguided choices. However, the fact that every choice, good or bad, has consequences is a truth that cannot be ignored. I know the frustration and anguish of rectifying the consequences of the horrific choices of others. I know because on October 24, 1998, I survived two violent crimes. In 2002, I was formally diagnosed with Post Traumatic Stress Disorder with Suicidal Ideation and placed on Social Security Disability Income. Nine months after my diagnosis, I again survived two violent crimes, and three additional traumatic life-experiences. Every memory that I had, good and bad, was muted into abstraction and my ability to trust anyone was shattered.

Indeed, I've lived in a fear-based reality that included hyper-vigilance, sleep deprivation, flashbacks, panic attacks, and nightmares. My ability to communicate with others was crushed, as was my confidence and self-esteem. I believed God was wishful thinking, suicide was my best option, and that I wanted to die. With more hard work than I sometimes care to remember, I recovered. But to do so, I was required to take responsibility for the actions of those that hurt me. I chose to forgo traditional therapy and instead opted for the holistic path offered through art interventions, mindfulness, and meditation.

As part of my recovery I created original artwork in every form of media that was available to me and I readjusted my fear-based reality by embracing my ability to make positive choices. However, the term 'choice' is a luxury that is absent in the daily lives of dementia patients. I know how strange and frightening their world has become, and I know the despair they feel but can't voice. I am forever grateful for the many people who chose to help me help myself and fortunately have the opportunity to offer the same for others. Without hesitation I have chosen to help dementia patients survive the symptoms of trauma by facilitating communication through the art therapy processes. I am confident that employing art interventions, as a vehicle for therapy and cognitive rehabilitation, holds positive limitless outcomes for dementia patients and their caregivers.

Topic and Purpose

Most types of dementia are neurodegenerative conditions for which there are no treatments capable of halting, let alone reversing, disease progression (Simpson, 2014; Chancellor, Duncan, & Chatterjee, 2014). According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) the defining features of dementia are at least two distinct cognitive deficits affecting memory and at least one of the following impairments: (1) language (aphasia), (2) motor movement (apraxia), (3) object and facial recognition (agnosia), (4) and planning, organizing, prioritizing, and abstract reasoning (executive functions) (Christensen & White, 2006). The difference between mere forgetfulness and clinical dementia is that the latter will interfere with the individual's ability to live an independent life. DSM-V, the most recent version, divides dementia and other neurodegenerative disorders into two main classifications: mild and major neurocognitive disorders (NCDs) (Simpson, 2014). All types of dementia are included in the major NCD classification.

A definitive cause of dementia remains unknown, but defects in protein folding, which contribute to the formation of neurotoxic ?-amyloid plaques, has become one of the primary theories used to explain the loss of brain neurons (Riverol & Lopez, 2011). Other types of dementia include vascular, Lewy bodies, and frontotemporal dementias, in that order, from common to rare (Christensen & White, 2006).

In addition to the sometimes severe symptoms, the stigma associated with being diagnosed with dementia can have profound consequences (Milne, 2010). The patient not only has to cope with cognitive decline and memory loss, but also with being defined by the 'dementia' label. In addition to the lower quality of life (QOL), increased vulnerability, reduced independence, loss of social roles and identity, lower self-esteem, and lost social value, patients diagnosed with dementia tend to experience social exclusion and isolation, not only in the communities where they reside, but also within the healthcare system. Milne (2010) described the 'double-whammy' that most dementia patients' experience, which involves discrimination due to advanced age and a mental illness diagnosis. The 'dementia label has also been observed to result in what researcher call 'excess disability,' which implies that residual cognitive and psychological functional capacity are ignored and the activities available to dementia patients, whether at home or in a formal care setting, are too simplistic to be engaging (MacPherson, Bird, Anderson, Davis, & Blair, 2009). High quality dementia care should therefore strive to preserve cognitive abilities, lower the frequency and severity of adverse events, improve health, eliminate threats to safety, increase the health and well-being of the family caregiver, and improve the social environment inhabited by the patient (Odenheimer et al., 2013).

In the absence of effective medical interventions capable of slowing, halting, or improving the symptoms of dementia, there is a great need for non-medical interventions that can make a significant difference in the lives of patients and the people who care for them. One intervention gaining wide acceptance is patient engagement in creative activities, which has generated countless reports of positive outcomes for both patients and caregivers (Chancellor, Duncan, & Chatterjee, 2014; Kinney & Rentz, 2005; Rusted, Sheppard, & Waller, 2006; Stallings, 2010; Hattori, Hattori, Hokao, Mizushima, & Mase, 2011; Ferrero-Arias et al., 2011; Peisah, Lawrence, & Reutens, 2011; Mimica & Kalinkic, 2011). For example, Ruth is an art therapist who enjoys connecting with the intact parts of a patient's mind and watching them blossom (Alzheimer's Association, 2014a). When her own mother was diagnosed with Alzheimer's disease (AD) she was struck by how uninhibited and uncritical her mother had become towards her own drawings, a stark contrast to a pre-AD habit of unforgiving self-criticism. Observations like these are becoming more common and art activities are increasingly recognized as effective interventions for moderating the symptoms of dementia (Alzheimer's Association, n.d.). There have also been reports of accomplished artists producing remarkable works for years after receiving an AD diagnosis and using art to enhance remembrances of the past (Chancellor, Duncan, & Chatterjee, 2014).

The findings of a limited number of quantitative studies generally support the use of an art intervention for improving patient QOL, but little is known about the subjective experience of the patient, caregivers, and art therapists, which Ullman (2005) believed to be necessary for improving the provision of care. The purpose of this study is to provide insight into stakeholder experience during the provision of art therapy to patients suffering from mild to moderate dementia.

Significance

In 2013 an estimated 5.2 million Americans suffered from Alzheimer's disease (AD), which represented between 60 and 80% of all diagnosed cases of dementia (Alzheimer's Association, 2013). Close to 5 million were over the age of 65, a fact that highlights age as a major dementia risk factor. Accordingly, the prevalence of this disease increases to 44% for individuals' who surpass 75-years of age. Most of the care provided to dementia patients comes from informal caregivers, such as family members and friends, who in 2013 contributed nearly 17.7 billion hours of unpaid care with an estimated value of $220.2 billion dollars (Alzheimer's Association, 2014b). This amount is approximately equal to the total amount spent on direct medical care annually for dementia ($214 billion). Unfortunately, the stress associated with caring for loved ones with dementia can be substantial, resulting in an additional $9.3 billion in direct medical care expenses annually. In light of the lack of effective medical treatments or promising cures, and the growing burden of dementia care on society and families, any intervention that can improve patient QOL would represent an important contribution. Currently, art therapy represents one of the more promising interventions currently available (Chancellor, Duncan, & Chatterjee, 2014) and therefore deserves the attention of researchers.

In the State of Utah, an estimated 32,000 individuals suffered from AD in 2010 (Alzheimer's Association, 2013). This is a relatively small number compared the rest of the country, but current projections suggest that the number of Utah residents suffering from dementia will more than double by 2025 (127%). A quick word search for dementia on the Utah Museum of Fine Arts website retrieved no results. A similar search on Google created the impression that art and creative activities have not found their way into Utah dementia care, although the Utah chapter of the Alzheimer's Association is aware of the potential health benefits associated with art exposure (Jarvik, 2006). One sign that progress is being made however, comes from an initiative to implement the Music & Memory Initiative into Utah residential treatment facilities caring for dementia patients (Sneed, 2014), but much more needs to be done to optimize art exposure and its benefits for this patient population .

Framework and General Research Questions

The Kolb Experiential Learning Theory will represent the framework used for understanding the meaning dementia patients may be assigning to the art process. According to Kolb's (1984) theory, "Patients able to assign meaning would be transitioning through four sequential steps in learning: (1) concrete experience, (2) reflective observation, (3) abstract conceptualization, and (4) active experimentation"

(p. 21). Should a patient spend more time in one of these steps compared to the others, it may reflect a learning style preference (Turesky, 2005). The purpose of developing a theoretical framework for understanding the art process is to craft individualized art therapy approaches that are informed by learning style preferences. Communication and personal fulfillment, in particular, directly links the conceptual paradigms of Bruner's (2004) with Kolb's (1984) theories, because they both assume construction of a narrative in the mind of the patient. If communication and fulfillment become evident, this would suggest that the ability to assign meaning to events remains intact in these patients.

Given the language difficulties often experienced by dementia patients, kinesthetic and embodiment learning adds depth to the intellectual framework; therefore, these conceptual paradigms, which are associated with Bruner's (2004) and Kolb's (1984) learning theories, will be employed in this study's methodology. Kinesthetic learning depends on the physical experience of the learning process, so the senses, motor movement, and real-life application will be important dimensions for understanding the art process (Dunn, 2009). In a similar fashion, embodied learning depends on the physical experience, in addition to the cognitive, emotional, and social experience (Kerka, 2002). Mottram (2003) acknowledged the value of art activities as diversionary and calming, yet believed the term 'art therapy' has more to do with how dementia patients communicate with the world. Chancellor and colleagues (2014) conceded that the process of art therapy focuses on the remaining cognitive and psychological abilities of the patient by encouraging utilization; therefore, art therapy is patient-centered. Consequently, the terms 'art therapy' and 'art process', for the purposes of this study, will be aligned with the perspectives of Chancellor et al. (2014) and Mottram (2003).

The main research questions addressed by the proposed study are the following: (1) what are the experiences of dementia patients exposed to the art process and (2) what are the experiences of the art therapist during the provision of art therapy to dementia patients? Chancellor et al. 2014 offers a theoretical framework for providing art therapy to dementia patients, which are (1) preserved abilities, (2) vehicle for emotional expression, and (3) a process capable of creating a state of flow and thus a sense of well-being. This framework will be tested during the proposed study by looking for these themes in the data during reflexive activities.

Limitations

Although numerous theories of learning were discussed above, the proposed study, due to its qualitative nature, cannot provide support for or undermine these theories, since qualitative studies tend to be theory-generating, rather than theory confirming. Nothing will be measured or quantified, such as patient and caregiver QOL; therefore, any claims of efficacy will be based solely on subjective, rather than objective, data. In addition, the very small sample size will preclude making a claim of generalizability to dementia patients in general, as well as to settings other than the one planned for this study. Any claims of credibility, as Golafshani (2003) notes, will depend on researcher skill and effort. The variables that may limit credibility include my lack of expertise in dementia care and conducting qualitative research. This shortcoming will be addressed to some extent by establishing rapport with clinicians involved in dementia care and by examining the research literature.

Researchers Statement

I am a 55-year-young nontraditional graduate student in the Master in Education program at Westminster College and pursuing certification as an Adult Arts Educator. I am an academically trained visual artist with expertise in ceramics, sculpture, drawing, 2- and 3-dimensional multimedia, non-digital photography, and to a limited extent, graphic design. My academic preparation includes certification for primary and secondary arts education in the State of Utah. Professionally, I am engaged as a teaching artist in the field of Creative Aging and facilitate the cognitive rehabilitation of individuals suffering from dementia. Accordingly, I am both academically and professional prepared to pursue this research project. Comment by Robin: Got rid of chapter summaries, but they can easily be revised and included if you wish. The rubric did not call for a summary, except for the Data Analysis Chapter.

Chapter II: Review of the Literature

Chapter Introduction

As noted in the introductory chapter, this study is framed by the Kolb's (1984) Experiential Learning Theory and the conceptual paradigms associated with Bruner's (2004) Constructivist Theory. Accordingly, the guiding research question for this study is "what do dementia patients experience when exposed to the art therapy process?" To develop timely and informed answers to this research question, a review of recent and relevant peer-reviewed research and scholarly literature concerning dementia care quality, art interventions for dementia patients, and adult learning theories facilitating cognitive rehabilitation for dementia patients, will be presented next.

Dementia Care: Quality and Limitations

Current treatment strategies are designed to improve the QOL for dementia patients and their caregivers; however, there are systemic problems with the care patients typically receive. For example, a concerned family member revealed some of the problems associated with the quality of dementia care provided in contemporary healthcare facilities (Armstrong & Byrne, 2011, p. 13). The family's mother, who was 66-years old, was diagnosed with AD and had been managing well at home, but after being admitted to a hospital for a perforated ulcer the patient died within three months. The family became convinced that the diagnosis of AD conferred second class patient status, which gave the staff permission to wash the patient with the curtains open, leave her sitting in feces during family visits, remain indifferent to a need for feeding assistance, and keep family members in the dark about treatment plans. The family members ultimately concluded that their loved one had been starved to death.

The report by this family member seems to confirm the existence of discrimination based on a diagnosis of dementia, especially within the healthcare system. Given the widespread acknowledgement that the care provided is suboptimal, standards of dementia care were recently issued by a working group consisting of representatives from the American Academy of Neurology, American Geriatrics Society, American Medical Directors Association, American Psychiatric Association, and the American Medical Association (Odenheimer et al., 2013). Topping the list is maximal preservation of the patient's cognitive and functional abilities. The other standards include reduced symptom severity and frequency, preservation of the patient's general health, minimized threats to patient health and safety, and the provision of comprehensive support for family caregivers. Quality dementia care would therefore be expected to address the cognitive, psychological, and behavioral problems associated with dementia.

The available pharmacological interventions are extremely limited in both number and efficacy. According to the American Family Physician, all three categories of symptoms have been shown to be responsive to acetylcholinesterase inhibitors (AChEI), although the benefits appear to be marginal (Butler & Radhakrishnan, 2014). Antipsychotic medications are no longer recommended for a variety of reasons, including substantial side effects and safety concerns. Other interventions that have been tried include antidepressants, talk therapy, exercise, statins, fish oil, and cognitive stimulation activities such as music therapy, but rigorous empirical evidence supporting their use is lacking.

Societal Roles. Society plays a significant role in how dementia patients are perceived and treated, both inside and outside the healthcare system (Milne, 2010; Odenheimer et al., 2013). One solution receiving international attention is increased patient and caregiver exposure to art activities. The National Gallery of Australia in Canberra welcomes dementia sufferers and their professional and family caregivers once a week, as part of a program designed to compensate for the social isolation and stigma surrounding the disease (Dyett, 2014). Anecdotally, caregivers reported that anxiety levels caused by cognitive impairment seem to be reduced, which may explain why this program has survived for seven years (Dyett, 2014). This track record is consistent with apparent increases in well-being experienced by dementia patients and, by extension, family and professional caregivers.

More recently, a pilot program having similar goals was implemented in London, England (Gould, 2012). The London Arts Challenge organizes weekly art workshops at numerous venues around the city for patients suffering from early stages of the disease, along with their family caregivers. The goals are to reduce stress associated with memory loss and provide a fulfilling sense of connection to their communities. At the Museum of Modern Art (n.d.) in New York City, the education department created the MoMA Alzheimer's Project in 2007 to provide training resources for professionals interested in exposing dementia patients and caregivers to art and offering on-site art education programs. The MoMA's Alzheimer's Initiative has helped similar programs come to life in at least 60 other museums (Chancellor, Duncan, & Chatterjee, 2014). Many of these programs are based on art appreciation, but more than a few have incorporated creative activities into their dementia outreach programs.

Art Interventions for Dementia Patients

As previously mentioned, Mottram (2008) acknowledged the value of art activities as diversionary and calming, yet believed the terms 'art therapy' and 'art process' has more to do with dementia patients communicating with the world. She suggested that any intervention that improves patient cognition and moderates the neuropsychiatric symptoms would improve patient and caregiver QOL substantially. She suggested that a more holistic and potentially enjoyable dementia care intervention is art therapy, which emphasizes the remaining cognitive abilities. This perspective is echoed by those who agree that cognitive rehabilitation for dementia patients has been shown to provide measurable benefits, in isolation or in combination with AChEIs (Carrion & Lopez-Bemejo, 2013; Clare et al., 2010; Giordano et al., 2010). Chancellor and colleagues (2014) agreed as well and suggested that dementia patients are helped in three important ways by the art therapy processes: (1) use of intact cognitive capabilities, (2) facilitation of emotional communication, and (3) the creation of an opportunity for prolonged concentration and personal fulfillment. Recommended activities can be as simple as coloring line drawings with crayons or watercolors for patients with mild dementia (Hattori, Hattori, Hakao, Mizushima, & Mase, 2011), to coloring and shading cut felt shapes for patients with severe dementia (Peisah, Lawrence, & Reutens, 2011). Reduced apathy and increased calmness were some of the more prominent outcomes noted by researchers. Comment by Robin: Got rid of the quotation marks a page numbers because I paraphrased the information. Paraphrased information does not require quotation marks or page numbers.

Many in the field agree that patients with severe dementia may require one-on-one instruction, non-verbal instruction, and frequent eye contact to encourage the prescribed activity (Carrion & Lopez-Bemejo, 2013; Chancellor et. al., 2014; Clare et al., 2010; Giordano et al., 2010; Mottram, 2014). If an improved social environment contributes to the health and well-being of patients and caregivers, then art interventions may have the potential to delay transitions to residential care facilities. The medium employed during art therapy is less relevant than the quality of the interaction between patient and therapist, because the patient is not only suffering from an organic disease, but also from psychologically-debilitating social isolation (Waller, 2002a, p. 2). The quiet and supportive atmosphere created in the art studio by the therapist has the potential to help many patients regain a modicum of purpose, value, and control over their lives, in addition to creating a medium for communicating with others.

Qualitative Evidence. Qualitative study designs cannot provide empirical support generalizable to the wider patient population, but evaluating individual patient responses to an intervention can provide detailed insights unavailable through a quantitative study design. For example, an 82-year-old woman suffering from severe dementia presented with persistent agitated behavior unresponsive to pharmacology interventions (Peisah, Lawrence, & Reutens, 2011). Nothing seemed to work, not doll therapy, distracting activities, or exercise. When evaluated, the patient was judged to have strong visual-spatial perceptual and manual dexterity skills, including the recognition of colors and shapes. Based on these strengths, the art therapist used colored shapes cut from felt and modified with lines to encourage shading and coloring. The coloring cues were provided to compensate for severe executive function deficits. The observed benefits were a calm demeanor during the art process and a positive social attitude at the end of each session. The patient, formal caregivers, and the family universally welcomed the intervention. Similar benefits were observed for patients in Kansas (Stallings, 2010) and Croatia (Mimica & Kalinkic, 2011), who engaged in creating collages from precut magazine images and pencil drawings, respectively. The benefits observed included reminiscing about the past, effective reduction in behavioral problems in the absence of drugs, and in one case the creation of truly remarkable drawings by a patient with no history of art expertise.

A mixed-method analysis of patient and caregiver experiences while attending MoMA Alzheimer's Project (Meet Me at MoMA) activities was recently completed (Camic, Tischler, & Pearman, 2014). Quantitative measures of caregiver burden, activities of daily living, and QOL failed to reach significance for a small sample (N = 12) of patient/caregiver pairs; however, thematic analysis of interview data revealed three themes and 12 categories. The theoretical framework employed was a constructionist museum model, which assumes a co-constructed learning experience made possible when the impact of cognitive impairments (e.g., memory) is minimized by family caregiver co-participation. The art experiencing process was iterative, rather than highly structured, so that all stakeholders contributed to the process and outcomes. Patients suffering from mild to moderate dementia reported feeling more included socially, having improved cognitive function, and experiencing an enhanced quality of life. Uniformly, all patient/caregiver pairs reported enjoying the program, regardless of whether they attended at a museum or more contemporary art gallery setting.

Quantitative Evidence. The Memories in the Making intervention, first developed in Orange County, California, was adapted for use in multiple adult daycare centers located in the Greater Cincinnati area (Rentz, 2002). A formal evaluation process of the program's efficacy was undermined by the lack of control group; however, patients were observed to have sustained attention and pleasurable experiences during art therapy sessions (Kinney & Rentz, 2005). The theoretical framework for evaluating the benefits of the intervention was Lawton's definition of well-being, which is based on the interaction between an individual and environment. The objective and subjective factors assessed were engagement in the task, expressions of pleasure, displays of self-esteem, and emotional expressivity. A follow-up study incorporating a cross-over control condition and a 19-item validated instrument (Greater Cincinnati Chapter Well-Being Observation Tool) revealed significant (p < .03) benefits of an art therapy intervention in terms of interest, sustained attention, pleasure, self-esteem, and feelings of normalcy (Kinney & Rentz, 2005). Only negative affect and sadness were unchanged, but a study based on a larger sample size may have revealed a significant reduction in sadness (current study: N = 12, p = .079 for sadness).

In April of 2013, Dr. Dan Cohen established the Music & Memory (M&M) Initiative based on the findings of these studies. To demonstrate the study's findings, distinguished neurologist Dr. Oliver Sacks, musician Bobby McFerrin, and Eden Alternative creator Dr. Bill Thomas assisted Dr. Cohen in producing the cutting-edge documentary, Alive Inside. Their evidence-based research revealed that music stimulates activity in certain parts of the brain, allowing for transformations in a dementia patient's ability to engage with family and caregivers (Sneed, 2014). Wisconsin Department of Health Services Advisory Board members Mr. Kevin Coughlin and Ms. Pat Benesh facilitated the full implementation of the Music and Memory Initiative. Currently, 100 nursing homes are certified as M&M facilities and are fully equipped with iPods. Through a grant from Zion's Bank and donations from Apple computers, Utah is implementing this art intervention into residential treatment and nursing home facilities (Sneed, 2014).

A more rigorous study design was used to evaluate the long-term efficacy of art therapy among patients suffering from dementia (Rusted, Sheppard, & Waller, 2006). The length of the intervention was 40 weeks, with follow-up evaluations conducted 1- and 3-months post-intervention. Forty five patients attending adult daycare or residential facilities were randomly assigned to weekly art therapy sessions or non-art, non-craft activities; therefore, a true control group was created. Due to attrition, however, only 21 participants were able to complete the 9-month study, which undermined the benefits of randomization. Despite this limitation, significant (p < .01) improvements in mental acuity, calmness, physical involvement, and sociability were found for the art therapy group, while these measures worsened for the controls. The only negative effect of the art therapy intervention was a doubling of the depression score after the last session; otherwise, depression scores trended towards improvement during the intervention. The authors concluded that art therapy provided more durable benefits than the control interventions.

These studies revealed a consistent pattern of beneficial effects due to art therapy, but the variables that reached statistical significance varied considerably between the studies. Some of this variability could be due to differences in study design, sample size, and the instruments used, in addition to variation in the cognitive and behavioral symptom mix within each patient sample. Overall, patients with mild to moderate dementia benefit the most from art therapy and these benefits include greater momentary QOL and mood, and reduced behavioral symptoms. Researchers have studied music as a treatment for dementia symptoms, but a recent literature review found insufficient evidence to support its clinical use (Butler & Radhakrishnan, 2014). A few researchers have likewise studied dance, but the universality of the intervention is limited primarily by the physical and psychomotor limitations common among dementia patients (Guzman-Garcia, Mukaetova-Ladinska, & James, 2013).

Theoretical Framework

Waller's (2002b) interview of Kamal Beeharee, a community psychiatric nurse with extensive experience working with dementia patients, provides a perspective that is consistent with the most important dementia care standard: preservation of a patient's cognitive abilities (Odenheimer, 2013). This perspective, however, seems to be nuanced in important ways. The preservation of a patient's cognitive abilities necessarily implies deficits, but these deficits can vary widely among the patient population. Beeharee suggests that interventions designed to improve the cognitive and psychological state of dementia patients must strive to improve cognitive impairments, while at the same time preserving and strengthening the cognitive abilities that remain relatively intact (Waller, 2002b, p. 139). According to Beeharee, if dementia patients are provided an opportunity to display their cognitive strengths this will have a direct positive impact on their mood and self-esteem, because the anger, frustration, and behavioral symptoms common to dementia sufferers are fueled by feelings of social isolation and devaluation. This perspective was echoed by Edwards (2004, p. 43-44), who noted that cognitively-normal people will react in the same way to social isolation; however, cognitively normal people will suppress these feelings, while dementia patients lacking executive control do not have this option. Combine these potentially volatile symptoms with verbal language impairments and the emotional and behavioral problems common to dementia patients begin to make intuitive sense.

Cognitive Rehabilitation Theories. There is a wide array of theoretical models that can be used to effectively explain how dementia patients learn, including the Kolb Experiential Learning Theory (Akella, 2010). In this regard, Kolb (1984) defined experiential learning as a "holistic integrative perspective on learning that combines experience, cognition and behavior" (p. 21). Adult learning, from Kolb's perspective, is "a continuous process grounded in experience" (p. 41). The adult experiential learning process conceptualized by Kolb is a step-wise cycle that is composed of four stages: (a) concrete experience, (b) reflective observation, (c) abstract conceptualization, and (d) active experimentation (Akella, 2010, p. 101). Others have expanded this concept:

"Individuals tend to emphasize different stages, resulting in different learning styles and their associated strengths and deficiencies. For integrated learning to occur, it is necessary to go through all of the phases of Kolb's learning cycle. When one or more of these dimensions are underdeveloped or overlooked, individual learning is blocked" (Turesky, 2005, p. 59)

Therefore, Kolb's Experiential Learning Theory appears to be well suited for explaining the efficacy of art therapy in dementia care.

John Tyler (2002), an art therapist and teaching artist, unintentionally argued in favor of experiential learning. In his chapter on art therapy for dementia patients, he noted that "People with dementia will have undergone dramatic and often-traumatic experiences in their recent lives, which necessarily creates countless unresolved conflicts" (p. 68). In addition, the author personally observed well-intentioned efforts by medical staff to structure an art therapy session to ensure a recognizable creative product would be produced by the end of the session, therefore deemphasizing the importance of the art process. Tyler concluded, "This approach seemed to be more about addressing the needs of the staff than of the patient's" (p. 70). Perhaps Kolb would have argued that the creative process could help patients work through conflicts, but only if the emphasis of the art therapy intervention is on the process and not the product.

Constructivism. Bruner (1966) states, "Constructivism is consistent with the focus of Kolb's Experiential Learning Theory, which emphasizes the process of learning rather than the outcome. The focus on process implies that a person's thoughts and beliefs are malleable by experience" (p.72). Kolb even quoted Bruner to make his point: "knowing is a process, not a product" (Bruner, 1966, p. 72; as cited by Kolb, 1984, p. 27). Both constructivism and experiential learning depend on the processing of multiple sensory inputs, the engagement of multiple cognitive abilities, and the always-important emotional salience (Bruner, 1966; Kolb, 1984). Conversely these theories suggest that knowledge is acquired through experience, not rote memorization. Comment by Robin: The page numbers for these quotes do not match the citation and based on my research the citation in APA should be:Greenfield, P.M. & Bruner, J.S. (1966). Culture and Cognitive Growth. International Journal of Psychology, 1(2), 89-107. Comment by Robin: Same note as above

The impact of social isolation on a person's quality of life can be viewed through the lens of Bruner's (2004, p. 708) constructivism. According to this theory, persons receiving a diagnosis of dementia would incorporate this information into their life narratives, which in turn would influence how they lead their lives post-diagnosis. The creation, maintenance, and modification of a life narrative is necessarily based on imperfect sensory experiences, the thought process, and triggered emotions; therefore, the narrative is inherently unstable, which in turn renders it prone to social, cultural, and interpersonal influences. Although it may appear unfortunate that a person's narrative is continually informed by external negative forces, such as society's devaluation of persons with dementia, Bruner's constructivism implies that the narrative can also be influenced in a positive manner by the therapeutic process. Accordingly, art therapy can help dementia patients change their narrative from hopelessness, anger, frustration, and social isolation to one that highlights their cognitive strengths, capacity to create pleasurable art, and the ability to communicate through art. Comment by Robin: I returned this paragraph to its original form because nothing was quoted from the reference. This was me simply adapting Bruner's Constructivism to dementia. I was being philosophical, therefore, no citations are warranted

An example of an art activity reflecting the constructivist approach would be the creation of collages using precut images from magazines. Stallings (2010) employed this technique with three older adults suffering from dementia, with a largely interpretive goal; however, all three subjects used the collage to reminisce about their pasts. The collage making process was therefore a reflection of each subject's narrative and the need to communicate this narrative to others. As the author noted, the reminiscing is also an essential part of the life-review process, which suggests that all three dementia patients were engaging in a normal aging process. Accordingly, art therapy may help dementia patients change their narrative from hopelessness, anger, frustration, and social isolation to one that highlights their cognitive strengths, capacity to create pleasurable art, and the ability to communicate through art. Comment by Robin: Reverted this section back to the original, because the quotation marks were not bracketing any quoted material. I was paraphrasing the information from Stallings; therefore, quotations marks should not be used. Short research articles like Stallings do not need page numbers, based on my experience, if the information is being paraphrased.

Clark (2001) suggested that "just as constructivism supplies adult learners with the essential tools to conceptualize content both kinetically and narratively, experiential learning is learner-centered and functions on the evidence that persons best learn through experience" (p. 83). In support of Clark's perception, Tyler (2002) described his experience as a teaching artist and the title of the section is clearly 'Kolb-esque:' "The freedom to be yourself" (p. 68). Tyler elaborated in his case study thus:

"An elderly woman with memory and verbal impairments would arrive each week as if it was her first time and create essentially the same drawing each time. After months of this pattern she arrived in the studio and exclaimed that she had been there before. After several more sessions she asked to see the old drawings and began to add additional elements to ensure they were 'completed.' Anecdotally, she seemed to become cognizant of the continuity between art therapy sessions and immersed in remembrance of a joyful period in her life" (cited in Waller, 2002a, pp. 70).

Bruner's narrative is readily apparent in this case example, as is Kolb's continuity of experiences during the learning process. Whether the patient was resolving conflicts is unclear, but one reasonable interpretation would be that she was engaging in the life-review process, which would imply the resolution of conflict through an experiential learning process.

Cossio (2002, p. 52-55) finds that dementia patients engaged in the art process will often show language improvements, become socially expressive in positive ways, and develop a stronger sense of self. Without any reference to Bruner's constructivism, Cossio claims the art process allows patients to unveil hidden worlds of affections and unique experiences, regardless of the aesthetic quality of the art. In an unconscious nod to Kolb's emphasis on learning as a means to resolve conflicts, one woman being treated by Cossio drew tear drops on faces and began to cry. While other interpretations are possible, Cossio believed the crying represented a catharsis for unacknowledged pain incurred during her life. Constructivist and experiential themes therefore readily emerge when dementia patients engage in the art process. Comment by Robin: Reverted to original, for the same reasons. All information presented is paraphrased, therefore quotation marks and page numbers are inappropriate

Chapter III: Methods

The rationale for proposing a phenomenological study is based in part on the inconsistent findings across multiple quantitative studies (Kinney & Rentz, 2005; Rusted, Sheppard, & Waller, 2006; Hattori, Hattori, Hokao, Mizushima, & Mase, 2011; Ferrero-Arias et al., 2011). The inconsistent findings, although generally positive, reveal the shortcomings of a quantitative approach when symptoms and impairments are highly variable across the patient population. If the goal is to preserve cognitive and global functioning, and reduce symptom severity and frequency, it may be less important to quantify changes in mental acuity, depression, and apathy following art therapy and more important to understand how art therapy is experienced by both patient and therapist. Hidden benefits of the intervention could be uncovered, especially on an individual level, and contribute to an understanding of the art therapy process. A phenomenological approach can provide insights unobtainable through quantitative methods and create a more grounded foundation upon which quantitative studies can be based (Black & Fauske, 2008).

One of the more common phenomenological approaches is ethnography, which concerns the study of social groups and cultures (Chang, n.d.). Autoethnography, therefore, concerns the interactions between the researcher and the subjects of interest. There is thus an autobiographical component to autoethnographic research, such that the researcher becomes one of the subjects in the study. Other qualitative approaches, such as grounded theory and interview data, are undermined by what Struthers' (2012) called a "crisis of representation" (p. 69). Autoethnography, instead, focuses on the dialog that takes place between researcher and subjects, which in turn allows data collection and analysis to be an ongoing process. With time, concepts emerge and themes are identified, which tend to support the trustworthiness of the data.

From Struthers' (2012) perspective, the methods and methodology that defines autoethnography are alone sufficient to provide a theoretical framework, but the interpretive methodology used requires a more detailed understanding. Hermeneutic (interpretive) phenomenology is a research philosophy that attempts to assign meaning to the experiences of participants (Lopez & Willis, 2004; Ajjawi & Higgs, 2007). Martin Heidegger (1889-1976), a founder of hermeneutic phenomenology, was primarily interested in the phenomenon of 'being' (Giogi, 2007, p. 66). His methods of understanding 'being' were reduction, construction, and destruction. According to Heidegger's theory, reduction would be the process of understanding how beings come to be projected or unconcealed to a researcher, while construction is the movement of the researcher towards' being,' freely projected, and 'constructed' out of antecedent 'beings.' Destruction, on the other hand, represents the researcher's understanding that the concept of 'being' is informed by the researcher's philosophical training and experience and is therefore biased by this history. Comment by Robin: This is paraphrased information derived from Giogi; therefore, quotation marks are inappropriate. Typically, the information that follows a citation within the same paragraph does not need to be cited again, because it is assumed to follow from the most recent citation.

Although it may seem from this description that Heidegger's phenomenological methods were concerned with the conscious experiences of the researcher, this is not so. Instead, hermeneutic phenomenology is used to intuit or deduce the meanings a patient attributes to experiences, while recognizing the intuitive and deductive process is biased by the observer's history and philosophical orientations. Edmund Husserl (1859-1938) went further by suggesting a researcher continue to work at reducing the impact of preconceived notions on data interpretations, thereby getting to the essence of the phenomenon being studied; however, Merleau-Ponty (1962, as cited by Colaizzi, 1978, p. 55) concluded that Husserl's reductionist approach only proves how impossible it is to reduce preconceptions to the point they become irrelevant.

The real-world application of hermeneutic phenomenological produces "… rich textural descriptions of the experiencing of selected phenomena in the worldview of individuals that are able to connect with the experience of all of us collectively" (Smith, 1997, as cited by Ajjawi & Higgs, 2007, p. 616). Dementia patients, however, suffer from a number of cognitive impairments, including verbal and memory, so the ability of patients to connect to the collective experience will be relatively limited. Ajjawi and Higgs (2007) further elaborated by stating that hermeneutic phenomenological research "… occurs through increasingly deeper and layered reflection by the use of rich descriptive language" (p. 616). The 'being' of interest in this study is that of 'learner' as framed by Kolb's (1984) Experiential Learning Theory, although data will be collected from the researcher and stakeholders as well. According to Kolb (1984), learning is a process, not an outcome; therefore, the proposed study will focus on the meanings a dementia patient assigns to the experience of art therapy as interpreted by the researcher and other stakeholders. The primary aim will be observing patient use of multiple sensory inputs, the processing of this information using intact cognitive abilities, and assignment of emotional salience to the learning process. As mentioned in the introductory chapter, this approach fits well with the Kinesthetic (Dunn, 2009) and Embodied (Kerka, 2002) Learning theories, which are the conceptual paradigms associated with the Bruner's Constructivist theory.

Triangulation, based on interviews, researcher journal entries, and observations, made during an art therapy session, will be used to increase the quality of the findings. The quality of qualitative studies, however, can be defined in a number of different ways. Golafshani (2003) discussed the difference in how reliability and validity are defined in quantitative and qualitative research paradigms by invoking a distinction between the instruments a quantitative researcher uses to generate data and the researcher 'as instrument' in qualitative research. Reliability in quantitative research, which is the ability to generate reproducible data, has little meaning in qualitative research, since a phenomenon can be ever changing and interpreted differently by different observers or participants; however, the contributions from diverse findings (triangulation) may be equally valuable for meeting the goal of qualitative research, which is to generate a deeper and thus more truthful understanding of a phenomenon. Reliability in qualitative research, if invoked, can therefore imply the development of an understanding of a phenomenon that can be generalizable.

It therefore follows that research credibility depends on a qualitative researcher's competence to conduct the study. Common terms used to describe the quality of qualitative findings, and thus a researcher's competence, include credibility, transferability, and trustworthiness (Golafshani, 2003). Ryan and colleagues (2007) used the term 'believability' in place of credibility, which they defined as dependent on a qualitative researcher's academic and professional credentials. Additional evidence of believability can be supplied by the researcher clearly identifying the phenomenon to be studied, explaining the purpose and need for a qualitative study, and discussing how the study will contribute to a general understanding of the phenomenon. The use of a qualitative study design and chosen methods will also need to be defended successfully.

Setting

The art intervention was conducted mid-day at a private liberal arts college in Utah, which the researcher attends, in a classroom within a graduate studies building on campus. The carpeted classroom environment included comfortable chairs, sturdy tables, appropriate overhead lighting, climate controlled central heating, privacy of location, and classical background music provided by the researcher. The public restrooms were located across the corridor and immediately accessible from the classroom. Handicap placards were made available to patients and caregivers, thereby providing free access to campus parking close to the classroom where the art intervention was held.

Participants

Dementia patient AIP01 suffers from dementia due to Alzheimer's disease, the third and final stage of this condition (Alzheimer's Association, 2014b, p. e52). AIP01 is experiencing a rapidly advancing loss of focus and concentration, but episodes of confusion remained sporadic. AIP01 still understands most conversations and is able to toilet independently, as well as self-feed. The predicted life expectancy of AIP01 is less than 5 years.

Dementia patient AIP02 also suffers from dementia due to Alzheimer's disease. AIP02 is experiencing a moderate loss of focus and a progressive loss of concentration, but confusion was not pervasive. AIP02 still understands most conversations, but is unable to toilet independently. The predicted life expectancy of AIP01 was not revealed to the researcher.

AIP03 is a teaching artist that has provided respite for a state chapter of the Alzheimer's Association community since May of 2011. AIP03 recently completed two artist-in-residency fellowships at a gallery known for making fine art accessible to people with disabilities, after earning a 4-year undergraduate degree in Art and Visual Design.

Ethical Considerations

Informed consent was obtained from patients when possible and always from the primary caregivers or healthcare proxies; however, the study will be fully explained to all patients and some sign of voluntary assent obtained before the patient will be included in the art therapy intervention. In addition, consent will only be obtained under the direct supervision of a registered nurse or physician. The confidentiality of all participants will be maintained throughout the study, first by assigning codes to participants and second by keeping individually identifiable information in a location distinct from the collected data. All data records, whether written or digital, will be kept in a locked container and this container will remain in the personal possession of the researcher. When the study is finished and the report published, all individually identifying information will be destroyed, including all video recordings. De-identified aggregate data, however, will be maintained indefinitely. Consent will also be obtained prior to publishing photos of patient art.

Art Intervention

The Montessori teaching method has long been considered appropriate and effective for persons suffering from dementia (e.g., Camp et al., 1997; Judge, Camp, & Orsulic-Jeras, 2000). According to this method, a task is first taught in its simplest form and subsequent teaching encounters typically involve increased complexity. A flow chart of this teaching method, when applied to ceramic art, is provided in Appendix A. The slip-cast jars would represent the easiest task in this sequence, one that would need to be mastered before the patient is transitioned to the Oaxaca animal task. These activities are designed to provide immediate feedback, increase the chance of success, and encourage repetition. The art medium chosen for this study was water-based acrylics on an 8"x8" canvas paint board, with the therapist directing the creation of an image of a flower in bloom. Other art supplies provided included a non-odorless flow extender, wide variety of bristle and foam brushes, re-usable plastic painting pallets, and painting cloths.

As Camp and colleagues (1997) discussed, learning and memory processes can occur in the absence of conscious awareness. Unconscious learning is believed to remain relatively intact as dementia progresses and patients often demonstrate an ability to learn through procedural/implicit memory processes. The progressively complex manipulation of art materials, as part of a Montessori approach to art therapy, would therefore be possible for dementia patients with mild to moderate forms of this disease. The expected immediate outcomes would be enhanced performance.

An art therapy session was scheduled for midday and attended by two dementia patients and art therapist. A midday session would avoid the behavioral problems associated with sundowning.

Data Gathering Methods and Rationale

The primary method of data acquisition will be video journaling, a method increasingly utilized by educators (Clarke, 2009) and clinicians (Brandt & Hillgren, 2005) to understand their own strengths and weaknesses as professionals. The function of video journaling will be to capture a patient's reactions during the art process, thereby augmenting the researcher's recollections of the patient-therapist interactions and the patient's responses to the art process. The researcher is equipped with a MacBook Pro, which has a built-in video camera. The video recording software provided by Apple will be used to capture the sessions. An encrypted hard drive has video storage and the contents of each video will be transcribed after each session.

The second method of data acquisition will be journaling to record the researcher's experiences and thoughts about the meaning patients may be attributing to the art process, a method equivalent to taking field notes. Journal writing has been shown to be a powerful technique for self-reflection (Walker, 2006), a process essential for determining the meanings a patient may be attributing to the art process. This technique is used to engage in the reduction, construction, and destruction methods of Heidegger's hermeneutic phenomenology.

The art therapist will be interviewed for the study. The interview will be semi-structured and be framed by 10 questions (Appendix B) that will prompt dialog on the phenomenon. The interview represents the third leg of a triangulation approach to data analysis.

Data Analysis

Ajjawi and Higgs (2007) generated a structural framework for data analysis in hermeneutic phenomenological research. The six stages they utilized were (1) immersion, (2) understanding, (3) abstraction, (4) synthesis and theme development, (5) illumination and illustration of phenomena, and (6) integration and critique. Data analysis was an iterative process, consisting of testing pre-research assumptions against findings and cross-checking interpretations with field notes. This process would tend to uncover any biases in the interpretations, a process equivalent to Heidegger's method of destruction. The cross-checking contributes to construction of the researcher's being, by remaining faithful to the original observations. An equivalent process in the current study consisted of cross-checking journal notes and interpretations with the more objective video journal.

Ajjawi and Higgs (2007) organized their data sets into 'texts,' which are written summations of the data collected for each subject. The texts for the current study would be based on the video journals, researcher notes, therapist interview, and demographic data. The first stage of data analysis is immersion, which involved creating a text for each participating dementia patient. Creating a text requires going over the data for each participant repeatedly, until some sense of meaning can be attributed to the data. The hermeneutic circle, which entails moving between the data and the emerging meaning over and over, explains this iterative process so that each informs the other. As Ajjawi and Higgs (2007) describe, questions emerge from examining the data, as do the answers, and from this emerges the texts.

The second stage is 'understanding,' which is the process of identifying first order or participant constructs (Ajjawi & Higgs, 2007). Second order or researcher constructs are identified during the third stage, abstraction. The second order constructs are also grouped into subthemes. Themes are developed from the subthemes, further elaborated, and compared across sub-discipline groups during the synthesis and theme development stage. Once themes have been identified and defined, support for the themes is identified in the literature. This process occurs in the fifth stage called illumination and illustration of phenomena, as it involves creating stories out of the data interpretations. The final stage, integration and critique, involves the researchers and external colleagues critiquing the themes, followed by reporting the findings in the research literature.

The rigor of the current phenomenological study was assessed using the proposed criteria of De Witt and Ploeg (2006): (1) balanced integration, (2) openness, (3) concreteness, (4) resonance, and (5) actualization. These terms are defined as striving for a balance between the 'voices' of the dementia patients and philosophical interpretations, using an explicit process of data interpretation, assessing the clinical relevance and utility of the findings, predicting the expected impact of the findings on dementia researchers, and projecting the expected future outcome of the resonance, respectively. Comment by Robin: This information was paraphrased, not a quote

Chapter V: Data Analysis

The focus of this phenomenological study was to better understand the experiences of both dementia patients and the art therapist during the provision of art therapy, since the research literature has largely ignored this aspect of this intervention. Most prior studies have focused on quantitative measures of dementia symptomology and perceived improvements in patient and caregiver quality of life. What is unique about this study is that the patient and therapist experiences, rather than symptomology, become the data.

Bracketing

The first step in any phenomenological study is the bracketing of preconceived notions regarding the phenomenon of interest (Hycner, 1985). As recommended, the researcher reflexively examined biases, assumptions, and beliefs concerning the provision of art therapy to dementia patients. The presuppositions identified were the following:

1. Bias in favor of quantitative research designs, which tend to render a phenomenological study design less comfortable, frustrating, feeling overwhelmed, and stressful.

2. The art intervention investigated was administered by a practicing art therapist and my role was in the intervention was observer/researcher. This was not the original plan for this research project, since I had hoped to be both art therapist and researcher. Some mild feelings of resentment are occasionally and transiently felt, which could potentially introduce a bias into the data analysis process.

3. At the end of the opening vignette I mentioned feeling a sense of identity with dementia patients because of an assumption that they must feel trapped by their disease. I realize that this may or may not be true for all patients, especially in light of remarks by some cancer patients that the quality of their lives has improved after getting cancer (e.g., Edwards, 2007).

4. In the opening vignette I also make the assumption that dementia has left patients feeling that the world they now inhabit has become strange and frightening. This, of course, may not be true for all patients or for any patients.

5. Another assumption introduced in the opening vignette is that art therapy is a way to help dementia patients help themselves transition through traumatic symptoms. I cannot know if this is true and whether dementia patients experience their symptomology as traumatic.

6. I also expressed confidence in the healing potential of art therapy for dementia sufferers and caregivers, a sentiment that any competent phenomenologist would consider a bias. In fact, there is no empirical evidence to date that any intervention, medical or otherwise, can be rehabilitative for dementia patients, including art therapy.

The themes that emerged from the bracketing process are quantitative bias, resentment for being relegated to observer, patient trapped bias, patients' world is strange and frightening, dementia symptomology is traumatic, and the belief that art therapy is healing for patients. This list represents the process of 'reduction' under Heidegger's hermeneutic phenomenology, which is how a dementia patient would be projected or unconcealed to the researcher (Giogi, 2007, p. 66).

Immersion

Therapist interview.

The respite approach of the therapist was based on a philosophy emphasizing the value of hands-on activities, as a way to refocus the attention of patients away from their symptomology and towards the task at hand. This requires close engagement between the therapist and patient, in order to encourage the patient to take the leap and engage in the creative process. A positive attitude, lots of encouragement, and a gentle touch, according to the therapist, can go a long way towards creating an activity the patient will want to participate in. In addition, the less technical an art project is, the more enjoyable the activity becomes. Abstract Expressionism and Impressionism are therefore conducive to an art intervention designed for dementia patients. Difficult patients, however, can rapidly change the mood in the room and the therapist must be quick to validate patients' experiences, while separating them from the rest of the class. Patients resistant to the art process may be unable to communicate an issue they are struggling with. In this situation, participation may be a possible outcome using a gentle one-on-one approach to determine the exact nature of the issue in order to bring about a solution.

Private art intervention.

The art therapy session was midday and the video journal of the session lasted 15 minutes. The art medium was water-based acrylics on canvas, with the therapist guiding the two patients in the creation of an image of a flower in bloom. No family caregivers were present during the intervention. The video journal was begun as the art therapy intervention was beginning, but after the patients were already sitting and the art materials spread out in front of them. The video journal began as the patients started to apply paint to canvas. The researcher held the video camera while it was recording and walked around the small classroom capturing patients and the therapist during the session. The therapist began by painting a flower on her canvas and led patients in the task of creating a similar image. Patient AIP01 had little trouble creating an easily identifiable flower, complete with a stem and leaves, while patient AIP02 added primarily dark colors to the canvas to create an abstract expression of the flower. The palette for patient AIP01remained clean with individual colors contained in individual wells, but by the end of the video journal the palette for AIP02 was covered in paint, colors were mixed together, and parts of the easel and table were freshly painted.