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Running head: THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 1

Thesis Proposal: Determining the Efficacy of Art Therapy for Mild to Moderately Depressed

Older Adults

Jo-Anne van Draanen

Toronto Art Therapy Institute

May 27th, 2014

THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 2

Thesis Proposal: Determining the Efficacy of Art Therapy for Mild to Moderately Depressed

Older Adults

Introduction:

This study proposes to determine whether participation in art therapy for depressed older

adults (between the ages of 68 – 88) living in a long term care facility lowers their level of

depression. Art Therapy may be a viable part of a multi-disciplinary team approach as it is a tool

used to provide individuals with a medium for emotional expression. In particular, it can give

older adults (OA) the opportunity to reduce their social isolation and give them an environment

where autonomy and choice are still options (Waller, 2002).

Problem:

Depression is a significant concern among older adults. Studies show that up to 20% of

Canadian older adults living independently in the community suffer from depression. This

percentage increases to 25% for those older adults with a serious medical illness or those in the

early stages of Alzheimer’s disease. For those older adults living in a long term care facility, the

percentage suffering from depression raises from 30% – 50% (www.cpa.ca).

According to the 2011 census, there are currently over 11 million adults living in Canada

who were born between 1941 and 1965. This is a huge increase from the over 3 million born

between 1919 and 1940. There is a large group of baby boomers who are just entering older

adulthood and today, they can expect to live longer than those in generations before them.

Today the average ago for men is 78 and for women it is 83 (www.cboc.ca). Given the

prevalence of depression in older adults, with this increase in the demographics of older adults

here in Canada, depression may have an overwhelming impact not only on the individuals

affected by this but also on their family, the long-term care facilities where these adults may live


and our health care system. With a rapidly increasing aging population, the treatment of

depression in this group should be treated as a priority (Rodda, Walker, & Carter, 2011).

Fiske, Wetherell, and Gatz (2009) suggest that “a common pathway to depression in

older adults, regardless of which predisposing risks are most prominent, may be curtailment of

daily activities Accompanying self-critical thinking may exacerbate and maintain a depressed

state” (Fiske, Wetherell, & Gatz, 2009). With this in mind, it could be suggested that adding an

activity with an older adult in and of itself may assist in the lessening or alleviation of the

depressive state they are in. When this activity is art therapy, the benefits may go beyond that of

a simple activity to an opportunity for exploration and growth, an opportunity to work through

past disappointments and to move forward, embracing the ups and downs of life with renewed

confidence.

With older adults in particular, emotional needs may sometimes be overlooked as the

physical health issues they may be experiencing take precedence. Art therapy is one way to

respectfully, efficiently and comprehensively address the emotional needs of older adults. Art

therapy offers the opportunity for healing by providing social connection, and the chance to

express and manage emotions. It allows for deep nonverbal communication possibly for those

for whom verbal communication is a challenge. It offers hope and provides an opportunity to

create meaning through life review (Johnson & Sullivan-Marx, 2006).

Waller (2002) states that older adults often live with consuming levels of hopelessness

and despair due to all the losses they have suffered (for example the end of their working life,

children grown, possible death of a spouse, physical ailments that may limit mobility, loss of

their home etc.) . Art therapy allows them to express their deep sadness at the losses they are


experiencing. Art therapy is a meeting of the therapeutic process and the creative process. It is

communication that can be felt, seen and heard (Johnson & Sullivan-Marx, 2006).

Aim of Study

This study will attempt to determine whether adding art therapy into the weekly routine

for depressed older adults will assist in decreasing the level of depression they are currently

experiencing. The study hypothesis is that after an eight week art therapy one-on-one

experiential with a qualified art therapist, levels of depression will decrease in older adults

currently suffering from mild to moderate depression.

Research Question

Will eight weeks of one hour a week, individual art therapy sessions decrease mild to

moderate levels of depression in older adults living in a long term care facility?

Rationale

To date, little research has been done on art therapy with adults in a long term care

facility. This proposed research will offer insight into therapeutic alternatives for older adults in

long term care facilities. More specifically, it will suggest ways that may decrease the levels of

depression thereby increasing the quality of life of these older adults. This study will add depth

to the current research done on older adults and depression and will offer a concrete possibility

for assisting in the treatment of depression with this population. This study’s findings can be

transferred into other long term care facilities and also general day programs for older adults.

The study will also offer physicians another treatment modality in treating their older adult

patients who suffer from depression. This study will provide clinical support for the increased

use of art therapy as part of a treatment plan for older adults suffering from depression.


Addressing the issue of depression with older adults will assist in bringing the issue to the

fore front, thereby helping to dispel the stigma, shame and guilt that sometimes accompanies this

illness in older adults today.

This study will also add additional credence to the field of art therapy, thereby increasing

the awareness and validity of the profession of art therapy. It will enhance and build upon the

current existing research, and expand on a population segment that is current in need of support

for the ever increasing illness of depression.

There are significant implications for the art therapist working with this population as

well. There will be an opportunity to develop and prefect directives which focus on successes

and disappointments, opportunities for coming to terms with one’s life and understanding the

purpose and meaning in life. This research will offer an opportunity to expand the current

understanding of the needs and desires of older adults faced with depression. The study will also

highlight how reflecting and reminiscing over one’s life can be of benefit to older adults. These

findings will be transferable into situations with older adults, other than long term care facilities.

Services such as community day treatment programs, senior’s day care centres, respite programs

or hospital based senior’s programs could all benefit from offering art therapy to older adults.

Definitions of Terms

Older Adults – Men and women, age 65 and older.

Long Term Care Facility - It is a place of residence for people who require continual

nursing care and have significant difficulty coping with the required activities of daily living.

Nurses and nursing aides are available 24 hours a day. A doctor is on staff and visits each

resident on a weekly basis or more often if there is a critical or specific need. Recreation staff

offer daily leisure activities for residents. This facility offers a few single rooms, several double

http://en.wikipedia.org/wiki/Activities_of_daily_living

http://en.wikipedia.org/wiki/Nursing


rooms and a majority of rooms with four residents per room. Women room with women and

men room with men except in the case of a married couple, in this case they would share a room.

This particular Long Term Care Facility is part of a chain of residences that was founded in

1972. They have homes through-out Ontario and British Columbia. The facility where this

study will be carried out is in Scarborough, Ontario.

Mildly Depressed as defined by the DMS-V – One of the following: depressed mood,

loss of interest and enjoyment in usual activities and / or reduced energy and decreased activity

AND one or two of the following: Reduced self-esteem and confidence, ideas of guilt and

unworthiness, pessimistic thoughts, disturbed sleep, diminished appetite and / or ideas of self

harm.

Moderately Depressed as defined by the DMS-V – One of the following: depressed

mood, loss of interest and enjoyment in usual activities and / or reduced energy and decreased

activity AND two or three of the following: Reduced self-esteem and confidence, ideas of guilt

and unworthiness, pessimistic thoughts, disturbed sleep, diminished appetite and / or ideas of self

harm.

Severely Depressed as defined by the DMS-V – All of the following: depressed mood,

loss of interest and enjoyment in usual activities and / or reduced energy and decreased activity

AND at least three of the following: Reduced self-esteem and confidence, ideas of guilt and

unworthiness, pessimistic thoughts, disturbed sleep, diminished appetite and / or ideas of self

harm.


Literature Review

Depression in Older Adults

As a society, depression is often seen as part of the natural aging process for older adults

but this is not the case. Older adults do not suffer from depression as a result of aging. Children

leaving home and relocating, and / or the death of a spouse, sibling and / or friends may

contribute to depression in older adults as there is less of a social support network and bonding

relationships may be different or changed. There might also be a change in financial or social

status as adults’ age. Older adults are also faced with decreased mobility often, especially if they

live in a long term care facility. The day to day activities of an older adult living in a long term

care facility would be significantly different to what they would have been accustomed to, once

again, adding to a greater propensity towards depression (Stickle & Onedera, 2006). All of these

examples would be much more a cause for depression than the simple process of aging itself.

Waller (2002) noted: “Living and working with older adults who know that the life they

took for granted is gradually disappearing, that they may be physically and mentally declining

but they do not know how long this will go on for, and that the outcome will be that they will be

totally dependent on others, is hard in itself. Living in environments where they watch others

deteriorate and disappear, and know that is probably going to be their fate, is hellish.” (Waller,

2002, p. 6) This is exactly the situation for those living in long term care facilities. They are

surrounded by their peers who are all in various states of decline. Older adults also experience

on a daily basis, changes that have huge impact such as deteriorating vision and hearing. The

toll that this all takes is huge.

Depression in older adults can be difficult to diagnose as it can be overlooked as a

symptom or another medical condition. Depression worsens an older adult’s experience of


medical problems and makes it harder for them to recuperate as they tend to become less active

and independent when depressed which can lead to a decline in their overall physical condition

and can lead to greater disability (www.cpa.ca).

With older adults in particular, emotional needs may sometimes be overlooked as the

physical health issues they may be experiencing take precedence. Art therapy is one way to

respectfully, efficiently and comprehensively address the emotional needs of older adults. Art

therapy offers the opportunity for healing by providing social connection, and the chance to

express and manage emotions. It allows for deep nonverbal communication possibly for those

for whom verbal communication is a challenge. It offers hope and provides an opportunity to

create meaning through life review (Johnson & Sullivan-Marx, 2006).

Depression among older adults can occur in response to chronic physical impairments.

Since approximately 80% of older adults have at least one chronic condition, it is easy to see

how this medical condition could add to one’s emotional distress or depression. Conditions

often seen include but are not limited to older adults in Parkinson’s disease, stroke, Alzheimer’s

disease, dementia, cancer, arthritis and sensory loss to name just a few (Stickle & Onedera,

2006).

Research has shown that older adults suffering from depression are more likely to have

been exposed to risk factors as children, such as poverty, and parental separations. Many older

adults with depression may have experienced similar depressions in early life but may have had

better coping resources in the past, such as better physical health, family protection, special skills

or mental health services. Some adults may have been better able to address symptoms related to

depression earlier on in life (Stickle & Onedera, 2006, p. 39). They also found that events like

marital and work-related experiences may be predictive of depression in later life. Achievements


or life dreams not attained, an unsuccessful marriage may produce shame, disappointment and /

or discouragement.

Studies show that up to 20% of Canadian older adults living independently in the

community suffer from depression. This percentage increases to 25% for those older adults with

a serious medical illness or those in the early stages of Alzheimer’s disease. For those older

adults living in a long term care facility, the percentage suffering from depression raises from

30% – 50% (www.cpa.ca).

According to the 2011 census, there are currently over 11 million adults living in Canada

who were born between 1941 and 1965. This is a huge increase from the over 3 million born

between 1919 and 1940. There is a large group of baby boomers who are just entering older

adulthood and today, they can expect to live longer than those in generations before them

(www.cboc.ca). Given the prevalence of depression in older adults, with this increase in the

demographics of older adults here in Canada, depression may have an overwhelming impact not

only on the individuals affected by this but also on their family, the long-term care facilities

where these adults may live and our health care system. With a rapidly increasing aging

population, the treatment of depression in this group should be treated as a priority (Rodda,

Walker, & Carter, 2011). Finding cost-effective, self-directed, and safe methods to alleviate

and/or prevent depression will assist healthcare providers and others to facilitate health and well-

being in older adults.

Depression is not a sign of weakness nor is it a problem that can be just willed away.

People who are depressed cannot just snap out of it. Without proper treatment, depressive

symptoms can last for months or years and may worsen (Alexopoulos, Katz, Reynolds, & Ross,

2001).


Depression is an illness that is more than just a sad feeling. Depression in older adults

has wide ranging effects. Specifically, depression in older adults may include physical changes

such as a change in appetite, sleep disturbances, decreased energy and / or stomach upsets. A

change in thinking might also be noted. For instance, avoiding decision making because it is

difficult or obsessive ruminations with a sense of impending doom or a loss in self-confidence

might be evidenced as a sign of depression. Loss of interest in activities that once brought

pleasure or feelings of worthlessness, hopelessness and excessive guilt might become evident.

Crying for no apparent reason or irritability, impatience and anger are also signs of depression.

Changes in behaviour might also indicate depression, for instance withdrawal from social and

leisure activities or a decrease in physical activity, or reduced self-care such as personal

grooming may indicate depression. Any combination of all or some of these symptoms could

indicate depression (www.mooddisorders.ca).

Fiske, Wetherell, and Gatz (2009) suggest that “a common pathway to depression in

older adults, regardless of which predisposing risks are most prominent, may be curtailment of

daily activities Accompanying self-critical thinking may exacerbate and maintain a depressed

state”. It is their belief that life review or reminiscence is not done often enough (Fiske,

Wetherell, & Gatz, 2009). With this in mind, it could be suggested that adding an activity such

as art therapy with an older adult may assist in the lessening or alleviation of the depressive state

they are in. In particular, it would be important to offer art directives that focused on life review

and reminiscence.

Research Pertaining to Art Therapy

There has been some interesting research to date on the validity of art therapy with both

general populations and older adults. Rusted, Sheppard and Waller (2006) in their study using


art therapy with older adults with dementia, found very positive results. Not only did the quality

of life and depression measures improve, the improvement was also sustained over time. Their

study provides clear evidence of positive and durable benefits with regard to mental alertness,

sociability, physical and social engagement in study participants (Rusted, Sheppard, & Waller,

2006). Likewise, Gussak (2007) in his study on the effectiveness of art therapy in reducing

depression in prison populations, found strong correlations between participation in art therapy

and decreased depression. Improvement in the inmates’ socialization and problem-solving

abilities was also noted (Gussak, 2007). Hanser (1990), Johnson & Sullivan-Marx (2006),

Phillips (2007), Pot, Bohlmeijer, Onrust, Melenhorst, Veerbeek and De Vries (2010) and

Slayton, D’Archer & Kaplan (2010), in their studies or their review of studies, found a positive

correlation with art therapy (or in one case music therapy) and gains in overall sense of well-

being. Participants using art therapy made fewer contacts with mental health providers or

medical specialists. They experienced fewer somatic symptoms and complaints and reduced the

use of medical and mental health services (Slayton, D’Archer, & Kaplan, 2010, p. 116).

Interestingly, older adults who participated in art therapy were found to have fewer falls than

control group members and they were found to use less medication than their control group

counter parts (Johnson & Sullivan-Marx, 2006, & Phillips, 2007).

In considering art therapy with older adults, it is important to take into consideration the

roles of the left and right hemispheres of the brain. The left side of the brain contains the

language center; information processed here is labeled, linear, and orderly. The left hemisphere

functions are considered to be verbal, analytic, rational and abstract. The right side of the brain

is oriented to processing visual-spatial information. Information processed by the right side of

the brain is intuitive, emotional, and spiritual (Malchiodi, 1999, p. 30). The right hemisphere


main functions are preverbal, synthetic, and concrete. Without words, and using images instead,

information is more likely to be processed on the right side of the brain and to contain emotional

and spiritual truths (Hinz, 2006, p. 17). This is particularly important to keep in mind as many

older adults lose some cognitive abilities. Stroke and Alzheimer’s and / or dementia may well

play a part in the health and well-being of the older adult. With a possible change in how the

older adult has use or uses the right and left hemispheres, art is a medium of expression that is

conducive to working with these changes offers hope and a voice where there might not have

been one before. Art therapy has the ability to bridge the gap between a person’s inner and outer

worlds. Art making allows the non-verbal brain to ‘speak out’ in its own language.

One other benefit of art therapy that should be mentioned here would be in the process of

art making itself. This process, where an older adult is encouraged to try a myriad of different

art materials, where the older adult is able to make decisions for themselves and where they are

given a voice, also builds confidence that they can successfully learn and adjust to roles required

by their present circumstances. Art therapy can be used to support coping skills when they face a

loss of independence, loss of choices, or a loss of health. Older adults can also express

satisfaction over their production of art pieces, adding to a strong sense of self, who they are and

what they are capable of (Johnson & Sullivan-Marx, 2006).

Erik Erikson’s 8 Stages of Psychosocial Development Theory

Erik Erikson, in his Eight Psychosocial Stages of Development Theory, refers to the final

stage, stage eight, which occurs in late adulthood, as the stage of Ego Integrity versus Despair.

In brief, successful resolution of the eighth stage takes place when the individual can accept what

has gone before as inevitable and satisfying, and they realize the meaning and purpose in their

life. They can also accept without fear that death will occur probably in the not too distant


future. This will result in ego integrity. If a person feels that his or her life has been a failure, and

that it is too late to start in a new direction, then he or she will be filled with despair (Brown &

Lowis, 2003).

This despair that Erikson refers can be seen manifested in the depression that so many

older adults living in long term care facilities are afflicted with. In art therapy, if the desire is to

lessen depression, following Erikson’s Developmental Theory, it would stand to reason that

working towards integrity, and the understanding of the meaning and acceptance of the older

adult’s life, and the acceptance that life was satisfying, would be a logical goal. Using art

therapy to look at a client’s life story with the aim of reviewing and re-authoring that life story,

would allow the older adult to process their life with the benefit of wisdom and hindsight.

Possible Art Therapy Directives for working with Older Adults

Art directives such as life maps would become a visual representation of the life journey

both outwardly traveled and inwardly lived. It would also be a powerful prompt for more

specific reminiscences in the life review process. Creating boxes that were representative of

their inner and outer selves would also allow the older adult to differentiate, understand and

represent both their inner selves and the outer self their share with the world. Possible directives

around smells from the past, houses lived in, and turning points would all allow the older adult to

look over their life in review and find acceptance in their life as they have lived it (Pot et al.,

2010). Using photographs and images found in magazines or created, a memory book might be

created to allow the older adult to process any losses they might be grieving and honouring the

people in their lives (Johnson & Sullivan-Marx, 2006).


Bringing the Pieces Together

The facts are straightforward: depression in older adults living in long term care facilities

is a common reality. Art therapy has been shown to be effective in lessening depressive

symptoms in older adults. Erik Erikson postulates that the goal for older adults is to resolve the

conflict between ego integrity and despair. Offering a series of art directives that lead the older

adult on a journey of discovery and reconciliation with the goal being to understand the meaning

and acceptance of their life, and the acceptance that life was satisfying would be an effective

method to assist the older adult in decreasing their level of depression.

Research Design

This study will be a single-subject pre / post-test research design which will look at

cause-and-effect relationship between art therapy and depression by comparing individual’s pre-

and post-intervention responses. The same participants will serve as both the experimental and

the control sample. Measures of the baseline condition of depression will be made by a staff

member at a Scarborough Long Term Care Facility (LTCF) using the Geriatric Depression Scale

Short Form. An eight week art therapy one-on-one intervention will be offered to all

participants. At the conclusion of the eight weeks, the same staff member will once again

administer the Geriatric Depression Scale Short Form. The results of the second Geriatric

Depression Scale will then be compared with the first baseline data in order to see if the

treatment effected a change (Kapitan, 2010, p. 58). After each of the eight week sessions, a

visual assessment will also be made by the art therapist and this simple qualitative assessment

will be included with the final findings.


Sample

Participants for the study will be drawn from residents at a Scarborough Long Term Care

Facility. A group of 39 residents who have received a diagnosis of depressive episode by a

physician at the Long Term Care Facility within the past two years will be approached to see if

they would be interested in participating in this study. Once interest is ascertained, and consent

forms have been signed, the Geriatric Depression Scale will be administered to all those

interested by one of the staff at the long term care facility. A final group of potential participants

will be formed based on a depressive rating (greater than 5) using the Geriatric Depression Scale.

If this final group contains more than 10 potential participants, 10 participants will be randomly

selected from this group by means of computer assisted random selection to participate in the art

therapy sessions. If this group of potential participants is less than 10, the entire group will

participate in the art therapy sessions. These residents will range in age from 68 – 88 years old.

The art therapy sessions will take place over eight weeks at the Scarborough LTCF in one of the

sun rooms at the back of the facility.

Instruments

A variety of art directives will be used, focusing on a life review, offering participants the

opportunity to make meaning of their lives. Quantitative models require structured procedures

that will identify all the interacting variables, in other words, pre-determined directives offered to

each participant in the same order. This would be done in order to reduce error and bias so that

if the premises are correct, the conclusion can be deduced from the data and assumed to be

correct rather than due to extraneous or untested variables (Kapitan, 2010, p. 54).


If at all possible, the following directives will be used:

Creating a self-portrait;

Creating a piece of art around their life journey, mapping their journey;

Creating art around the idea of boxes that house their inner emotions and what

they show the world on the outside;

Creating art around smells from the past;

Creating art around the community of selves (woman, wife, mother, sister, etc.);

Creating art around the houses they lived in;

Creating art around their weddings (if they were ever married) or the birth of their

children; and

Creating a memory book.

Unfortunately, this may not be possible with this research as the student art therapist will

need to have the option of being spontaneous, using inductive reasoning and the flexibility to

make creative shifts to meet the evolving needs of participants (Kapitan, 2010, p. 54). Along

with the art directives will be a variety of art materials including but not limited to: a variety of

types of paint, clay, crayons, pencil crayons, markers, and collage materials.

The Geriatric Depression Scale, created by Dr. Jerome Yesavage in 1983, will be used as

a pre- and post-test measure for depression. There has been significant research over the years,

all indicating that this tool is highly successful at determining depression in older adults. The

research also has determined that it is best administered by someone other than the older adult

(Almeida & Almeida, 1999; Hermann et al, 1996; Montorio & Izal, 1996). Although there are

several versions of this measure, with the original being a 30 point scale, this scale was revised

in 1986 to a 15 point scale. The validity of the scale remained strong and therefore, for the


purposes of this study, the 15 point scale, also known as the ‘short form’ will be used as it is as

valid as the long form but more sensitive to the needs and abilities of the older adult population.

See Appendix A.

Procedures

Participants will attend a 60 minute art therapy session once a week for eight weeks.

These sessions may be shorter in duration if needed by the participant. The researcher is aware

that older adults tire easily and can also become confused or disoriented and that might lead to a

shorter time period for the art therapy. Where at all possible, the effort will be made to have the

sessions be consistently set at 60 minutes.

Prior to the sessions beginning, the Geriatric Depression Scale that will be administered

by the facility staff member to each participant individually. They will also sign the necessary

consent forms from the TATI. After the completion of the eight weeks of art therapy, they will

once again complete the Geriatric Depression Scale that will be administered by the same facility

staff member. All forms will be collected by the researcher for analysis at the end of the study.

Risks / Discomforts / Confidentiality

It will be made clear to all participants that they may withdraw at any point in time. The

potential risk of working with difficult emotions will be made clear to all participants and they

will be assured that everything that happens in the art therapy sessions will remain confidential.

It will be stressed to all participants that the only time this confidentiality bond will be broken is

when there is disclosure that the participant is harming others, or that the participants is being

harmed or that the participants is harming or has plans to harm themselves.


Benefits to Participants and the Long Term Care Facility

This study will offer the participants the opportunity to experience art therapy and the

benefits it provides (increased communication, alternate means to communicate, a relaxing

experience to name just a few). The Scarborough LTCF will benefit from having art therapy

offered to 16 of their clients and also from the study’s outcomes. It is the researcher’s beliefs

that they will see the benefit of offering art therapy to their clients as the level of depression in

these clients will have improved.

Qualifications of Investigator

The investigator for this study is a graduate level student in art therapy. With an

undergraduate degree in Psychology and Sociology and years of experience working with older

adults, including older adults with Aphasia, this researcher is well versed in communication and

engagement strategies for this population. This researcher has been previously published and is

well versed in research methodology.


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thesis proposal: determining the efficacy of art … · web viewthis study proposes to determine...

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