Gestalt Art Therapy for people with Dementia

BackUp_8425_Research_1
04-06-16
17.16
Sida 149
Gestalt Art Therapy for people with Dementia
Margaret Muir
Egg whites sugar and … is the first session in
GATE-ways (Gestalt Art Therapy/ Experiential
ways)1 and detailed below. In Australia Pavlova,
an extremely popular dessert for celebrations is
made from egg whites and sugar (see recipe at
the end) so by making it the initial, and non-traditional art material, immediately indicates it
will be both a fun and celebratory experience for
the women with dementia and the staff. The
GATE-ways program for women with dementia
is a comprehensive integrated psychotherapy
programme that has been developed on strong
psychological and psychotherapeutic foundations bringing, together research on dementia,
trauma, Gestalt Art and Psychotherapy in a
playful and rewarding manner.
Margaret Muir, Ph.D.
Candidate
Margaret completed her Bachelor of
Science (Hons) in Psychology, at the
University of Newcastle (Australia).
On graduation, her clinical placement was in a large institutionfor children and adults
with neurological impaiment. Margaret was able to
successfully develop innovative programmes for the residents, their families and staff. Counselling, Gestalt and
Art Therapy enabled her to develop innovating approaches to assist people with neurological impairment
and/or experiencing trauma. Margaret currently
works as a Psychologist/Psychotherapist in Private
Practice and is a PhD (Medicine) candidate at the
University of Newcastle. As part of her research,
Margaret is bringing together over thirty years of experience in Psychology, Gestalt and Art Therapy with
people experiencing neurological impairment and trauma. International Academy for Design and Health World Congress and Exhibition Montreal 25-29 June
2003 research field is music and music in combination
with therapeutic suggestions to patients in surgical care.
As most investigators adopt a biological perspective, viewing dementia from a perspective
of trauma has been neglected. The illness of
dementia, with its changes in cognition and
memory, can threaten a person’s identity, resulting in emotions of both trauma and loss, defined as complex trauma2. People with dementia
experience multiple traumas from the loss of
cognitive abilities, to rejection by family and friends. In addition to the above traumatic events,
there are fewer and fewer opportunities to
maintain and develop social interaction. People
with dementia show signs of depression and
anxiety. In complex trauma, anxiety and depression are considered to be normal responses to
an overwhelming experience. Further the
Behavioural and Psychological Symptoms of
Dementia (BPSD)3 are consistent with responses to Post Traumatic Stress Disorder (PTSD) 4.
This poses the question as to whether it may be
appropriate to view and respond to dementia as
a traumatic experience and therefore take a
trauma recovery model to facilitate positive
Traumatic events are extraordinary, not because
they occur rarely, but rather because they overwhelm
the ordinary human adaptations to life. Unlike
commonplace misfortunes, traumatic events generally involve threats to life or body integrity, or a
close personal encounter with violence or death. They
confront human beings with the extremities of
helplessness and terror and evoke the response of
catastrophe. The common denominator of trauma is
a feeling of intense fear, helplessness, loss of control
and threat of annihilation
Judith Herman, MD Trauma and Recovery
‘In Life After Trauma’
Rosenbloom and Williams, 1999
159
BackUp_8425_Research_1
04-06-16
17.16
Sida 150
GESTALT ART THERAPY FOR PEOPLE WITH DEMENTIA
change. Through reducing anxiety and depression with people with dementia, it promotes a
respectful and meaningful lifestyle together
with kindness to them, their relatives and the
staff who care for them.
self-esteem, mastery and control, trust and safety. Therefore in effective trauma recovery therapies, there is an emphasis on the need to systematically re-develop safety, trust, mastery or
control, self-esteem and intimacy to facilitate
recovery from trauma.
One approach to reduce this distressing and
overwhelming experience for people with
dementia is Person Centred Dementia Care5 .
In this approach Kitwood6 places the emphasis
on “personhood”7 and well-being of the person
with dementia. The definition given to “personhood … is a standing or status that is bestowed upon one human being, by others, in the
context of a relationship and social being. It
implies recognition, respect and trust”. Wellbeing8 for people with dementia is the sum of
Neurological Impairment, Health/Physical fitness, Biography or Life History and Social
Psychology. Kitwood9 perceives that the main
psychological needs of people with dementia
are
“Attachment,
Comfort,
Identity,
Occupation, Inclusion and Love”. Following
Kitwood, Shepard and Rusted, (1999),
Thormigsen (2002) have conducted groups
with people with dementia in England that have
shown quantitatively, significantly reduced
levels of depression although not anxiety. The
qualitative results from these studies have
shown increased satisfaction, and social interaction. The perspective being presented here, of
dementia as trauma, has developed from a review
of the literature on dementia 10and trauma11.
The responses to trauma can involve more
defences, that last longer and may have more
intensity than usual defences. They are normal
responses to abnormal demands. If trauma ‘is
experiencing an event outside the range of usual
human experiences that would be markedly distressing to almost anyone’ 13 it is beneficial to find a
suitable analogy that brings it back within our
understanding.
Muir, Margaret (2002) “GATE-ways to Recovery (Gestalt
Art Therapy/ Experiential ways)” Unpublished
2
Herman, J.L. (1992). Cited in Rosenbloom, D and
Williams Mary Beth (1999) Life After Trauma The Guilford
Press New York
3
Ballard, C et al (2001) Dementia: Management of
Behavioural and Psychological Symptoms Oxford University
Press
4
American Psychiatric Association (APA) (1994) Diagnostic
and statistical manual of mental disorders (4th Edition)
Washington DC: Author
5
Kitwood, T Dementia Reconsidered The person comes
first (1997) Buckingham Open University Press
6
Kitwood, T Dementia Reconsidered The person comes
first (1997) Buckingham Open University Press
7
Kitwood, T. Dementia Reconsidered The person comes
first (1997) Buckingham Open University Press. Page 8
8
Bradford Dementia Group, University of Bradford (2002)
Person Centred Dementia Care and Dementia Care
Mapping Basic Certificate Manual
9
Kitwood, T. Dementia Reconsidered The person comes
first (1997) Buckingham Open University Press Page 82
10
Cheston, R and Bender, M (1999) Understanding
Dementia: The man with the worried eyes. London Jessica
Kingsley Publishers
11
van der Kolk, B et al (1996) Traumatic Stress: The effects
of overwhelming Experience on Mind, Body and Society.
New York, The Guilford Press
12
Williams, Mary Beth (1999) Life After Trauma The
Guilford Press New York
13
Herman, J.L. (1992). Cited in Rosenbloom, D and
Williams Mary Beth (1999) Life After Trauma The Guilford
Press New York
1
Traumatic experiences can be different in nature, intensity, frequency, and duration and include life-threatening illnesses. Trauma also has
different impacts on people, even the same people at different times of their lives. Different cultures see different events as traumatic. From
these differences a variety of reactions and adaptations to those traumas can be observed although there are common elements in the experience of trauma. From these common elements
a construct of trauma12 has been developed
where depending on the frequency, duration and
or intensity of the event (s), following trauma a
person can loose social and sexual intimacy,
International Academy for Design and Health
160
BackUp_8425_Research_1
04-06-16
17.16
Sida 151
GESTALT ART THERAPY FOR PEOPLE WITH DEMENTIA
to respect the landholder and not force any
repairs. There can be some frustration and
delay is if the helper goes to the wrong gate.
Additional problems can occur, if the helper
assists in an inappropriate manner or takes over
the task from the landholder. The most effective process is for the helper to respect and evaluate the skills, ability and resources of the landholder by going with the landholder to assess
each area. Through this respectful approach by
the helper, together with the landholder’s
knowledge of the territory, they become a team.
As a team, they can check all gates together, and
only apply energy to the gate or gates that are
stuck. Each gate that opens leads to more
resources and increased opportunities. The
process, with the appropriate recovery strategies, continues to make the various gates functional again. With the gates functional the landholder can utilize all of their land as they choose, until the final gate at the all weather road is
re-opened to effective increased social interaction with the passers by.
GATE-ways Analogy
Imagine that there is an area of land beside an
all weather road on which many people can
travel and interact. The land is divided into
five paddocks or meadows that are made to
meet various requirements of social intimacy,
self-esteem, mastery of skills, trust and safety.
Each paddock may be of the same overall area
but the perimeter of each fence is less in the
areas towards the centre. Each of these perimeter fences has a gate for ease of access. In
normal conditions, the gates can easily be
adjusted to suit the needs of the landholder.
The landholder, dependant upon various
events, may see the need to conserve the area
at different times in different ways by closing
the gates providing opportunities for beneficial rest and regeneration.
If, in the environment, there are sudden events
such as storms, or changes such as prolonged
drought or rain, the gate closures may have a
different outcome. Dependant on the enormity
of this event, the landholder may choose to
firmly close gates so that, initially, the situation
can be assessed without interruption But if
through these changes the landholder becomes
traumatised, experiencing intense fear, helplessness, the gates may be locked or the gates damaged by the events. When this happens opportunities are missed and options are lost. The landholder is now experiencing both trauma and
grief. In this situation there is neither energy
nor motivation to carry out routine tasks.
The GATE-ways concept and program
This is a systematic concept of trauma recovery
that brings together Kitwood’s “Person
Centered Dementia Care”14, William’s construct of trauma15 detailed above, Self
Actualization16 , Gestalt Therapy17 18 and
Gestalt Art Therapy. Self-actualization is the
humanistic psychology, promoted by Abraham
Maslow based on the ideas of holism and actualization19. Gestalt (Psychotherapy) is the human
potential movement developed by Fritz Perls20.
“ Gestalt is” described by John O. Stevens and
Barry Stevens as “ a word for an orientation, a
description of the process involved in individual human awareness and functioning a rich
diversity of experiences” 21. Gestalt Art Therapy
was developed by Janie Rhyne, a pioneer Art
Therapist, who was trained by Perls, and worked with him in the human potential movement22. Rhyne23 combined the Gestalt experimental approach, which focused on sensations
and perceptions with the work of Rudolf
Arnheim24. In Gestalt Art Therapy a wide diversity
So this lack of maintenance can lead to the gates
not just being closed but becoming no longer
functional. At this stage if the gates are to be
reopened the landholder would benefit from an
external helper.
Sometimes when a number of gates have been
closed, the helper may need to find their way in to
the area to where the landholder has retreated.
For the landholder they may have retreated while
endeavouring to maintain their personal safety
and that is all they can manage. The helper needs
161
BackUp_8425_Research_1
04-06-16
17.16
Sida 152
GESTALT ART THERAPY FOR PEOPLE WITH DEMENTIA
of conventional and non-conventional art materials are used to express feelings and experiences
and it is the client who does the interpreting
with the assistance of the therapist. This is quite
a different the to the Eclectic Approach which
involves selections based on the beliefs and
values of the therapist25 or the Psycho-dynamic
Approach which follow a more formal structure
and where the interpretations are made by the
art therapist.
kinesthetic activities that promote safety, trust,
self-esteem the re-establishment of skills that
promote social intimacy. The role of Art
Therapist or the helper is to assist and to
encourage the reestablishment of skills and in
promoting awareness in the form of openended questions such as: What are you noticing? What are you remembering?
The GATE-ways program is constructed from a
number of resources26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
and is one that involves gentle exploration and
experimentation in a sensory enriched environment where the participation chooses the level
of involvement in the activity and interprets the
outcomes. This program involves all senses in
What are you feeling? It is important that
appropriate time for exploration of the medium
is given so that memories or ideas can become
more clearly formed and expressed that assists
with making meaning of life experiences and
events. It is through the finding meaning for life
experiences and events that the feelings of being
overwhelmed or out of control are reduce or
eliminatedo44 45 46.
Kitwood, T Dementia Reconsidered The person comes
first (1997) Buckingham Open University Press
15
Williams, Mary Beth (1999) Life After Trauma The
Guilford Press New York
16
Maslow, A Dominance, feeling, behaviour and status
Psychology Review, 1937,444, 404-429 Cited Murphy, G
( 1946) Personality a bio-social approach. Harper Bros
Publishers New York
17
Marcus, Eric (1980) Gestalt Therapy and beyond: An
Integrated Mind-Body Approach Preston Institute of
Technology Press, Melbourne
18
Smith Edward W.L. Ed (1977) The Growing Edge of
Gestalt Citadel Press Secaucus NJ
19
Shane, Paul (2002) The rise and fall of Gestalt Psychology
Australian Gestalt Journal, Vol 6. No.2
20
Perls. . F.S. Gestalt Therapy Verbatim Lafayette, CA: Real
People Press 1969
21
Stevens John O. (1975) Ed. gestalt is Real People Press
Moab Utah
22
Ruben, J(1999) ART THERAPY: An Introduction BRUNNER/MAZEL Philadelphia
23
Rhyne, Janie (1973) The Gestalt Art Therapy Experience
Brookes/Cole, Monterey, CA
24
Ruben, J (1998) ART THERAPY: An Introduction.
Edwards Brothers Lillington NC
25
Wadeson, H. (1980) Art Psychotherapy NY Wiley
26
Steven, John O (1971) Awareness: exploring, experimenting, experiencing. Real People Press Moab Utah
27
Rhyne, Janie (1973) The Gestalt Art Therapy Experience
Brookes/Cole, Monterey, CA
28
Rush, Anne Kent (1976) Getting Clear Body work for
women Wildwood House Ltd. London
29
Crowe B (1984) Play is a feeling Unwin Paperback Sydney
30
Oaklander, V. (1978) Windows on our children Lafayette,
CA: Real People Press
Edwards, Betty (1986) Drawing on the Artist Within: How
to release your hidden creativity William Collins Sons & Co
Ltd. Glasgow
32
Wadeson, H. (1985) The dynamics of Art Therapy NY Wiley.
33
Ruben, Judith (1987) APPROACHES TO ART THERAPY:
Theory and Technique Brunner Mazel Publishers New York
34
Cohen, B et al (1995) Managing Traumatic Stress through
Art: Drawing from the Centre. The Sidran Press Baltimore
35
McInally, A and Hatfield, (1998) Evaluating the use of
(Psycho-dynamic) Art Therapy for people with dementia A
Control Group Study Brighton Area Brach of the
Alzheimer’s Disease Society
36
Wadeson, H (1995) The Dynamics of Art Psychotherapy
John Wiley & Sons New York
37
Ruben, J (1998) ART THERAPY: An Introduction.
Edwards Brothers Lillington NC
38
Rosenbloom, D and Williams Mary Beth (1999) Life After
Trauma The Guilford Press New York
39
Waller, D.E. (1991) Becoming a Profession; The history of
Art Therapy in Britain, London Routledge
40
Wadeson, H (2000) The Dynamics of Art Psychotherapy
John Wiley & Sons Inc. New York
41
Innes, A and Hatfield (2001) Healing Art Therapies and
Person Centered Dementia Care Jessica Kingsley Publications.
42
Wylie, Kim (2001) Valuing sensation and sentience in
dementia care Unpublished (Nursing) dissertation
University of Newcastle NSW Australia
43
Thorgmison, L (2002) Quality of Life in Dementia PhD
Unpublished University College London
44
Frankkl, Viktor ( 1984) E. Man’s search for meaning
Washington Square Press Published by Pocket Books New York.
45
Kushner, Harold (1982) When bad things happen to good
people. Pan books
46
Kushner, Harold (1996) How Good Do We Have To Be?
A New Understanding of Guilt and Forgiveness VIKING
31
14
International Academy for Design and Health
162
BackUp_8425_Research_1
04-06-16
17.16
Sida 153
GESTALT ART THERAPY FOR PEOPLE WITH DEMENTIA
the sensory and kinesthetic criteria of a suitable
art materia in that it is sensual and non-threatening, it immediately signals a celebration.
Pavlova is obviously the refreshment served at
the end of the first session. The second session
involves making patterns with rice grains, subsequent sessions use more conventional art
media such as, pencils, inks papers and clay
together with the art media utilised by most
women, for self expression, textiles. This
research differs from previous care group
psychotherapeutic studies in that it considers
the value of person-centred approach to
dementia care in combination with the provision of efficient trauma recovery therapies.
GATE-ways for Women with Dementia and
their Carers in Australia
The current study of “GATE-ways for Women
with Dementia and their Female Carers” is
being conducted in rural New South Wales
Australia. Each group will consist of three to
five women and one carer,(employed by the
facility and the Art Therapist. The sessions are
of 1-hour duration and two mornings a week
for six weeks. This current psychotherapy project is assessing two trauma recovery programs,
(1) “GATE-ways (Gestalt Art Therapy
/Experiential)-ways to recovery”47 and (2) a
subsection
of
“GATE-ways”,
“Eass”
(Experiential anxiety self-soothing). The programme uses both quantitative methods to
assess a variety of cognitive and behavioural
indices with the women with dementia and
quantitative and qualitative measures with the
female carers.
GATE-ways can be used in other countries and
cultures providing that the customs and cultural
heritage are respected and by giving consideration to the participant’s rights, beliefs, perceptions of both individuals and to groups.
Both programs start the reduction in anxiety
with ‘Ease’ “Experiential Anxiety Self-soothing
exercises”. Ease combines exercises of “drawing
breath”48 with increased awareness of
breathing49 and making patterns50. ‘Ease’ involves the person holding one hand on the lower
rib cage and noticing what happens when
breathing in and out. What changes occur if
the person draws breath more slowly…? More
quickly…? This focus, on the way in which
breath is drawn, encourages more control in the
breathing and in turn heart rate and adrenaline
output enabling the participants to feel safer
and less anxious
Resources required for each “GATE”
Safety
Art Materials
To support further the sense of safety, the art
materials need to be familiar, have smooth texture and be easily moved or manipulated by one
person only. This could be soapsuds, shaving
cream, or meringue on a colour plate. To give
a visual form to the drawing of breath, marks
can be made with the other hand to indicate the
movement of the rib cage. This process needs
to be slow to establish a reliable foundation for
other activities.
Refreshments
Preferably festive food that is relevant for the
landholder but if using meringue as an art material, cooked meringues in various styles, and
lemonade or apple juice would be appropriate.
This complete GATE-ways program has been
designed to reflect the experiences, and meet
the needs of the participants, the majority of
whom have been born in Australia. The first
session of the GATE-ways program in Australia
is exploring the patterns of breathing by making
marks in a mixture of beaten egg whites and
sugar. In Australia, Pavlova a confection of egg
whites, sugar, beaten to froth and then baked is
a festive dessert. It is something most women in
Australia would have made, so it is familiar and
safe. In addition, it not only effectively meets
Muir, Margaret (2002) Gestalt Art Therapy/Experiential
Trauma Recovery programs (unpublished)
48
Cohen, B et al (1995) Managing Traumatic Stress through
Art: Drawing from the Centre. The Sidran Press Baltimore
49
Steven, John O (1971) Awareness: exploring, experimenting,
experiencing. Real People Press Moab Utah
50
Rhyne, Janie (1973) The Gestalt Art Therapy Experience
Brookes/Cole, Monterey, CA
47
163
BackUp_8425_Research_1
04-06-16
17.16
Sida 154
GESTALT ART THERAPY FOR PEOPLE WITH DEMENTIA
Trust
lop their skills. This section is about selfexpression through lines, direction of the
objects, colours, shapes, different sizes, tonal
contrasts and changes in textures. The making
of three-dimensional (3-D) objects could be
helpful to the person. It may be useful to group
materials in clusters e.g. textiles with needles
and thread; wood with wood glue.
Refreshments
Given that the artwork may be joining objects
or ideas together, food that is joined such as slices or cakes, or sweets that have two or more
layers. The drinks could involve adding water
or soda to syrup.
Art Materials
To consolidate the sense of safety, the material
needs again to be familiar but be of a harder texture such as grains or seeds on a metal tray. The
person would again make marks in the grains but
after a few minutes, the assistant or peer would
then take a turn in the same tray of grain. Then
the two people would share the space, making
patterns, negotiating non-verbally how to utilise
the space. Allow time for the process before
beginning to talk about what has been happening
or any memories that have resurfaced.
Refreshments
The refreshments need to relate to the medium
e.g. corn is the grain then foods from corn. The
drinks could be milk or juice.
Social Intimacy
Art Materials
The person may enjoy continuing or developing the previous activities or they may work in
a new media eg. dough or clay making, 3-D
objects, or an idea developed with a partner.
The emphasis in this session is co-operation,
e.g. by holding onto something or passing
something to someone; making a helpful suggestion that would make the activity easier.
Refreshments
Cake, chocolates, cordial, tea coffee would provide reminders of other times when co-operative efforts were enjoyed.
Re-establishment of skills (Mastery)
Art Materials
Following the re-establishment of safety and
trust it will be time to start the re-establishment
of former skills such as writing or drawing. The
materials would be those that are culturally relevant to the person, the materials may include
papers, pencils, inks, and paints. Depending on
the occupation of the person other media such
as textiles, wood, or metal may be appropriate.
Refreshments
Food and drinks that relate to school or work,
e.g. sandwiches, Bento boxes or items that
would assist are the recall of memories associated with schooling or other learning.
Conclusion
It has been shown that group psychotherapeutic
programs for people with dementia enable and
encourage positive changes. It is important that
facilities have adequate and private space to conduct group psychotherapy sessions so that fear,
helplessness and loss of control can be replaced
with calm, self-esteem and social interaction.
Self-Esteem
Art Materials
The person will have more confidence when
they have begun to re-develop or further deve-
International Academy for Design and Health
164
BackUp_8425_Research_1
04-06-16
17.16
Sida 155
GESTALT ART THERAPY FOR PEOPLE WITH DEMENTIA
Postscript
Pavlova one of Australia’s contributions to the culinary world was named after the great ballerina
Anna Pavlova. The classic Pavlova has a crisp meringue outside, delicate marshmallow-like softness on
the inside. The aim is to leave the confections outside
white and crisp while leaving the inside soft and creamy. When cooked this confection is decorated with
cream and fresh fruit.
of vinegar; 1 teaspoon of vanilla; whipped cream for filling and fruit or other toppings of your choice.
Method
Beat the egg white and water in a glass bowl at high
speed until soft peaks form. Add sugar, 1tablespoon at
a time, beating well after each addition. Stop beating
when all the sugar has been incorporated and then
fold in vinegar and vanilla. Pipe (or pile mixture) in
a 20cm circle onto baking paper on a flat tray. Cook
at the lowest temperature for 1-_ hours until it is
crisp. When cooked, remove from oven and cool completely before adding cream and fresh fruits.
Ingredients
6 egg whites, at room temperature; _ teaspoon of cold
water; pinch of salt; 2 cups of castor sugar: 1 _ teaspoons
Sinclair, E Ed .(1982) The Australian Women’s Weekly
Original Cookbook Golden Press Pty Ltd Sydney pp 17-174
51
165