Drama therapy with older people with dementia

The Arts in Psychotherapy 43 (2015) 40–48

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The Arts in Psychotherapy

Drama therapy with older people with dementia—Does it improve quality of life? Joanna Jaaniste, PhD a,∗ , Sheridan Linnell, PhD b , Richard L. Ollerton, PhD c , Shameran Slewa-Younan, PhD d a

School of Social Sciences & Psychology, University of Western Sydney, Penrith, NSW, Australia Art Therapy, School of Social Sciences & Psychology, University of Western Sydney, Penrith, NSW, Australia c School of Computing, Engineering & Mathematics, University of Western Sydney, Penrith, NSW, Australia d Mental Health, School of Medicine, University of Western Sydney, Penrith, NSW, Australia b

a r t i c l e

i n f o

Article history: Available online 31 December 2014 Keywords: Dementia Drama therapy Elderly people Mixed method Quality of life

a b s t r a c t This article describes a pilot study that aimed to evaluate the effect of drama therapy on the quality of life (QoL) of elderly people with mild to moderate dementia, using a mixed method (quantitative and qualitative) approach. Study participants (N = 13; age range 61–88 years; 1 female) were Australians of European descent, principally with Alzheimer’s disease, living in the community in an east-coast Australian context. The drama therapy group (N = 4) was compared with a group of participants (N = 9) who watched movies over a four-month period. All participants were assessed for QoL using the quantitative Quality of Life Alzheimer’s Disease (QoL-AD) scale of Logsdon, Gibbons, McCurry, & Teri (1999, Journal of Mental Health and Aging 5, 21) prior to and following 16 group meetings. Qualitative data were generated and examined using phenomenological methods including recording and transcribing body language and dialogue, as well as narrative, ethnography, group themes and metaphor. Although not statistically significantly different, the average QoL-AD score increased for the drama therapy group while it decreased for the movie group. Qualitative findings established an unambiguous participant ability to express ideas and feelings through drama therapy as well as an unveiling of conscious awareness of participants’ own wellbeing and QoL. The findings also indicate the potential worth of a future larger study along the lines exemplified here. © 2014 Elsevier Ltd. All rights reserved.

Introduction The World Health Organisation estimates that in 2010 some 35.6 million people globally were living with dementia (World Health Organisation & Alzheimer’s Disease International Report, 2012, p. x). The same report gives dementia prevalence in Australasia as 6.91% and in the USA as 6.46% of the population (p. 14). Moreover, the report predicts a significant global increase in both absolute and percentage terms, so that by 2030 there will be close to 66 million people worldwide living with dementia. Dementia as a syndrome involves deterioration of the higher cortical functions of the brain (Coulson, Fenner, & Almeida, 2002). Its most common form is Alzheimer’s disease (AD), possibly

∗ Corresponding author. Tel.: +61 295186519. E-mail addresses: [email protected], [email protected] (J. Jaaniste). http://dx.doi.org/10.1016/j.aip.2014.12.010 0197-4556/© 2014 Elsevier Ltd. All rights reserved.

accounting for 60–70% of cases (World Health Organisation & Alzheimer’s Disease International report, 2012). There is abundant evidence that amyloid production in the brain from protein is a major indication of AD, sometimes with genetic aetiology (Masters & Bayreuther, 1998). The amyloid protein produces neuro-fibrillary tangles which are known to underlie brain degeneration (Ginsberg, Hemby, Lee, Eberwine, & Trojanowski, 2000). Commonly recognised features of AD include lack of recall (Greene, Baddeley, & Hodges, 1996), language deterioration (Price et al., 1993) and visuospatial deficiencies (Esteban-Santillan, Praditsuwan, Ueda, & Gelbmacher, 1998). This litany of deficits can be devastating to the person with dementia as well as their family and caregivers. Drama therapist Casson (1994) calls this “potential loss of personhood in a confused elderly person . . . one of the most devastating aspects of dementia” (p. 2). Drama therapy can provide interventions which help people with AD to access their creativity and spontaneity in the face of loss of physical movement, their freedoms, loved ones, partners, recognition of others and deprivation of

J. Jaaniste et al. / The Arts in Psychotherapy 43 (2015) 40–48

the self they thought they knew (Johnson, Smith, & James, 2002). In selecting a definition of drama therapy, Jones (2007) believes that local practitioners can offer a more refined sense of what drama therapy aims to be in a particular context. For our purposes, a local (Australian) definition is as follows: Dramatherapy purposefully uses drama techniques and theatre-based models to encourage the client’s creativity and expressive ability. It helps the clients to tell their story, express feelings, set goals, extend inner experience and try on new and more fulfilling roles, so far unexplored (Dramatherapy Centre, 2014). This description emphasises the availability of new-found roles for participants in drama therapy. There is a core loss of significant life roles for people with dementia, and drama therapy can assist people to gain confidence through orientation into the present moment (Bailey, 2006; Langley, 2006). Potential drama therapeutic gains for people with dementia include opportunities to find meaning for those affected by AD dealing with coherence of role into the present (Gorst, 2011). Drama therapy through stories can assist with sociability (Gersie, 1997), through humour can promote mental acuity (Jennings, 2005), through improvisation can assist with end of life issues (Johnson, 1986) and through stimulation of the imagination can reduce stigma (Davis Basting, 2009). A review of the literature revealed that little research has been published on drama therapy in the specific context of dementia. More generally, successful mixed method research into elements of the wellbeing of elderly participants has been carried out by nursing home care staff in Davis Basting’s (2006, p. 18) “Timeslips” project. Rather than relying only on drama therapy techniques, staff members helped participants build a story on the basis of a set of open-ended questions, accepting all responses and weaving them into a story form. Davis Basting (2001) strongly recommends the use of images to stimulate reflection, memory and group process. Feil and de Klerk-Rubin (2012) describe their validation method (VM), a psychogeriatric approach that can be helpful to drama therapists by offering solutions to communication difficulties with people who have memory loss, as one of acceptance of people with dementia, based on practical techniques of touching and reminiscence. They apply sensitive, non-judgmental listening to the elderly to enhance self-esteem and provide emotional release. Research conducted by Feil (1990) and Kohn (1993) shows that through the use of VM with clients, caregiver burnout decreases. However, Finnema, Droes, Ribbe, & Tilburg (2000), in their review of psychogeriatric models, found no evidence of VM having been empirically tested for people with dementia. Weisberg and Wilder (2001) investigated the psychosocial change in self-expression of their elderly participants and stress the value of adult creative play. They showed how engaging even the most unwilling participants in drama and movement could “stimulate happy participants, shared experiences and moments of optimism even in the bleakest environments” (2001, p. 96). In their case study of initial engagement of ten participants, what began as total resistance by one reluctant volunteer ended up as an opportunity for her to re-visit a detailed 40-year-old memory of a colourful scenic drive through the mountains. Another group member said: “Except for this hour with all of you, I’m getting dopey sitting in this place . . . no one to talk to. I’ll forget who I am” (p. 97). Such comments reveal the importance and value of a sense of identity. Core themes emerging from the above literature include a sense of connection with others, confidence to express feelings, spontaneous interaction, engagement of imagination, shared memories and motivation. These attributes are all important aspects and qualities for people with dementia which can be developed through drama therapy.

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More specifically related to the focus of our research, Lepp, Ringsberg, & Holm (2003) conducted a study where two groups of randomly assigned elderly people (N = 12; age range 73–95 years; 10 female) with mild to moderate dementia met weekly and were given an experience of either dance, rhythm and songs using costumes (Group A: N = 6) or storytelling (Group B: N = 6). Seven nursing staff were also randomly allocated to the groups and a drama teacher and a storyteller ran the relevant group. The groups were not compared, as the researchers were investigating improvements in two categories: one for clients (interaction) and the other for nursing staff (professional growth). Using phenomenography, the authors found that the people with dementia in groups A and B showed improved abilities in communication and confidence. The authors do not explain why these two treatment groups were used or why a drama therapist was not used, but their data analysis indicates that both groups improved in fellowship, communication and reactivated memory. There is a recognition in their article that storytelling, with its associated songs and poems, is an integral part of drama (as it is of drama therapy). Although the study was not designed to examine relationships between clients and staff, one conclusion was that improved interaction between clients and staff may result from use of both methods described. Additionally, the importance of professional development of staff was highlighted (see also Jaaniste, 2011). Using a mixed methods approach, an earlier pilot study assessed the use of drama therapy over a six month period with 16 elderly people with dementia (Wilkinson, Srikumar, Shaw, & Orrell, 1998). This research did utilise a drama therapist. The drama therapy group participants (N = 9; average age 79.6 years; 9 female) were pre-selected for their higher level of communication abilities while the control group (N = 7; average age 80.0 years; 1 female) were mainly non-verbal and cognitively impaired. Activities undertaken by the control group were not stated. It was reported that, although not statistically significantly different, members of the drama therapy group had (perhaps unsurprisingly) better cognitive function, better daily living skills and lower dependency than the (non-randomised) control group, using six neuropsychological measures pre- and post-intervention. The authors admit that their methodology needs modification: in particular, they disclose in the discussion that the drama therapist selected participants who were more likely to do well. They conclude that the qualitative findings nevertheless support the idea that drama therapy may help people with dementia to build communal spirit, increase self-understanding and acceptance and facilitate reminiscence. The non-random group selection (along with other aspects of the methodology) emphasises the need for systematic research into the use and benefits of drama therapy for people with dementia, possibly based on the model described in the present study. In recent years, awareness and acceptability of a range of arts therapies in medical journals have increased, with calls for further research to be conducted in this area. In a Lancet Neurology article, Burton (2009) groups together studies of art therapy, drama therapy, music therapy and dance therapy. While Burton notes that most evidence for arts therapies is observational and anecdotal, there has been one multi-centre, randomised controlled trial (RCT) of art therapy with people with dementia (Rusted, Sheppard, & Waller, 2006). Again using mixed methods, Rusted and colleagues conducted an art therapy intervention with people with dementia using an RCT design. Although described as a multi-centre study, facilities included a day resource unit in a hospital, a privately owned nursing home as well as a nursing home and a resource centre both funded by social services. Hence, a more useful categorisation may have been that clients were either in long term or day care. The 45 participants had diagnoses of probable dementia of the Alzheimer type (N = 18; 11 females), multi-infarct dementia (N = 19; 13 females) and unspecified dementia (N = 8; 7 females).

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The average age of women was given as 84.05 years and of men 80.33 years. They were randomly assigned to “art therapy” or “activity” (control) groups for 1 h each week for 40 weeks, with a maximum of six in each group. Group-interactive, psychodynamic methods were used in association with the art therapy, while the activity groups were run by occupational therapists (OTs) who were instructed not to use formal OT methods or art/craft work. Prior to and following the 40 weeks, numerous neuropsychological scales were administered. Researchers found no significant differences between the two groups in many of the scales; however, there was a statistically significant change in the within-session measurement of the Bond–Lader mood scale (B–LMS) (Bond & Lader, 1974). For the art therapy group, B–LMS scores in mental acuity, physical involvement, sociability and calmness increased/improved over time, while in the activity group they decreased over time. The authors determined that all of the standardised measures selected met all of the criteria for validation and reliability as reported in their original verification studies. The B–LMS was the measure that produced the most compelling evidence for change through art therapy. Since the B–LMS attributes referred to above have distinct resonance with quality of life (QoL), we considered the above study to be a useful model for the present investigation. Good QoL is recognised as one of eight essential evidencebased practice (EBP) recommendations for people with dementia (Karttunen et al., 2011) and is described by Banerjee (2010) as “doing the diagnosis well” (quoted in the Alzheimer’s Disease International report 2011, p. 10). The World Health Organisation’s vision is for “an improved quality of life for people with dementia and their families throughout the world” (Alzheimer’s Disease International report, 2013, p. 33). QoL encompasses “the achievement of goodness and meaning in life and well-being, satisfaction and dissatisfaction” (Farquar, 1994, quoted in Moyle, McAllister, Venturato, & Adams, 2007, p. 176). QoL in dementia is considered by some as having been largely ignored and worthy of much greater examination (Moyle et al., 2007). As a partial result of seminal work by Kitwood and the Bradford Group (Kitwood, 1997), QoL for people with dementia in the UK is considered to encompass the following attributes, in order of importance: • • • • • • • • • •

Relationships; environment; physical health; sense of humour; independence; ability to communicate; sense of personal identity; ability to engage in activities; ability to practise faith or religion; ability to be treated fairly

(Alzheimer’s Society report, 2010, pp. 17–22). Our study was informed by this view of QoL. Both the Wilkinson et al. (1998) and Rusted et al. (2006) studies described above used a mixed method approach, defined in the present study as research in which the investigator collects and analyses data, integrates the findings, and draws inferences using both qualitative and quantitative approaches or methods in a single study or programme of inquiry. An important advantage of mixed method research is that one of the approaches can balance the deficits of another (Johnson and Onweugbuzie, 2004) and therefore more effectively support the findings. While some researchers believe that a qualitative approach is more relevant to the clinical practice of the arts therapies (Tüpker, 1990; Rogers, 1995), others point out that if a qualitative approach is “slavishly followed” (Grace and Everard, 2001, p. 723) then the wider healthcare research community, who

use EBP models, may not recognise the effectiveness of these therapies (Pothoulaki, MacDonald, & Flowers, 2006). EBP combined with high practitioner standards and a flexibility of approach to research is important for many clinical practitioners who want to apply the results of evidence-based research in the general area of health where the biomedical model is strongly supported (Evans, 2003). However, to date few studies have been conducted in the field of drama therapy using quantitative measures. Both the incidence and prevalence of dementia are on the rise and good QoL is clearly significant for people with dementia themselves as well as their families, caregivers1 and the society in which they live. Important research has been carried out in each of the areas of dementia, arts therapies and QoL but there has been little cross-over research using drama therapy. Drawing upon the relevant literature, and in particular the evaluation of short and long-term effects of art therapy on older people with dementia (Rusted et al., 2006), we sought to explore the effect of drama therapy on the QoL of elderly people with mild to moderate dementia, using a mixed method (quantitative and qualitative) approach. Study design Two groups of elderly people with mild to moderate dementia living in east-coast Australian communities were compared, one of which participated in drama therapy sessions while the other watched movies. The groups were located in Sydney and Newcastle NSW, respectively. Movies were chosen by consensus and this group was regarded as the “normal activity” (control) group. Quantitative and qualitative data collection was undertaken over a five month period between April and August 2011. The study programme involved an initial three-week period for pre-session assessment (T1), two eight-week blocks of sessions with a threeweek break in between and a two-week period for final assessment (T2) (see Table 1). Sessions for both groups lasted for 1.5 h and were run on a Friday (drama therapy) and the following Monday (movies). Two art therapy students assisted as members of the drama therapy group and two Alzheimer’s Australia staff members attended alternately; provision of resources for this group was shared between their organisation and the drama therapist. The movie group was supervised by an art therapy student with staff support. The room at the Newcastle facility was set up as a movie theatre and ice creams and other refreshments were provided. The drama therapy sessions always included the same structural elements, whichever techniques were being used. A group contract was made in the first session, employing suggestions from participants on confidentiality, time and place boundaries, self-responsibility and drama therapist responsibility. All parties

1 After careful consideration and vigorous debate, we have chosen the word “caregiver” as a generic descriptor for the people, all of them family members and most of them spouses, who supported the involvement of the research participants in this study and accompanied them to the drama therapy workshops, as well as caring for them in their daily lives. We are aware of the critique of such terms as “carer” and “caregiver” in the work of Molyneaux and her colleagues (Molyneaux, Butchard, Simpson, & Murray, 2011, p. 422). We agree that such terms have become bureaucratised and can render invisible the specificity and mutuality of diverse relationships that can and do exist between people living with dementia and others in their families and networks. In day-to-day situations, we support the recommendation to carefully negotiate specific, relational ways of naming each unique connection between a “carer”/“caregiver” and a person living with dementia. Here however, we needed a generic description for the purposes of our research. In choosing “caregiver”, our intention was to honour the etymology “carian” [Old English]: to feel concern, and “carity” [17th Century English]: “dearness” from Latin “caritas”, (Onions, 1950, pp. 265–266). We also aimed thereby to honour nuances of the words “care” and “giving” in relation to the mutually enriching and demanding commitment of caring for and about someone living with dementia.


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Table 1 Quantitative and qualitative investigations.

agreed on safety of performance space and participants’ rights to absent themselves from performance at any time. It was also agreed that any aggressive behaviour necessary to the drama would be improvised, so that no one would actually be harmed. Each weekly session was based loosely on an overall theme, such as seasons, favourite animals or families. Issues which would normally occur in a group of people with dementia tend to be different from other targeted groups, and the prominence of socialisation (Langley, 2006) and end of life issues (Johnson, 1986) influenced the choice of session topics. Sessions began with warm-up exercises and games using balls and coloured cloths to get to know one another, energise and prepare the body for activity and encourage spontaneity and awaken creative imagination in the participants (Langley, 2006). Opportunities for physical contact are valuable, since loss of identity and sense of self can occur when people do not receive human touch (Ehrenfeld, 2003). There was a further warmup period to facilitate connection between group members, some pair work, some group improvisation and then reflection, de-roling and closure. De-roling was of particular significance for this group. Jones (1996) suggests that “to leave a client in role or suddenly to close the dramatic activity can be highly problematic” (p. 27) and drama therapists have several means at their disposal to assist with disengagement from a role. Over-stimulation of participants’ imaginations was sometimes challenging for them if cognitive strengths and boundaries were weakened through the unwelcome persistence of a role which should have been left behind in the group space after a session. A period of reflection at the end of each group session assisted in the de-roling process and each meeting ended with a song relevant to the topic as a form of closure. A ritualised ending such as a song can provide “the final boundary between the therapeutic space and the outside world” (Langley, 2006, p. 101) and allows completion, the closing of the emotional space and a sensitive end to creative engagement. Developmental Transformations (DvT) techniques were among those used in the drama therapy that is the focus of this research.

Johnson (2009) describes DvT as “a form of drama psychotherapy that is based on an understanding of the process and dynamics of free play. The essence of Developmental Transformations is the transformation of embodied encounters in the playspace” (p. 8). DvT methods, including transformation, embodiment, encounter and playspace (Johnson, 2009), enable participants to develop some of the Alzheimer’s Society (2010) QoL attributes listed above. For example, relationships became more flexible when participants transformed scenes from a scenario where an action was “stuck” and their spontaneity loosened it. They were able to engage using humour in encounters, as well as achieve purposeful communication. Embodiment through movement within the safety of a specified playspace assisted their physical health and gave them a sense of independence and personal identity through their nondirected choice of activity in the engagement. Other techniques used throughout the 16 session weeks were story making (Gersie, 1990), where a story was told and then offered to participants to improvise, as well as role playing and improvisation of personal stories. A large number of reminiscence objects and photographs were provided by the drama therapist and sensory material, painting and drawing resources were also available to group members during sessions. As Davis Basting (2001) points out in describing her “Timeslips” project, pictures and images can assist participants to engage in hitherto unexplored roles, as they “stretch the boundaries of traditional reminiscence activities . . . as storytelling groups make up new stories” (p. 80). A mixed method (quantitative and qualitative) analysis of the data obtained during the study was undertaken. The University of Western Sydney Ethics Committee gave ethical approval for the study. Participants Alzheimer’s Australia, Sydney and Newcastle, supplied contact details of 80 people, most of whom had dementia and had

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been involved in the organisation’s Living with Memory Loss programme. Of the people contacted, 17 agreed to participate and were included in the study (see Table 1). The inclusion criterion was a prior diagnosis by a medical doctor or geriatrician of dementia (mixed origin). There was no age criterion. Exclusion criteria were other diagnosed co-morbid psychiatric conditions. All participants were volunteers, gave informed written consent and signed releases to allow withdrawal from the study at any time. Informed consent was also obtained from their agents with power of attorney. The diagnostic profile of the entire group was dementia of the Alzheimer type (N = 14; 2 females) and unspecified dementia (N = 3; 2 females). The average age of the group was 74.8 (range 61–88) years. All participants were of Australians of European descent living in east-coast Australian communities. Of the 17 people with dementia originally invited to take part in the research project a total of 13 (drama therapy: N = 4; movie: N = 9) completed the study. Two drama therapy participants absent from the quantitative assessment were included in the qualitative aspect of the study. One participant died, one discontinued after the first assessment, one became depressed and entered a nursing home and one found it too uncomfortable to concentrate on movies but completed both assessments. Another participant had an accident after the thirteenth drama therapy session and was hospitalised. The remaining participants completed both assessments and attendance in both groups was regular.

Table 2 Participant characteristics and QoL scores pre and post intervention. Variables

Level

Age, average (SD)

Drama therapy (N = 4)

Movies (N = 9)

70.5 (7.1)

74.0 (7.7)

Gender (N)

Male Female

3 1

9 0

Education (N)

High school only Tertiary degree

1 3

6 3

Diagnosis (N)

Alzheimer’s disease Other dementias

3 1

9 0

QoL score (scale 13–52), average (SD)

Time 1 (baseline) Time 2

47.0 (4.4) 48.0 (4.7)

48.3 (6.4) 47.0 (6.1)

attainment (p = 0.27), type of dementia (p = 0.31) or baseline QoLAD score (t(9) = −0.44, p = 0.67). On average, over the study period the drama therapy group QoLAD scores increased by 1.0 (SD 3.9) points (with 3 of 4 participant scores increasing) whereas those of the movie group decreased by 1.8 (SD 5.5) points (with 7 of 9 participant scores decreasing). However, this difference was not statistically significantly different (t(8) = 1.03, p = 0.33).

Quantitative investigation

Qualitative investigation

Baseline demographic data were recorded at time T1. QoL was measured at times T1 and T2 using the Quality of Life Alzheimer’s Disease (QoL-AD) tool Logsdon, Gibbons, McCurry, & Teri (1999) which assesses QoL from the perspectives of “family and friends”, socialisation, “life as a whole” and “self as a whole”. QoL-AD is a 13item self and caregiver measure rated on a 4-point scale (1 being poor and 4 being excellent) with a total score between 13 and 52. QoL-AD provides a composite score of the person with dementia and caregiver responses. The psychometric properties of this scale are considered to be “reliable and valid” for older adults (Logsdon, Gibbons, McCurry & Teri, 2002, p. 510) and the test–retest reliability of this scale for patients with cognitive impairment and their caregivers was 83% and 90% respectively (p. 510).

Qualitative data were obtained and examined using phenomenological methods including recording and transcribing body language and dialogue, as well as narrative, ethnography, group themes and metaphor. However, qualitative research can be seen as “complementary” rather than “incompatible” with its quantitative counterpart (Malterud, 2001, p. 483). Qualitative enquiry investigates the reasons behind “how things happen” (Grainger, 1999, p. 74) while quantitative inquiry is generally concerned with assessing change statistically. Drama therapy in the context of this study aimed to improve QoL (quantified by QoL-AD) as well as heal aspects of self and relationship of the participants, and our parallel qualitative investigation was a means of exploring and richly describing if and how any improvement occurred through drama therapy. Themes emerge within any therapeutic process, including drama therapy, and part of the professional training of the therapist is to identify and work further with these themes. Thematic analysis is also a primary technique of qualitative research where the investigator needs to show through choice of themes “something important about the data set in relation to the research question” (Braun & Clarke, 2006, p. 82). In the present case, the chosen themes were all loosely indicative of the QoL attributes listed earlier. This convergence might best be understood by regarding the qualitative aspect of the present project as a cooperative enquiry (Heron, 1996), wherein the research participants are simultaneously clients and co-producers of knowledge. Moreover, producing knowledge about one’s condition, individually and/or collectively, can itself be therapeutic. The fact that the therapist/researcher is engaged in both therapy and research at once also requires sensitivity and is not without its pitfalls (Human, 2010). However, conducting an on-going, reflexive meta-analysis of the phenomenological data can provide a balance as well as enhancing the therapeutic process and contributing to research outcomes. (Inter-) subjectivity is a strength and a limitation of such practitioner-led qualitative research, and in this study is also balanced by a quantitative dimension.

Statistical analysis Demographic and study quantitative data were analysed using an independent samples t-test and Fisher’s exact test as appropriate to provide comparisons between the drama therapy and movie groups. To examine changes in average QoL-AD scores over time and between groups, a (paired) QoL-AD change score was first calculated by subtracting each participant’s score at T1 (baseline) from that at T2 (completion of the intervention). Statistical comparisons were two-tailed and a p-value of less than 0.05 was taken to indicate statistical significance. Data were analysed using SPSS Version 20.0 (SPSS, 2012) and Excel 2007 (Microsoft).

Quantitative results Table 2 presents the study characteristics of the drama therapy and movie groups. The study groups were not statistically significantly different in terms of age (t(11) = 0.79, p = 0.46), gender (p = 0.31), educational


Themes emerging in the drama therapy Themes of anger and frustration, family members, dementia/memory loss and grief arose during the drama therapy sessions. Participants’ names have been changed for de-identification purposes. Anger and frustration Very early in the life of the group, Tanya, an 88 year old woman with moderate dementia who often spoke for other participants, voiced frustration that she had “lost her brain” and that she had no idea who had brought her to the facility. Johnson (1994) writes of the shame that clients can suffer when they feel constantly humiliated, as Tanya surely did. She demonstrated her shame by hiding her face and saying she wished not to be there. At other times she would adopt an air of wanting to control the group, finding fault with others, and in so doing failed to make interpersonal contact. These defences increased her frustration and contributed to her repeated “shame-prone” incidents during the programme (p. 176). In the first session, photographs were offered to and chosen by participants. The selections made spoke volumes about anger and frustration. In Tanya’s chosen picture, the farmer is pouring grain out of his bag onto a drought-stricken, grassless field for his sheep, surrounded by heat haze. It looked like a hard and thankless task; getting up in the mornings may have been like that for most participants. Tanya was not sure why she chose the picture but noticed that the sheep were being fed. Neil, a 62 year old man with early onset dementia, said he was heavier in mood than he had been recently and chose a “light” hang-gliding photo. Neil had not initially wanted to come to the group, as he felt he was often singled out for “programmes”. Somewhere in his frustration may have been this hope of lightness of being. As the sessions progressed, participants embodied their frustrations. David, a 74 year old man with unspecified dementia who had introduced himself on the first day with fists at the ready, improvised a bull-fight. He was lonely at home by himself and craved attention. He was encouraged to talk in sessions about his anger (as recommended in the talking therapies, see Daldrup, Engle, & Greenberg [1988]). However, for some clients “the promotion of action methods appears to promote significant clinical change” (Wiener, 1999, p. xiii). Two spontaneous dramas involving all participants occurred during the programme. It is significant that both were concerned with strong feelings of anger and frustration: a march to Parliament House was dramatised, waving banners and protesting to a politician, and the figurative expulsion from the drama space of an abusive teacher in the early life of Leanne, a 70 year old woman with moderate dementia, was also enacted. Difficulty in articulating thoughts, painful feelings of shame, of being a disappointment to a caregiver and fear of abandonment can all be factors in bringing these frustrations and anger to group sessions. Unarticulated and irrational feelings that are usually held within often come to the surface through drama therapy (Emunah, 1994) and were prevalent during these drama therapy sessions. Family There were times during the sessions when participants’ accompanying family members were actually or figuratively present within the space. This was not surprising, as each participant had a relative as their caregiver. Occasionally, a family member was focused on instead of the participant. For example, in one session Neil was offered a new life opportunity or gift from an improvised Magic Shop (Emunah, 1994). He did not choose one for himself but instead wanted to give his wife something special. He went

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away thinking about shaving off his beard for her. He never actually removed his beard, but in the session he transferred his own opportunity for life improvement to his wife, perhaps because he felt he owed her a lot, or perhaps because magic did not fit with the religious beliefs he had shared with us. There had been hard times early in the lives of more than one of the middle class, well-educated participants. In Leanne’s case, her parents had been poor and she had led a “hand to mouth” existence. Leanne’s mother had not been able to persuade an abusive school principal to change her behaviour towards Leanne. Leanne’s memories were inspired by the selection of projective material. Objects and toys, “which use the metaphorical distance provided by drama” (Langley, 2006, p. 136), are often used in drama therapy interventions. Used as a distancing technique, the objects assist clients to access memories rather than constrain them with open questions which can be difficult for people with dementia. For the purposes of this group, objects relevant for the average age of the participants were chosen by the drama therapist. Leanne chose a silver serviette ring, a type of item which had been of no use to the family and “stayed in the drawer”; in other words, they lived simply and such items were irrelevant to their lives. Ben, a 73 year old man with moderate dementia and whose verbal abilities deteriorated over the study period, had improvised the role of a stove in a kitchen where people had left notes for each other when he was a teenager. His father was rarely at home. “That was a shameful kitchen,” he said. He could not say why this was so (participants were often questioned about their memories, but frequently declined to or could not reply); however, his mood changed and he seemed sad. Drama gave Paul, an 85 year old retired architect with moderate dementia, the opportunity to celebrate his parents, children and wife, while the projective qualities of a babushka doll stirred Tanya’s memories of her brave father who had made sure they left their Nazi-occupied country. David took on the role of a glass window, behind which he remembered snuggling up with his beloved family dog and his lost twin brother, mentally diving through the glass between them and their grandfather - to get the attention he never was given as a child at a boarding school he hated. The story of Ulu and the Breadfruit Tree (Gersie and King, 1990) was role played by Neil and David, together with two art therapy students. Once again, David was able to get attention in the role of the invalided young son. Neil played the dying father which assisted him to grieve and resolve his paternal relationship. Situations involving family members and others emerged through use of DvT techniques, in the story-making and in the improvisations, and allowed others to witness loving, joyful, uncomfortable, burdensome and sad family times without emphasizing or stereotyping anyone as elderly or having dementia. The movement of the sessions from warm-ups to play, to “main event”, to reflection and closure allowed previously blocked memories to flow and participants to be free for a while from the expectations of their caregivers.

Grief and loss In her article dealing with death anxiety in older adults, Grunberg Smith uses case examples to highlight how DvT techniques can show how, even though we are all born alone and die alone, we can be together in our aloneness. Coming up against the bony truths of the existential givens of life, the older adults in this nursing home found a soft resting place within the Developmental Transformations group (Grunberg Smith, 2000, p. 331). The contract made initially with the group ensured a safe place to grieve, as did warm-up trust exercises in the two grief and loss

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sessions. Safety boundaries of confidentiality and time management helped to establish trust and enabled participants to feel comfortable about expressing their losses. One of the art therapy students taking part in the sessions lost her mother during the course of the programme and her sharing of her own grief assisted others to express instances of loss and mourning. Examples of loss were manifold, partly because the participants themselves realised the sessions were a forum for memories. For example, it was a natural progression for Neil to “re-cognise” a scent in one smelling game and go on to celebrate memories of his mother, feeling the yearning that came when he realised she could not live forever. Early in the first grief and loss session, Leanne criticised the lack of consideration of those who advise the grieving person to “get over it”. The bereavement story of Ulu and the Breadfruit Tree was told and then dramatised by participants and students in the reflection time after a trust exercise. Emotionally affected by the story, even though he had objected to its appropriation from a different culture, Paul told us of some German immigrants who were not allowed to stay in Australia after being incarcerated during World War II and who experienced environmental dislocation and stigma as a result. The symptoms of loss of a sense of place and loss of social status apply to people with dementia as well. Dislocation can also be experienced by those who are placed in care. These forms of loss affect the QoL of people with dementia (Alzheimer’s Society report, 2010). Two male participants regretted wartime deaths (all those killed in war and a father who fought in World War II), as well as a twin’s death in an aerobatic flight. Such regrets can add to a person’s burden of lack of recall, language deprivation and loss of friends. Bowlby (1998) considers that such losses, if not grieved at the time, may be associated with the onset of depression, a condition which frequently accompanies dementia. Johnson (2010), in an article on war veterans’ losses, explains how national and patriotic narratives can be used to give meaning to returned soldiers. People with dementia also need such narratives to make sense of their lives in the absence of comprehension. In Johnson’s (2010, p. 62) words: “To perform incomprehensibility, rather than trying to be comprehensible; to show absence through mime, gesture, tone and stillness, rather than only to tell the story through word” can assist people to cope with trauma; as was the case for Leanne, described below. In the second last session, after the dramatised group projection of her abusive teacher’s power over her, Leanne said that she “didn’t want to be one of those people who’s always looking down and feeling miserable”. Her choice of photograph in the very first session, had depicted a small boy, “unhappy because (he was) looking down”. Her later statement seemed to link her catharsis of grief and shame to the picture. The comments of Leanne and her coparticipants at the end of the later session brought it to a warm and cohesive close: Neil: Leanne’s the Queen of the Castle. Ben: It was certainly times coming to clear [sic] all those things that mattered and do something about it. Leanne: I’m so relieved that’s over. It’s been good. It’s been very thera-patic [sic] (also see Jaaniste, 2013a). Leanne’s caregiver, having called the memory of the emotional abuse “an obsessional memory” as it was so often repeated, reported one year after the closure of the drama therapy group that Leanne had never mentioned the issue again (Jaaniste, 2013b, p. 123). Leanne’s embodied experience in the drama therapy space assisted her to deal with the bleak memories and enhanced her feelings for group members. Grunberg Smith (2000) writes about isolation in aging nursing home residents, quoting Yalom, “No relationship can eliminate isolation, but existential aloneness can be shared in such a way that love compensates for its pain” (Yalom,

1980, p. 363). In contrast, the study participants lived in the community; but the drama therapy work with shared grief and loss also contributed to improving their QoL, bringing joy and support of one another rather than further sadness.

Memory and loss In the first memory session, entitled The Joys and Woes of Memory, some poignant moments in participants’ professional lives were elucidated. David remembered being articled as a solicitor’s clerk for £2 a week and Paul picked up an architect’s pen and fondly remembered his life’s work designing buildings. It became obvious that, for the men especially, working life was important and not working was associated with a loss of status. For Leanne, the only female participant of this session, there was a more homely memory. She rarely spoke of her teaching career except to say that she was a very different kind of teacher from the one who had abused her as a child. The act of choosing a cotton reel from a large group of objects helped her to remember how she had made her own clothes as an adolescent as there had been very little money in the home to spend on them. Early in the session entitled In the Land of Dementia there was conversation about dementia and memory. The following discourse occurred, delivered with humour about forgetfulness and the unforgiving and slippery power of words to hide and vanish. Paul: I discovered a lot of things about memory, or lack of memory. Joanna (drama therapist): What have you discovered? Paul: Well, I forget things left, right and centre. Forgotten. (broad smile) Leanne: Gone, gone, gone! Neil (laughing): Very good. Ah, good one! (general laughter) Ben, whose word retrieval ability seemed to be diminishing quickly, was confused by playing a Fruit Bowl game. Each time he was it in the centre of the circle and called out “apples”, “bananas” or “oranges”, he completely forgot to find himself a chair after everyone swapped places and so found himself back in the middle. Later in the same session, Neil spoke about his experience of picking up the “sticks of anger”, “stones of fear”, “petals of tears” and “bowls of emptiness” (see Macy and Young Brown, 1998 for symbolic designation) and related a conversation with staff member Delyse, his partner in the activity dyad: We talked about I suppose the bigger picture, our part in the bigger picture, what we can do and what we can’t do. Do you have any thoughts? Can you remember? He cried as he remembered family members and his conversation assisted Delyse to talk about the loss of her mother, which in turn allowed the participants to empathise with her and remember their own bereavements. Leanne practised a tune on the piano as we sang Hey, Ho, Nobody Home? (Simon, 1981, p. 194). When Leanne heard us sing, she said the song “pressed [her] buttons”. She remembered how her mother had worked, because they needed the money, and that Leanne had returned from school to an empty house. In summary, the choice of thematic description had three important functions. First, it enabled the researcher to track the progress of the expression of feelings such as anger, frustration, grief and loss over the 16 sessions. Second, the life situations of the participants and their relationships with family members past and present were highlighted, allowing expression of their feelings about those relationships. Third, participants’ attitudes to their own diagnoses of dementia and associated memory loss became more evident. There are many reasons for improvements in the social, psychosocial, confidence, decision-making and grieving areas of QoL.


Socialisation was a significant factor in the improvement of QoL observed qualitatively in the drama therapy group, and this can be perceived in the mounting ease with which the participants interacted and spoke together. QoL improvements which align with those advocated by people with dementia for themselves (Alzheimer’s Society report, 2010, pp. 17–22) were observed over time as drama therapy participants got to know and trust one another. Their abilities to communicate their anger and grief and to be treated fairly became obvious as they shared information about their relationships and the associated joys and losses. They had a confidential space in which to share information about their caregivers and to express their anger about childhood issues. The two main highlights of the sessions were the protest march and Leanne’s unpleasant experience with her teacher. Several participants’ sense of humour was apparent, especially when dementia and memory loss were discussed. Ability to engage in activities was never called into question, since the only occasions when participants refused to engage were when physical abilities were poor (Tanya) or there was objection to appropriating a story from a different culture (Paul). Even so, Paul showed independence in that particular judgement. Relationships were dealt with by Neil, Leanne and David and a sense of personal identity was displayed by all members of the group.

Discussion The aim of this pilot study was to examine the effect of drama therapy upon the QoL of elderly people with mild to moderate dementia. There was a suggestion of improvement for participants in the drama therapy group’s average QoL-AD score when compared with that of the movie group, although the difference was not statistically significant. It is interesting to note that this trend towards improvement was demonstrated in the context of the fact that the drama therapy group started with a lower QoL-AD score at baseline than the movie group, but by the end of the study this had reversed and the movie group was at a lower level. There are a number of postulated reasons that may account for the lack of statistical significance of the QoL-AD score comparison. First, of the 80 candidates initially identified from the Alzheimer’s Australia (NSW) database, only 13 participants went on to complete all 16 sessions and the final QoL-AD assessment. Consequently, the power of the study to detect a difference in average QoL scores was compromised by the small sample size. Second, the small sample size limited the ability to match on all related factors (baseline QoL, age, gender, education, location) which meant that both groups were not necessarily starting at an equivalent point. Further, both groups began with relatively high baseline QoL-AD scores which may also have limited the study’s ability to show any additional positive effect of drama therapy. Another source of variation was introduced by the pragmatic decision to hold groups in two separate cities when the number of volunteers in Sydney was inadequate for the project. Future randomised studies with larger numbers of participants of both genders are needed to examine further the effect of drama therapy on QoL while controlling for factors such as QoL starting point, date and type of diagnosis, gender, education level and location. It is important to note that the themes which emerged through phenomenological investigation support the suggestion of improved QoL-AD scores in the drama therapy group. The qualitative data reveal that powerful aspects of QoL such as relationships, ability to communicate and personal identity were involved which are in accord with the QoL-AD questionnaire as well as with the recognised QoL attributes listed previously (Alzheimer’s Society report, 2010). No behavioural disturbances of an aggressive or inappropriate nature occurred during the sessions and it is clear that

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drama therapy can help in this area, as anger, frustration and grief may be expressed responsibly within a safe space. The trend in the QoL-AD scale, which involves assessment of “family and friends”, socialisation, “life as a whole” and “self as a whole”, is congruent in many of its aspects with the qualitative findings. The study in its entirety can potentially serve as a resource and stimulus for further research. Conclusion As detailed earlier, Lepp et al. (2003), Wilkinson et al. (1998) and others have shown some improvements in the wellbeing of people with dementia when therapeutic drama and drama therapy are used. Although Rusted et al. (2006) were offering art therapy, the similarities between the foundations of these two arts therapies are significant and the findings of this earlier research project have been instructive. Given this contingency, it was hypothesised that the use of drama therapy could also show an improvement in the QoL of elderly people with mild to moderate dementia. Our findings provide support for this hypothesis. QoL is a growing concern of caregivers and organisations for aging populations worldwide. Future mixed method research with a randomised component that includes recruiting a larger sample of participants to better represent the wider community would be instructive. The qualitative research not only supports the suggested improvement in QoL, it demonstrates the ability of people with dementia to express feeling and show their wealth of experience brought to bear on the present moment. Further work conducting drama therapy sessions with people with dementia is recommended across a greater number of groups, as the outcomes of this study indicate a promising improvement of quality of life using drama therapy for people with dementia. Acknowledgements Dr Janice Ollerton, who proof read and edited this paper; Kerry Blake, Sally Dooner and Seiko Furuse, Art Therapists, who made valuable contributions to the group work and the anonymous reviewers who assisted us in positioning our work in the wider research context. Most of all our thanks go to the study participants for generously sharing their thoughts and feelings. References Alzheimer’s Disease International: World Alzheimer report. (2011). The benefits of early diagnosis and intervention. Alzheimer’s Disease International. Retrieved August 1, 2014 from https://www.google.com.au/?gws rd=ssl#safe=active& q=alzheimer+disease+international+world+alzheimer+report+2011. Alzheimer’s Disease International: World Alzheimer report. (2013). Dementia and risk reduction. Retrieved August 1, 2014 from https://www.google.com.au/?gws rd=ssl#safe=active&q=alzheimer+disease+international+world+alzheimer+ report+2013. Alzheimer’s Society. (2010). My name is not dementia: People with dementia discuss quality of life indicators. London: Author. Bailey, S. (2006). K-state perspectives, Fall/Winter. Lawrence, KS: Kansas University Press. Banerjee, S. (2010). Living well with dementia: Development of the national dementia strategy for England. International Journal of Geriatric Psychiatry, 25(9), 917–922. Bond, A., & Lader, M. (1974). The use of analogue scales in rating subjective feelings. British Journal of Psychology, 47, 211–218. Bowlby, J. (1998). Attachment & loss (Vol. 3). Loss, sadness & depression. New York, NY: Basic Books. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. Burton, A. (2009). Bringing the arts-based therapies in from the scientific cold. Lancet Neurology, 8(9), 784–785. Casson, J. (1994). Flying towards Neverland. Dramatherapy, 16(2 & 3), 2–7. Coulson, B., Fenner, S., & Almeida, O. (2002). Successful treatment of behavioural problems in dementia using a cholinesterase inhibitor: The ethical questions. Australian & New Zealand Journal of Psychiatry, 36, 259–262.

48


Daldrup, R., Engle, D., & Greenberg, L. (1988). Focused expressive psychotherapy. New York, NY: Guilford. Davis Basting, A. (2001). God is a talking horse: Dementia and the performance of self. The Drama Review, 45(3), 78–94. Davis Basting, A. (2006). Arts in dementia care: This is not the end. . .it’s the end of this chapter. Generations, 30(1), 16–20. Davis Basting, A. (2009). Forget memory: Creating better lives for people with dementia. Baltimore, MD: The John Hopkins University Press. Dramatherapy Centre. (2014). Sydney. Dramatherapy Centre. Retrieved November 18, 2014 from http://www.dramatherapy.com.au Ehrenfeld, M. (2003). Using therapeutic dolls with psychogeriatric patients. In C. E. Schaefer (Ed.), Play therapy with adults (pp. 291–300). Hoboken, NJ: John Wiley & Sons. Esteban-Santillan, C., Praditsuwan, R., Ueda, H., & Gelbmacher, D. (1998). Clock drawing in very mild Alzheimer’s disease. Journal of the American Geriatrics Society, 46(10), 1266–1269. Emunah, R. (1994). Acting for real. Brunner Mazel: New York, NY. Evans, D. (2003). Hierarchy of evidence: A framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12, 77–84. Farquar, M. (1994). Quality of life in older people. In R. Fitzpatrick (Ed.), Advances in medical sociology. Greenwich, CT: JAI Press. Feil, N. (1990). Validation therapy helps staff reach confused residents. Nursing, 16(12), 33–34. Feil, N., & de Klerk-Rubin, V. (Eds.). (2012). The validation breakthrough. Baltimore, MA: Health Professions Press. Finnema, E., Droes, R., Ribbe, M., & Tilburg, W. (2000). A review of psychosocial models in psychogeriatrics: Implications for care and research. Alzheimer Disease & Associated Disorders, 14(2), 68–80. Gersie, A. (1997). Reflections on therapeutic storymaking. London & Bristol, PA: Jessica Kingsley. Gersie, A., & King, N. (1990). Storymaking in education and therapy. London: Jessica Kingsley. Ginsberg, S. D., Hemby, S. E., Lee, V. M.-Y., Eberwine, J. H., & Trojanowski, J. Q. (2000). Expression profile of transcripts in Alzheimer’s disease tangle-bearing CA1 neurons. Annals of Neurology, 48(1), 77–87. Gorst, A. (2011). Awakening from the dream of thought: Research into dramatherapy and dementia. Dramatherapy, 29(2), 10–16. Grace, R., & Everard, L. (2001). Where to practise evidence-based medicine? The Lancet, 357(9257), 723. Grainger, R. (1999). Researching the arts therapies: A dramatherapist’s perspective. London: Jessica Kingsley Publishers. Greene, J., Baddeley, A., & Hodges, J. (1996). Analysis of the episodic memory deficit in early Alzheimer’s disease: Evidence from the doors and people test. Neuropsychologia, 34, 537–551. Grunberg Smith, A. (2000). Exploring death anxiety with older adults through developmental transformations. The Arts in Psychotherapy, 27(5), 321– 331. Heron, J. (1996). Co-operative inquiry: Research into the human condition. London: Sage Publications. Human, W. (2010). When research and psychotherapy meet. Indo-Pacific Journal of Phenomenology, 10(2), 1–2. Jaaniste, J. (2011). Dramatherapy & dementia care. In H. Lee, & T. Adams (Eds.), Creative approaches in dementia care (pp. 54–72). Basingstoke, UK: Palgrave Macmillan. Jaaniste, J. (2013a). Missing the point: Dementia, biomedicine and dramatherapy. In Conference papers of 21st century science: health, agency and wellbeing, Sydney Oxford, UK: Interdisciplinary Net. Jaaniste, J. (2013b). The intelligence of feeling and dramatherapy with people with dementia. In S. Petruzzella, M. Ross, & S. Scoble (Eds.), Arts therapies and the intelligence of feeling (pp. 117–129). UK: University of Plymouth Press. Jennings, S. (2005). The ageing fool: The importance of humour and stimulus for older people. Dramatherapy, 27(4), 14–16. Johnson, D. (1986). The developmental method in drama therapy: Group treatment with the elderly. The Arts in Psychotherapy, 13, 17–34. Johnson, D. (1994). Shame dynamics among creative arts therapists. The Arts in Psychotherapy, 21(3), 173–178. Johnson, D., Smith, A., & James, M. (2002). Developmental transformations in group therapy with the elderly. In C. Schaefer (Ed.), Adult play therapy (pp. 78–103). New York, NY: Wiley& Sons.

Johnson, D. (2009). Developmental transformations: Towards the body as presence. In D. Johnson, & R. Emunah (Eds.), Current approaches in drama therapy (2nd ed., pp. 89–116). Springfield, IL: Charles C. Thomas. Johnson, D. (2010). Performing absence: The limits of testimony in the recovery of the combat victim. In E. Leveton (Ed.), Healing collective trauma using socio drama and drama therapy (pp. 55–80). New York, NY: Springer. Johnson, R. B., & Onweugbuzie, A. J. (2004). Mixed methods research: A research paradigm whose time has come. Educational Researcher, 33(7), 14–26. Jones, P. (1996). Drama as therapy: Theatre as living. London & New York: Routledge. Jones, P. (2007). Drama as therapy: Theory, practice and research (2nd ed.). London & New York: Routledge. Karttunen, K., Karppi, P., Hiltunen, A., Vanhanen, M., Valimaki, T., & Martikaine, J. (2011). Neuropsychiatric symptoms and quality of life in patients with very mild and mild Alzheimer’s disease. International Journal of Geriatric Psychiatry, 26(5), 473–482. Kitwood, T. (1997). Dementia reconsidered. London & Philadelphia: Open University Press. Kohn, L. (1993). Validating current validation therapy [Letter to the editor]. Journal of Gerontological Nursing, 19(1 I), 6. Langley, D. (2006). Introduction to dramatherapy. London, New Delhi & Thousand Oaks, CA: Sage Publications. Lepp, M., Ringsberg, K., & Holm, A. (2003). Dementia–involving patients and their caregivers in a drama programme: The caregivers’ experiences. Journal of Clinical Nursing, 12, 873–881. Logsdon, R., Gibbons, L., McCurry, S., & Teri, L. (1999). Quality of life in Alzheimer’s disease: Patient and caregiver reports. Journal of Mental Health and Aging, 5, 21–32. Logsdon, R., Gibbons, L., McCurry, S., & Teri, L. (2002). Assessing QoL in older adults with cognitive impairment. Psychosomatic Medicine, 64(3), 510–519. Macy, J., & Young Brown, M. (1998). Coming back to life: Practices to reconnect our lives, world. Gabriola Island, Canada: New Society Publishers. Malterud, K. (2001). Qualitative research: Standards, challenges and guidelines. The Lancet, 358(9280), 483–488. Masters, C. L., & Bayreuther, K. (1998). Science, medicine and the future: Alzheimer’s disease. British Medical Journal, 316, 446–448. Molyneaux, V., Butchard, S., Simpson, J., & Murray, C. (2011). Reconsidering the term carer: A critique of the universal adoption of the term carer. Ageing & Society, 31, 422–437. Moyle, W., McAllister, M., Venturato, L., & Adams, T. (2007). Quality of life & dementia. Dementia, 6(2), 175–191. Pothoulaki, M., MacDonald, R., & Flowers, P. (2006). Methodological issues in music interventions in oncology settings: A systematic literature review. The Arts in Psychotherapy, 33, 446–455. Price, B., Gurvit, H., Weintraub, S., Geula, C., Leimkuhler, E., & Mesulam, M. (1993). Neuropsychological patterns and language deficits in 20 consecutive cases of autopsy-confirmed Alzheimer’s disease. Archives of Neurology, 50, 931–937. Onions, C. T. (Ed.). (1950). The shorter Oxford English dictionary on historical principles (Vol. 1). Oxford: Clarendon Press. Rogers, P. (1995). Music therapy research in Europe: A context for the qualitative–quantitative debate. British Journal of Music Therapy, 9(2), 5–13. Rusted, A., Sheppard, L., & Waller, D. (2006). A multi-centre randomised control group trial on the use of art therapy for older people with dementia. Group Analysis, 39(4), 517–536. Simon, W. (Ed.). (1981). The Readers’ Digest merry Christmas songbook. Pleasantville, New York & Montreal: The Readers’ Digest Association, Inc. SPSS, Inc. (2012). SPSS 20.0 for Windows [Computer software]. Chicago, IL: Author. Tüpker, R. (1990). Wissenschaftlichkeit Forschung. Musiktherapeutische Umschau, 11, 7–20. German language only. Weisberg, N., & Wilder, R. (2001). First encounters. In N. Weisberg, & R. Wilder (Eds.), Expressive arts with Elders (3rd ed., pp. 93–111). London & Philadelphia, PA: Jessica Kingsley. Wiener, D. J. (1999). Beyond talk therapy. Washington, DC: American Psychological Association. Wilkinson, N., Srikumar, S., Shaw, K., & Orrell, M. (1998). Drama and movement therapy in dementia: A pilot study. The Arts in Psychotherapy, 2(3), 195–201. World Health Organisation. (2012). Dementia: A public health priority. World Health Organisation and Alzheimer’s international report. Retrieved April 14, 2012 from http://whqlibdoc.who.int/publications2012/9789241564458 eng.pdf. Yalom, I. D. (1980). Existential psychotherapy. New York, NY: Basic Books.