Effectiveness and meaningfulness of art therapy as a tool for healthy aging: a comprehensive systematic review protocol

Abstract

Review question/objective 

The aim of this review is to determine the impact of art therapy on the physical and mental health outcomes of elderly people.

More specifically, the objectives are to identify:

• The impact of art therapy participation on the individuals' physical wellness and mental health/emotional needs.
• The experience and meaningfulness of the aged person and their participation either in group art therapy situations or in one on one situations.

Background 

As a concept, art therapy has been around in an accepted capacity since the late 1930s, involving work with mental health patients in America and the United Kingdom. Artist Mary Huntoon was one of the first to be accepted for her practice and began art therapy sessions with patients at the Menninger Clinic at Topeka in Kansas and called her work, Art Synthesis around 1936.¹

The American Art Therapy Association defines art therapy as a mental health profession in which clients, facilitated by the art therapist, use art and the creative process to explore emotional conflicts, foster self-awareness, manage behavior and addictions, develop social skills and increase self-esteem. The association goes on to say, the goal is to improve or restore a client's functioning and his or her sense of personal well-being.²

In an increasing aging population, together with the positive effects of modern medicine on human longevity, it is conceivable that greater percentages of the world's population will be residing in aged care facilities without any particular disease other than the effects of the normal aging process. As a possible delay mechanism for the onset of mental illness, depression, dementia and Alzheimer's disease, art therapy can mentally and socially stimulate residents.³ The elderly person may gain a sense of improved wellbeing, greater confidence and in turn a physical improvement on health and quality of life. Art therapy can also provide the aged person with increased cognitive abilities, social skills, feelings of self-worth and a possible link with the past.³ Most children have a naïve talent for visual expression which is often lost as other verbal languages are learnt. Therefore, many adults feel they once had a talent in making art and would like to explore the possibility of learning to paint, draw, sculpt or perform other forms of visual expression. Self-expression provides a vehicle for the aged care patient to overcome a sense of apathy and hopelessness; rather than retreating inwards, the patient may feel more encouraged to participate in the activities of living.

Modern medical research has paved the way for populations to live longer, healthier lives. That is a wonderful thing in itself; however, what are people going to do with themselves as they age and can no longer be as physically active as they once were? What will occupy their daily routines as they grow old and their friends and family pass on? Perhaps the creative therapies can fill the void left by these life-changing issues? It has been suggested that creative modalities can improve problem solving abilities, self-esteem and general life satisfaction.⁴ Ravid-Horesh questioned whether art therapy can enhance positive outcomes of the aged person's life review, allowing for self-acceptance, greater self-esteem and happy aging.⁵ What cannot often be articulated in words by a person is their inner most thoughts, experiences and feelings and often these can be deeply held within the psyche. Another form of communication, such as art, can help a person work through their emotional and health issues, by communicating to another individual in the form of art, when they are otherwise unable to verbalize what is making them behave a certain way, or appearing withdrawn from the world.

Another contemporary issue arising from greater longevity of the population is the question of a person's ability to support themselves financially; many will not have the funds to live as they once did, lowering their self-esteem and the feeling of their place in the world. Mental health is becoming more and more of a concern in the general aging population and even the broader realization that people are losing their sense of humanity and of self-worth, these human characteristics may be further lost through a lessening of cognitive abilities due to inactivity.⁴

There are thankfully an equally growing number in the research community who are interested in the aged to help with diverse and tailored approaches to therapy, providing important psychological support.⁶ A recent systematic review published in 2014 looked at the effect of art therapy and specific diseases, rather than the healthy individual, which is the focus of this study, and found only eight studies that met their inclusion criteria; all but one reported the benefits of the effects of art therapy on the individual.⁸ Although there have been some recent studies on the positive outcomes of art therapy, they have largely been devoted to those suffering from a particular disease. This will be the first systematic review to look at the healthy, older patient and the effects of art therapy as well as what it means to the patients themselves. This is a global issue and one of the human condition; therefore regardless of time, cultural background or differences, this review will not restrict the search for information to language or region, date published or other boundaries. This protocol is an update of a previously published protocol.⁹

Inclusion criteria

Types of participants

Participants will be people aged 65 years or over, who are considered “healthy’” i.e. with no evidence or diagnosis of dementia or other cognitive disabilities. They will either be in nursing home care, community care, day care, residential, low-care, supported living or the medical home. They may have no family or other emotional support and be suffering from increasing introspection, which can have a profound impact on a person's physical and mental health.

Types of intervention(s)/phenomena of interest

The intervention of interest will be art therapy with a focus on the visual arts. All available techniques will be considered, including for example, art therapy sessions using a variety of tools, drawing, painting, computer manipulated imagery, photography and any other mode of visual expression. Art therapy techniques examined will be those used in the group situation or with the individual aged person. There will be no limitations as to who runs the art therapy program (i.e. artist, professional art therapist, general therapist), and the therapy can be self-directed. Duration and frequency of sessions can vary, depending on a person's health and stamina.

The phenomena of interest will be the experiences and meaning assigned to participating in art therapy by elderly people.

Comparator

The comparator will be no intervention, that is, participants who experienced art therapy will be compared to those who did not.

Types of outcomes

Quantitative outcomes will look at physical and mental health outcomes and behavioral characteristics as measured by self-report or validated scales/instruments. Indicators will include measures of cognitive function, depression scales and frequency of participation in-group or individual art therapy activities. Changes in the participants' communication skills, social interaction, behavioral problems (e.g. stereotypic behavior, and attention and concentration skills) will be key outcome indicators of the intervention.

Qualitative outcomes will be subjective from the patient's point of view: how do they react to the feelings and emotions which they experience from the therapy sessions? Does the reminiscing help or make them feel sad for what they have lost, or happy for what they've had in their past? Does the person have an improved Quality of Life (QOL) because they are happier and feeling a sense of increased self-esteem by participating in group therapy, or achieving that painting they have always wanted to produce? As a result of the art therapy intervention, do they have improved cognitive abilities; do they cope with stress and adverse events more easily; has their outward demeanor changed all reflection their state of mental health?

Studies will be excluded if they have a focus on the performing arts - music, dance and drama. Participants will be excluded if they are under the age of 65 and if they have been diagnosed with dementia, Alzheimer's or other cognitive disorders. Editorials and opinion articles will be excluded.

Types of studies

Any quantitative, (e.g. comparative art therapy methodologies in the delivery of interventions) or qualitative study designs, (e.g. client self-evaluations or case progress notes) will be considered for this review. Each study will be classified according to the JBI levels of evidence (Appendix I) and preference will be given to those higher in the hierarchy of evidence such as randomized controlled trials (RCTs). Studies that are long term follow-up and observational cohorts will be included, as will guidelines from professional associations that are based on studies rather than expert opinion.

Search strategy

The search strategy will aim to identify both published and unpublished studies from 2004 to 2014. Although art therapy has existed as an intervention for some time, this review seeks to identify the best available, most up to date research. There have been a number of RCTs conducted in recent years, but to date, no systematic reviews on this topic has been published, and thus a time span of 10 years is deemed important to capture a substantive pool of research for the synthesis of this systematic review.

A three-step search strategy will be utilized in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Only studies published in the English language will be considered for inclusion.

The databases to be searched include:

MEDLINE

CINAHL

EMBASE

Cochrane Central Register of Controlled Trials (CENTRAL)

CSA Sociological abstracts

Clinical Trials

PsycINFO

Current Contents

AgeLine

Informit

ISI Web of Knowledge

Health Source: Nursing/Academic Edition

Scopus

The search for unpublished studies will include:

MEDNAR

ProQuest Dissertations and Theses

Index to Theses

The Networked Digital Library of Theses and Dissertations (NDLTD)

Experts in the field will be consulted such as those registered with the Australian and New Zealand Art Therapy Associations (ANZATA), American Art Therapy Association (AATA), British Association of Art Therapy, as well as any other countries with credible associations, together with University lecturers and Art Therapists.

Additional searches will be conducted in specialist journals such as ‘The Arts in Psychotherapy’ to eliminate any excluded citations in the databases.

Initial keywords to be used are:

Concept 1: art therapy, art psychotherapy, art therapists, therapeutic arts, artistic expression, visual expression

Concept 2: aged care, aged, gerontology, elderly, healthy aging, older adults

Concept 3: self-esteem, social interaction, well-being, quality of life, self-concept, memory, hope, behavioral research

Assessment of methodological quality

Quantitative and qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the appropriate standardized critical appraisal instruments, MASTARI (Meta Analysis of Statistics Assessment & Review Instrument) and QARI (Qualitative Appraisal & Review Instrument) from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI-SUMARI, Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data collection

Quantitative and qualitative data will be extracted from papers included in the review using the appropriate standardized data extraction tool from JBI-SUMARI (Appendix III).

Data synthesis

For quantitative data all results will be subject to double data entry. Odds ratios (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form.

Qualitative research findings will be pooled where possible, using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represents the aggregation through assembling the findings according to their quality and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings.

Conflicts of interest

The authors have no conflicts of interest to declare.

Acknowledgements

Grateful thanks to Dr. Sarahlouise White, for her assistance in the revision of this protocol.