Art Therapy: Using the CreativeProcess for Healing and HopeAmong African American OlderAdults

Carol M. Johnson, BSN, MA, ATR-BC, and Eileen M. Sullivan-Marx,

PhD, CRNP, FAAN

This article provides an introduction to thefield of art therapy and the potential it canoffer to address the emotional needs of thefrail elderly. Two case studies are discussed,and examples of artwork are provided. Thecase studies and artwork were created underthe guidance of an art therapist at a Programof All-Inclusive Care for the Elderly (PACE)site in an urban African American commu-nity. This article explores how art makingaddresses the specific developmental tasksof the elderly in a culturally competent man-ner. Included are practical considerations inthe choice of art media and directives forworking with elderly clients, as well as re-sources for further information on the use ofart in therapy. (Geriatr Nurs 2006;27:309-316)

Addressing the emotional needs of frail el-derly clients in today’s health care envi-ronment can be challenging. At times

emotional needs can be inadvertently over-looked because of the many physical healthproblems the client is experiencing. Art therapyis one way to address—respectfully, efficientlyand comprehensively—the emotional needs offrail elderly in a culturally competent manner.Art therapy offers healing by providing socialconnection, the experience of control and theopportunity to both express and manage emo-tions. It offers hope by facilitating nonverbalcommunication and providing opportunity tocreate meaning through life review.

Case studies and artwork gleaned from a Pro-gram of All-inclusive Care for the Elderly(PACE) serving frail elders in an urban AfricanAmerican community are discussed.

What is Art Therapy?

Grounded in human developmental theory,psychological theory, and current research in

the field, art therapy is “a meeting of the thera-

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peutic process and the creative process”1 (pp.4–5). The field of art therapy combines the po-tent resource of art with the creative process tobring healing and hope, thereby helping clientsmake meaning of their lives. Art making is com-munication that can be felt, seen, and heard. It isan assertive act, giving the client a measure ofcontrol and opening up creative discoveries andpossibilities for change.1-3

At PACE programs, older adults who are oth-erwise eligible for nursing home care continueto live in their homes in the community and areprovided transportation to a center where theyreceive comprehensive health services in an in-tegrated team model. Primary health care, in-cluding dental, podiatric, nursing, rehabilitative,recreational, and social services, are coordi-nated by an interdisciplinary team with the cli-ent and family financed by Medicare and Med-icaid in a capitation payment model.4 Arttherapy, provided individually or in a smallgroup format, has been a component of care atthe PACE program described in this article.

Art Therapy and Older AdultsArt is a concrete living expression of the lives whichhave created it and thereby a connection to tomorrow.3

(p. 9)

In their book Expressive Arts with Elders,Weisberg and Wilder quoted octogenarian sculp-tor Edna Eckert: “I think creative people areoften long-lived because we are always re-in-venting life; what we did yesterday, we createanew tomorrow. Inherent in this process ishope”3 (p. 25). Art therapy offers a unique op-portunity to help elderly clients engage in thecreative process to facilitate communication,manage emotions, and engage in the process oflife review. The art therapy process offers socialconnection, opportunity for control and

choices, improvement in physical and mental

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health, and a vehicle for nonverbal assessment.Each of these areas are now discussed.

Communication

Art therapy offers a nonverbal way for indi-viduals to be seen and heard and provides analternative form of communication for thosewith language impairment.3,5 This artwork inFigure 1, (“Colors”), created by a client whoexperienced a language deficit, reflects nonver-bal expression through appropriate choice ofmaterials and the opportunity to experimentwith a variety of paint colors. The tangible prod-uct created by the client allows others, includ-ing staff and family members, to recognize theindividual’s expressive abilities.

Managing Emotions

Participation in creating art provides a mech-anism for portrayal and resolution of emotion.The multisensory experience of art making un-leashes a creative process that can energize,stimulate memory, free emotions, and increaseactivity level.5-10 Creating art had a calming ef-fect on an agitated client, whose artwork isshown in Figure 2 (“Dots”). This client, diag-nosed with Alzheimer’s disease and agitation,could participate in creating art using paintmarkers. The structure and repetition of thismedia enabled her to focus and direct her en-ergy into art making. As a result, she remainedcalm and felt a sense of pride in the completedartwork.

Life Review

Telling of stories is a value held by African

Figure 1. “Colors”

American older adults.11 African American cli-

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ents who are facing declines in cognition,health, and ability to communicate can use artas a means to share life stories. Furthermore,expressing oneself through art creation helpspeople understand the meaning of their lives.This can foster achievement of Erickson’seighth stage of development, that is, ego integ-rity versus despair, and can also help expandpsychological development in this stage.12 Tell-ing their own stories through art allows clientsto share wisdom, leave a legacy, and find mean-ing in their lives.12-14 Art therapy creates a safeplace for clients to tell their own stories in lifereview, promoting self-awareness and accep-tance of past experience. Figure 3 shows part ofa small group timeline project that documentedpersonal as well as national and internationalevents. Sharing similar and common experi-ences invariably inspires other group membersto tell their stories, lending a sense of universal-ity and emotional connection.6,14,15 The oppor-tunity to reminisce and to have others partici-pate in the reminiscence honors their historiesand helps clients find meaning in their lives.

Social Connection

The small-group format of art therapy groups(5 to 7 clients) can help to decrease social iso-lation and offer connection and support.3,6,10,15

An art therapy group can provide a safe placefor social exchange, personal stories, and theexperience of working together. Sharing mate-rials and assisting one another provides the ex-perience of altruism. A client who can only use1 arm can be helped by another client to openmarkers or to tape down her paper while she

Figure 2. “Dots”

paints. One who can see clearly can help a client

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who is visually impaired. This can help clientsrealize their strengths and is a reminder thatthey still have something to give.16

Instilling Hope

Learning new things through art makingbuilds the confidence that one can successfullylearn and adjust to new roles required bypresent circumstances. Sharing wisdom and sto-ries in a small-group format can help integratepast and present circumstances, resulting in adecrease in depression and an increased sense

Figure 3. Timeline Project

of hope.1,8,10,16,17

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Offering Control

Using art in therapy provides the client theopportunity to make decisions, take responsibil-ity, and have control. This is often a profoundexperience for a population in which much op-portunity for control and choice has beenlost.6,10,15-17

Improving Physical and Mental Health

A growing body of research suggests that cre-ative activity can to restore, maintain, improvemental and physical health, and increase activ-

ity levels.1,3,7,8,10,16

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The authors of a study of 55 patients under-going treatment for cancer reported a statisti-cally significant reduction in pain, tiredness,anxiety, and fatigue that patients experiencedafter undergoing an art therapy session.7 Manyparticipants commented that participation in arttherapy actually gave them energy. In anotherstudy of 300 senior citizens, the authors notedthat individuals who participated in the artgroups made fewer visits to the doctor, fell lessoften, used less medication, and were less likelyto be depressed than the control group and alsoexperienced an increased sense of well-being.17

Providing Assessment Opportunities

In addition to the artwork itself observing andassessing the process of creating art can providea nonverbal avenue for assessing cognitive anddevelopmental deficits.18 Equally important,whether through taking the risk to try to learnsomething new or rekindling an interest fromthe past, art making can help the individual, andthe staff or family, recognize his or her availablestrengths and resources that often could nothave been uncovered in any otherway.1,6,9,10,13,15,16

The continuity of aging theory espouses thatindividuals incorporate lifetime coping strate-gies to adapt to changes in later years.19 Arttherapy is an adjunct that can be used to sup-port coping skills when an older person facesloss of independence, loss of choices, or loss ofhealth. Individuals with dementia, who mayhave lost verbal skills can express their feelingsthrough use of bright colors and tactile interac-tion with painting materials. Art therapy canfacilitate use of successful coping skills thathave been accumulated throughout an olderadult’s life by enabling the expression of satis-faction in group work as well as individual self-reliance as the art is produced and shared witha community. The opportunity to support othergroup members can help clients identify and usetheir own strengths. Working together on agroup project, such as a mural, can link peopletogether, giving a sense of ownership and be-longing (Figure 4, group artwork). The artworkis a visual reminder for participants that theycan still accomplish and learn new things de-

spite limited mobility or cognition.

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Challenges to Art Therapy and Tricks ofthe Trade to Overcome Them

Because art making can tap into emotions at avery deep level, the client’s defenses must beprotected through careful choice of media andstructure of art task.1,16 An art task or mediathat provides insufficient structure can result infrustration, regression, and further agitation onthe part of the client. Structured media is easyto control and allows for controlled expressionof affect and correction of mistakes. Graphitepencils are such a medium. Less structured me-dia can be messy and difficult to control butallow for emotional expression, as with the useof paint or clay. A client who feels like she islosing control may grow anxious if given claybut may do well, successfully managing her anx-iety, when using a pencil and stencils.

Art tasks need to use clients’ strengths toprovide success in art making. Whereas someclients respond well to a multistep task, such aspainting and rinsing the brush between colors,other clients need an approach that requiresonly one step, such as receiving a paintbrushalready dipped in paint. For some clients, havingchoices is invigorating. For others, havingchoices is immobilizing, and limiting theirchoices facilitates their successful participation.Some clients are capable of abstraction andimaginative play. For these clients, appropriatequestions can elicit stories, poetry, and in-creased affect and energy. Group stories andpoetry (Table 1) can be created in response to ashared experience or artwork. Sometimes talk-ing about the art they created helps clients toverbalize, tell their stories, and share memories.

Figure 4. Group Artwork

At other times, clients cannot verbalize about

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er 14, 2003

their artwork, and being asked to do so canresult in agitation and frustration.5,13,15

Although clients can benefit from any oppor-tunity to create art, there are times when con-sulting an art therapist is beneficial. Art thera-pists are graduates of master’s degree programswith developed expertise in the use of art intherapy.16 An art therapist can be a consultant, ateam member, or a collaborator. Guidelines forconsidering when to consult an art therapist arelisted on Table 2.

Practical Considerations

A variety of art supplies can offer a range ofstructure and expressiveness and need not beexpensive. Safety must be considered, and allsupplies must be nontoxic. A basic list is pro-vided on Table 3.

The technique of collage using precut maga-zine pictures from which clients may choose is astructured yet expressive art task. A client who

Table 1.Group Poem

Windy D

You cBut you can hear the w

from

I watcmoving the bublowing the tr

blowing a branch from a tblowing a plast

(I never saw a plastic bag

I hear theWhistling at my wind

Rattling the windothey will com

My mother would tell mewa

My grandson thanked meMy daughter was afr

I was afraid I would blowsome bricks in my pock

a

Now we are iWatching oth

—Group poem created by seven LIFE members, Novemb

ay in the Fall

an’t see it,ind blow, and the nuts fallthe trees.

h the windshes back and forth,ees back and forth,ree down in front of my house,ic bag up and down.

until I was a grown woman!)

wind rush by,ow as I lay in bed at night,ws until it sounds likee off The house!

to put warm clothes on when its windy.for telling him to dress warm.

aid she would blow away.away and thought I should putets to keep me from blowingway!

nside looking out,er people blow by.

is hesitant to try drawing may be engaged

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Table 2.Consult a Board Certified ArtTherapist If

1. you want further information about thetherapeutic uses of art.

2. your client experiences intense affectduring or after an art process.

3. your client has unresolved trauma or grief.4. you client has difficulty verbalizing.5. the verbal ability and the art ability don’t

seem to match (a minimallycommunicative client whose artwork isorganized and seems to include a greatdeal of information and detail or anapparently alert and oriented client whoseartwork seems bizarre).

6. your client’s artwork is disturbing or if youhave questions on how to respond to it.

7. your client has physical or cognitivelimitations that make it difficult to knowhow to provide success-oriented mediaand tasks.

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through collage making. For a client who haslethargy, sifting through pictures can be invigo-rating and can stimulate memories. When Ms. Rwas offered art therapy, her invariable responsewas, “Oh honey, I can’t do art, not today. I don’tfeel well.” When encouraged to come and watchothers participate, she was willing. While watch-ing other clients look through the collage pic-tures, she became engaged and created her ownpicture, proudly telling the following story tothe group: “I grew up in Georgia, and I raisedeight boys. I raised all my own vegetables andcanned them for the winter. We used to milk thecow by hand. My flowers were always beauti-ful!”

A client with expressive aphasia, Ms. W,created Figure 5. Although aware of what washappening around her, she could not verbal-ize. Writing was slow and tedious because astroke left her dominant hand paralyzed. Hersense of frustration was often evident in heroutbursts and crying. Ms. W. was given paintbecause of the expressive nature of the media.When it became apparent that she wantedmore choices, she was given many colors tochoose from. She used each color, and with

Table 3.Basic Art Supplies

Activity

Drawing

Painting

Construction

Supplies

Pencils (colored pencils, drawing pencils)Markers (water based both thin and thick)Oil PastelsWater colorsTempera paint (liquid or cakes)Brushes (a variety of thicknesses)Collage: a variety of papers, precut words, phrases

and pictures from magazinesPlasticine (oil-based clay)Homemade dough (to bake or air dry)Other SuppliesAdhesives● White glue● Glue sticks● TapesPapers● A variety of sizes of drawing and water color

paper● A variety of colors of construction paperTools● Scissors (safety)

some reinforcement, she learned to clean her

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Figure 5. “Untitled”

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brush between colors and filled page afterpage with color. As she finished each painting,she carefully lifted it up for everyone in thegroup to admire. Her pride and joy was evi-dent, in her body language as well as in herpaintings. She used paint as an alternative toverbal communication.

Attention span and physical abilities of theindividual and the environment need carefulconsideration. Tasks need to be success ori-ented but with enough challenge that there isreward for a task well done. If a client cannot dothe task, it is more useful to give different tasksrather than do it for them. Clear instructionsneed to be given, keeping in mind that many artsupplies are new to clients.

Two Case Studies

Ms. J. was diagnosed with Alzheimer’s dis-ease. She perseverated on the dominant obses-sive story of the events surrounding her hus-band’s death. She had to leave the home sheloved, moving to a new city to live with herdaughter, and she was diagnosed with Alzhei-mer’s disease, all within a short time span. Overand over, she obsessed on this story, becomingmore and more agitated as weeks and monthswent by.

Creating stories around artwork can help cli-ents grieve as they honor significant people intheir lives who have passed away. This oftenbrings closure and healing. It is imperative, how-ever, that professionals watch for and preventdominant obsessive stories in reminiscence. Ms.J. could not cognitively process the grief andloss she had experienced. Through art therapy,she was assisted to create a story about her lifeusing structured art materials (stencils, pencildrawings, and collage pictures) that allowed formaximum control. She told of her family, herpride in her children, her relationship with herfather whom loved her very much, her lovinghusband, and the beautiful rose bushes shegrew. What she talked about was included in thebook, as was the artwork she had created. Infocusing on her strengths and her happy andproud memories, she created a book that shecould share with her family. The book couldbring back those memories whenever shelooked at it, providing a calming influence and asense of pride in the knowledge that her life had

meaning.

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Ms. E. had a diagnosis of depression. Withlittle motivation, she was losing her physicalcapabilities because of her lethargy. She fre-quently spoke of her mother and how much shemissed her. In individual art therapy sessions,she created a memory book. Ms. E. was cogni-tively able to process the loss she felt, and cre-ating the book helped her move through griefand honor her mother and other people she hadlost. She brought in pictures of her mother andfamily members, which were photocopied andadded to the book. She looked through maga-zines and found pictures of foods her mothercooked and taught her to cook. She found pic-tures to remind her of fun times she had had.Her book moved through memories of hermother, to memories of others she had lost, tothe good times she had. The book ended withpages about her—pictures of her when she wasyounger. “Isn’t that a beautiful picture? Aren’t Ibeautiful?” She would say. There were alsopages about what she could do well. The bookgave her a tangible object to show others, whichshe did many times. Each time she showed an-other person and retold the story, she was hon-oring her mother, working through her owngrief, reinforcing her own strengths, and reflect-ing on the meaning in her life.

Conclusion

When effectively incorporated into their pro-gram, art therapy can help clients cope with thechallenges that aging brings. Art therapy is anonpharmacological, nonmedical interventionthat can have a direct impact on the wellness ofthe elderly. As can be seen in the case studiesand the artwork of the elderly African Americanclients in this PACE program, despite a varietyof limitations, they were quite capable of usingart materials and the creative process and ben-efited from the experience.

Although many clients benefit from the oppor-tunity to create art, a board certified art thera-pist can bring highly developed expertise in theuse of art in therapy and can become an integralmember of the treatment team to help meet theemotional needs of the clients in a creative,flexible, innovative, and cost-effective way. Anart therapist can work with other care providersas a consultant, collaborator, cotherapist, or re-searcher. Additional information on art therapyand ways to locate an art therapist in your area

is available in Table 4.

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Art therapy can help facilitate communica-tion, manage emotions, and provide an oppor-tunity for life review. It can offer social connec-tion and provides choices and control. It canbring about improved mental and physicalhealth and offers a vehicle for nonverbal assess-ment. Perhaps most important, art therapymakes it possible for the staff and the family tosee the client through the lens of their own lifestory and gain a glimpse into the core person, tosee beyond their limitations to the strengths andbeauty.

References

1. Wadeson H. Art psychotherapy. New York: Wiley;1980.

2. Innes A, Hatfield K. Healing arts therapies and person-centered dementia care. Philadelphia: Jessica Kingsley;2002.

3. Weisberg N, Wilder R. Expressive arts with elders: Aresource. Philadelphia: Jessica Kingsley; 2001.

4. Mukamel DB, Temkin-Greener H, Delevan R, et al.Team performance and risk adjusted health outcomesin the Program for All-Inclusive Care for the Elderly(PACE). Gerontologist 2006;46:227-37.

5. Zeltzer BN, Stanley S, Melo L, et al. Art therapiespromote wellness in elders. Behav Healthcare

Table 4.Additional Resources

1. The American Art Therapy Association:www.arttherapy.org. Resources andcontacts for using art in therapy.

2. Elders Share the Arts:www.elderssharethearts.org. Technicalassistance and training materials fordeveloping community-basedintergenerational arts programs.

3. National Center for Creative Aging (NCCA):www.creativeaging.org. Dedicated tofostering an understanding of therelationship between creative expressionand the quality of life of older people.Provides training education and resources.

4. National Coalition of Creative ArtsTherapies Association (NCCATA):www.nccata.org. Dedicated to theadvancement of the arts as therapeuticmodalities, including art, dance/movement,drama, music, poetry, and psychodramatherapies.

Tomorrow 2003;12:7-12.

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6. Skaife S, Huet V. Art psychotherapy groups: Betweenpictures and words. New York: Routledge; 1998.

7. Nainis N, Paice J, Ratner J, et al. Relieving symptomsin cancer: Innovative use of art therapy. J PainSymptom Manage 2006;31:162-9.

8. Rentz CA, Memories in the making: Outcome-basedevaluation of an art program for individuals withdementing illnesses. Am J Alzheimer Dis OtherDementias 2002;17: 175-81.

9. Jensen SM. Multiple pathways to self: A multisensoryart experience. Art Ther J Am Art Ther Assoc 1997;14:178-86.

10. Waller D. Art therapies and progressive illness:Nameless dread. New York: Brunner-Routledge; 2002.

11. Banks-Wallace J. Talk that talk: storytelling andanalysis rooted in African-American oral tradition.Qualitative Health Res 2002;12:410-26.

12. Newman BMN, Newman PR. Development throughlife: A psychosocial approach. 7th ed. Belmont, CA:Wadsworth; 1999.

13. Shore A. Promoting wisdom: The role of art therapy ingeriatric settings. Art Ther J Am Art Ther Assoc 1997;14:172-7.

14. Pipher M. Another country: Navigating the emotionalterrain of our elders. New York: Penguin Putman;1999.

15. Riley S. Group process made visible: Group arttherapy. Philadelphia, PA: Brunner-Routledge; 2001.

16. Rubin J. Artful therapy. New York: Wiley; 2005.17. Cohen GD. The mature mind: The positive power of

the aging brain. New York: Basic Books; 2005.18. Kaplan FF. Art, science and art therapy. Philadelphia:

Jessica Kingsley; 2000.19. Atchley RC. A continuity of theory of normal aging.

Gerontologist 1989;29;183-90.

CAROL M. JOHNSON, BSN, MA, ATR-BC is a nationally

registered, board certified art therapist. She currently

works as an art therapist at the Living Independently for

Elderly (LIFE) Program at the University of Pennsylvania

School of Nursing, Philadelphia. EILEEN M. SULLIVAN-

MARX, PhD, CRNP, FAAN, is associate professor and as-

sociate dean for practice & community affairs and Shearer

Endowed Term chair for Healthy Community Practices,

University of Pennsylvania School of Nursing, Philadel-

phia.

ACKNOWLEDGEMENT

The art therapy examples in this article were part of a

larger collection of artwork selected to be shown in an

exhibit featuring artworks by older adults in art therapy

programs from across the United States. The exhibit, “Cre-

ative Aging: Beyond Words” was sponsored by the Ameri-

can Art Therapy Association and was held in June 2004 in

the Russell Senate Office Building Rotunda in Washington,

DC.

0197-4572/06/$ - see front matter

© 2006 Mosby, Inc. All rights reserved.

doi:10.1016/j.gerinurse.2006.08.010

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