January/February 2014 Issue

Expressive Therapies for People With Alzheimer’s
and Related Dementias
By Kate Jackson
Social Work Today
Vol. 14 No. 1 P. 10

The primal response to certain forms of creative communication remains intact in individuals with Alzheimer’s disease and related dementias, even when memory, language, and cognition are impaired. Creative arts therapies help make the most of these abilities.

The narrator of Marcel Proust’s novel Remembrance of Things Past marvels at the startling intensity of a memory triggered when he lifted to his lips a spoonful of tea-soaked crumbs of a Madeleine cake: “No sooner had the warm liquid, and the crumbs with it, touched my palate, a shudder ran through my whole body, and I stopped, intent upon the extraordinary changes that were taking place. An exquisite pleasure had invaded my senses, but individual, detached, with no suggestion of its origin.”

This phenomenon, in which emotion and memory are stirred in the absence of conscious thought, is at the core of how expressive therapists are helping individuals with Alzheimer’s disease and related dementias through various artistic modes, from painting and poetry to music and dance.

While researchers are exploring the value of expressive therapies in treating those with cognitive deficits, most people have personal experiences that seem to prove the therapies’ indisputable benefits. We intuitively understand that music and movement tap into deep wells of memories because we know the feeling of being taken back in time by music or of being able, without thinking about it, to execute a movement not performed for years.

Expressive therapy and emotional and imaginative power of the arts, even over people who seem to be unreachable, was the subject of a 2011 movie, The Music Never Stopped, based on “The Last Hippie,” an essay by famed neurologist Oliver Sacks, MD, in his book An Anthropologist on Mars. It tells the story of a young man stricken by amnesia as a result of a brain tumor. With the help of a music therapist and a devoted father, he was able to engage with others and retrieve memories in response to the music that had inspired him in his youth, particularly that of the Beatles and the Grateful Dead.

In his book Musicophilia, Sacks explained this deep reach of music therapy for individuals with “widespread cortical problems,” such as those with Alzheimer’s disease and related dementias: “While music can affect all of us—calm us, animate us, comfort us, thrill us, or serve to organize and synchronize us at work or play—it may be especially powerful and have great therapeutic potential for patients with a variety of neurological conditions. Such people may respond powerfully and specifically to music (and, sometimes, to little else).”

Although intellect and cognition are involved in the creation of art and may enhance the understanding of works of art, to be appreciated at its most basic level, art relies equally, if not more heavily, on the senses. The primal response to certain forms of creative communication remains intact in individuals with Alzheimer’s disease and related dementias, even when memory, language, and cognition are impaired. Thus, expressive therapies can not only be especially useful with these individuals, they can also help providers focus on their clients’ abilities and what they retain rather than on their deficits and what they’ve lost.

Goals and Benefits
Expressive therapies and creative arts therapy are umbrella terms that encompass several disciplines: art, music, dance/movement, and drama therapies. Each of these modalities is practiced at CJE SeniorLife, an organization based in Chicago that provides skilled nursing care, memory care, assisted living, and adult day services. “Art therapy can range from insight-based support groups for those with early-stage dementia or mild cognitive impairment to nonverbal, sensory-based interventions for those in advanced stages of dementia,” explains Theresa Dewey, MAAT, ATR, LPC, an art therapist who works at the Lieberman Center for Health & Rehabilitation in Skokie, Illinois, CJE SeniorLife’s skilled nursing facility.

“The treatment goals of art therapy vary as widely as they would for any therapeutic discipline,” Dewey says. “I see many individuals for management of depression or anxiety symptoms. Increased engagement and enhanced communication are other common treatment goals for people with dementia, and for those with severe dementia, increased sensory awareness and connection to others are often goals.”

Experts say it’s important to note that the outcome of expressive therapies for individuals with Alzheimer’s and related dementias isn’t necessarily improved memory or cognition. “The goal in treating anyone who has a medical condition that does not lend itself to cure or rehabilitation should be personal comfort and maximizing remaining abilities. All interventions should be focused on enhancing the quality of one’s life,” says Daniel Kuhn, LCSW, community educator and project manager at Rainbow Hospice and Palliative Care in Mount Prospect, Illinois.

Tailoring the Approach to the Individual
While all expressive modalities have their benefits, music and dance therapies most often are effective for individuals with dementia because cognitive deficits are no barrier to participation. “When the level of dementia is not too far advanced, the specific art form that may be most helpful may depend upon which of their sensory modes were most trained and active earlier in their lives,” says Donna Newman-Bluestein, MEd, BC-DMT, CMA, LMHC, a dance movement therapist; senior lecturer at Lesley University in Cambridge, MA; and spokesperson for the American Dance Therapy Association, noting that an individual’s degree of sensory impairment influences the art form. “As they lose the ability to make sense of symbolism and imagery, the art forms most helpful remain music and movement.”

Kuhn notes that there are no head-to-head studies determining which therapy type is most useful for individuals with dementia. “It all boils down to individualization,” he says. His favorite, however, is music. “It’s built into our DNA from time immemorial.” He points to Sacks’ exploration of these theories in Musicophilia, adding that “the rhythms and sounds of music touch our deepest memories in ways we simply do not understand.”

“Even when someone is not responsive to music, a dance/movement therapist can continue to reach that person through movement and nonverbal communication,” Newman-Bluestein says. “Dance in particular often taps into muscle memory and may even evoke reminiscences of joyous occasions in the past,” adds Andrea Koch, MA, ATR, LPC, manager of life enrichment and creative arts therapy at the Lieberman Center.

Ultimately, “The modality that is best for a client is the one they respond to,” says Erica Hornthal, MA, BC-DMT, LCPC, owner and president of North Shore Dance Therapy, a psychotherapy practice in Chicago dedicated to helping individuals and families cope with the challenges of dementia through body-mind interventions.

Accentuate the Positive
Koch points to the potential of expressive therapies to bypass deficits and highlight abilities. “As those of us who work in dementia care well know, clients often find creative ways to adapt to their physical and cognitive limitations. Indeed, where memory falls short, creativity steps in,” she explains.

“For people who have dementia, verbal communication and expression can become challenging,” says Gail Adduci Gogliotti, MA, BC-DMT, LCPC, a dance/movement therapist at Norwood Crossing, a nonprofit senior assisted living and skilled nursing community in Chicago. She says expressive therapies—and dance/movement therapy in particular—provide an outlet to be expressive nonverbally. “By engaging them to be present in the moment in this way, you can truly meet the clients where they are. There isn’t any pressure to say or do the right thing or to remember what you had for breakfast or where you grew up,” she explains. Difficulty communicating can lead to isolation, she says, so movement therapy, through bypassing verbal communication, also helps those with dementia interact with others.

“Memories are stored in the muscles of the body, and moving can draw those memories out,” Newman-Bluestein says. “I have seen people who no longer remember how to use a knife and fork remember how to waltz—not just the step but the carriage.”

But neither previous knowledge of how to dance nor full mobility is required for such therapy. “The most primitive movement we have is breathing, and we can all breathe, even someone on a ventilator,” Hornthal says, and as long as someone can breathe, he or she can engage in dance therapy. Similarly, anyone whose hearing is intact can listen to music, and many individuals with dementia also can sing or create sound.

Older individuals and people with dementia often are told what they can’t do and what they shouldn’t do, Hornthal says, but expressive therapies “focus on what the patients can do, on their success, not on what they can’t do.”

“People with dementia may have difficulty remembering the past and certainly planning for the future,” Newman-Bluestein says. “When invited into the present through the arts, they can excel. They can be playful, innovative, and spontaneous. When others recognize their contributions, they feel empowered.”

Misunderstood and Underused
According to Kuhn, author of Alzheimer’s Early Stages: First Steps for Family, Friends and Caregivers, “Expressive therapies are far more beneficial than any drug treatments currently available, but I cannot prove it. Although I recommend a daily diet of expressive therapies, they are not readily available,” largely due to misconceptions. “Expressive therapies are too often seen as useful distractions instead of therapeutic activities for people with dementia.”

“Many facilities are still in the early stages of the culture change movement,” Koch says. “Nonmedical and nonpharmacological approaches are still the exception rather than the rule. Particularly now, with the mandate to reduce antipsychotic medication in nursing facilities, the need for nontraditional approaches to symptom management are particularly important.”

“What is misunderstood about expressive therapies is very much related to what is misunderstood about the arts: They are considered fluff, when in fact they are core,” Newman-Bluestein says. “The arts teach us a great deal about values, life, getting along, balance, and health. The dominant culture has values that I would consider upside down. Even though no more than 35% of what we express when we speak is verbal, the nonverbal is ignored. For people with cognitive issues, the nonverbal is of the utmost importance. The expressive arts therapies, in general, are something they can excel at and grow in.”

Further, expressive therapies aren’t arts and crafts classes, Koch notes. The point is not to produce aesthetically pleasing products. “The processes we employ, while often fun, are clinically oriented and aimed at helping clients reach specific goals,” he explains.

These misunderstandings are one reason these therapies aren’t used as widely as experts believe they should be. In addition, our culture has become accustomed to substandard care for older adults and people with Alzheimer’s and related dementias, Newman-Bluestein says. “The bottom line is money. This is terribly sad because we are not honoring our fathers and mothers.”

Bringing the Arts Into the Social Work Sphere
Social workers who wish to bring these modalities to their clients may benefit from advanced training, but they don’t need to be certified in an expressive therapy to make a difference. “Anyone who sings or has an ounce of creativity can engage someone with dementia,” Kuhn says. “Too often caregivers get caught up in their tasks or roles instead of making these personal connections at the heart level.”

To explore expressive therapies, he says, learn from the professionals. “Ask them to be your mentors, take some classes, and practice new skills with individuals and groups.” Expressive therapies, he adds, “are completely in sync with the goals of social work.”

Koch often recommends Anne Basting’s book Forget Memory to clinicians who want to explore the use of expressive therapies. “Basting points out that if we ask clients to recall specific facts and events, we are setting them up to fail. If we find ways to creatively engage with them in the here and now, it levels the playing field,” he explains.

“If you work with a client who seems to crave sensory stimulation, the creative arts can be very powerful,” Koch adds. “I worked with a woman with advanced dementia who continually stomped her feet rhythmically. Though I’m not personally trained in music therapy, I developed a few techniques where she and I could explore rhythm. I placed different surfaces underneath her feet to produce different sounds. I used handheld percussion instruments to mirror her beat, which sometimes lead to improvised duets. In this way, we developed a form of communication.”

With movement, “What’s most important is that the social workers enjoy dance and are self-aware about their use of dance and movement,” Newman-Bluestein says. “It is through modeling the integration of body, heart, mind, and spirit that we bring healing. To the extent that we are unaware of our own feelings in relating to people with dementia and the life challenges they face, we burden them with our blind spots.”

The benefits of expressive therapies may extend equally to the client and the healer. “I recommend using the creative arts as a means of self-care and reflecting on your work,” Koch says. “There have been times where making art about a particularly challenging case has helped me gain new insight, particularly with regards to any countertransference I may be experiencing. Once you have a handle on how you personally can use the creative arts as a tool for communication and coping, it will help you develop techniques for bringing these experiences to your clients.”

— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.