POLYPHONYJournal of the Irish Association of Creative Arts Therapists
Visuals

Art Therapy and Dementia: Lucidity, Consciousness, and Cognitive Capacity

Published on Mar 07, 2022 by Angel C. Duncan, Wendy Miller, Berna G. Huebner

Introduction

This article explores the use of art therapy, lucidity and cognitive capacity in dementia. Through film, museums and a book, the modalities of art and consciousness are recommended as a unique approach in treating dementia. The concepts of lucidity and cognitive capacity are discussed in reference to abuse, ethics and health. The use of art may help health professionals gain deeper insight into lucidity, and support caregivers. Additionally, this article encourages creativity to be viewed as a social prescription in treatment.

There is growing interest in art therapy and creativity programs in dementia care initiatives (Schneider 2018). Within the past decade, studies have demonstrated how the arts help preserve quality of life in a variety of ways from cognitive assessment to consciousness. However, art therapy tends to be overlooked as a therapeutic treatment (Graham 2020).

Defining Art Therapy 

In America, art therapy is a mental health profession, earned by a Master’s degree from an accredited university that requires a registration through the American Art Therapy Credentials Board. However, countries outside of the United States, such as Ireland and the United Kingdom, have their own definition and credential guidelines. Art therapy is a form of combining studio art techniques with counselling psychology (talk therapy) approaches (American Art Therapy Association 2020), and it is used in diverse settings and with all cultural populations from young to older individuals, including persons with memory and cognitive impairment.

The act of creating is an additional benefit for persons living with dementia because art allows for the self-expression of thoughts and emotions that may not be verbalized (Duncan 2019).

Despite memory impairments caused by neural death, additional benefits include insights gained from the artwork produced, providing a better understanding into their world. Furthermore, art therapy is an effective treatment modality for all stages of Alzheimer’s disease. Art therapy serves each stage in diverse ways, but with the shared commonality of preserving autonomy and strengthening relationships.

Young-Onset, Early Stage Alzheimers, Capacity and Art Therapy

Oftentimes, those given a Young-Onset or Early Stage diagnosis of Alzheimer’s disease typically find themselves in a helpless and hopeless state of mind (Thompson, Duncan and Sack, 2021). The goal of art therapy in this stage is to help empower these individuals and their families by supporting them in their process, helping them to better understand the disease, and recognizing that having dementia does not mean an immediate ‘death sentence’.  Art therapy, coupled with verbal therapy, can allow for couples and families to learn better ways of communicating with more empathy and understanding of what the needs are.

Moderate to Late Stage Alzheimers, Capacity and Art Therapy

Those living in the moderate to late stages of Alzheimer’s are unable to give their consent due to the inability of holding cognitive capacity (Muller 2017). Behavioural and mood disturbances, such as agitation and depression, are common symptoms that can lessen wellbeing. These individuals need more around-the-clock care. There is a need to monitor and safeguard the quality of life. The goal of art therapy is to help enrich wellbeing. Past memories often resurface while they create art, and it is usually within these moments when relational bonds are strengthened between their caregivers. Families are often overcome with emotion in discovering a memory was not lost, such as remembering a favourite family vacation. A professional caregiver may learn something new about their client’s history and express more empathy towards them. The art that sparked their memory can usually give them something to talk about, a phenomenon that has been documented in various art therapy programs (Chancellor, Duncan and Chatterjee, 2014).

Even in the severe stages, when words may be completely lost, the art therapist can engage significant aspects of that person (Duncan 2019).

Art Museum Tours and Art Therapy Programs

Art museum programs for dementia populations additionally allow for a better understanding of how the arts impact brain health and may offer deeper clues into consciousness. Angel Duncan, an art therapist with a background in counselling psychology and Alzheimer’s diagnostic and clinical trials, has combined the neurosciences with social prescriptions of creativity through her work with individuals and their families. In 2019, Duncan co-developed the Arts in Mind program in collaboration with the Yale University Art Gallery (Figure 1). The program is specific to those with a young-onset and early-stage Alzheimer’s diagnosis. The program combines art therapy modalities and museum education that enhances participants’ and their family members’ quality of life.

Figure 1: Jessica Smolinski, 2019, Arts in Mind program, photography, Yale University Art Gallery, New Haven, Connecticut

One example of how this work benefits the participants was a life partner and her significant other, a man living with young-onset Alzheimer’s disease, who expressed how the art-making process provided him with an alternative way of self-expressing his needs to her when words failed him

Healthcare providers, medical and health students, and family caregivers who attend the Arts in Mind program are additionally exposed to the psychological benefits of how this program provides deeper insight when observing the artwork created and the meaning behind it.

I Remember Better When I Paint

Berna Huebner, whose work is best known for helping people through the arts in museum tours from her book and film, I Remember Better When I Paint (Huebner et al. 2011) began her journey in arts programs when her mother progressed in the stages of Alzheimer’s disease. Huebner found that through the creative process, there was something deeper happening with memory loss. Her mother was an artist who stopped painting as she progressed in the disease. The catalyst for the award-winning film’s title that Huebner produced was inspired by her mother’s words when asked if she wanted to paint (Figure 2).

Figure 2

Figure 2: Hilgos, 1997, Sailing, watercolor painting, Hilgos Foundation Collection, Highland Park, Illinois

The support of the art students from the School of the Art Institute of Chicago who worked with Huebner's mother, provided Huebner the experience of recognizing how the power of the arts can impact one’s life, even after memory loss has changed one’s normal ways of responding to the world (Figure 3). The transformative power of art often remains misunderstood by those affected with Alzheimer’s disease and other forms of dementia.

(Figure 3) Hilgos, 1997, Waiving Lines, watercolor painting, Hilgos Foundation Collection, Highland Park, Illinois (Fashion designer, Oscar de la Renta was inspired by this painting and designed one of his dress collections using this image for two of his fashion runway shows in 1999 in New York City and Chicago)

There remains to be a large amount of work to be carried out in order to better educate and advocate for this type of approach in treatment. In the film, neurologist Sam Gandy, M.D. of Mount Sinai Hospital stated that parts of the brain are spared in people with memory impairment. Therefore, among the remaining undertakings needed, is the adaptation of this mindset. There is a vital need to include current and relevant information on the capabilities that art has in supporting brain development (Huebner et al., 2011).
 
A third-year Harvard medical student validated that the medical world only learns about how Alzheimer’s disease robs the mind, changes personality, and leaves only a caricature of the original self. It was acknowledged that this mindset of thinking is based on outdated knowledge and assumptions, and that as new concepts are explored in how the arts enliven the mind, this sense of awareness needs to be given careful attention to within medical communities, especially for incoming physicians and nurses (Huebner et al., 2011).

Lucidity and Cognitive Capacity

Art therapy demonstrates its effectiveness in care modalities. However, one of the areas that need further attention is the interdisciplinary work between physicians and cognition researchers in assessing cognitive capacity. Cognitive experts can help provide the answer to, ‘what really goes on in the brain when artists express themselves on the canvas?’ There needs to be a better understanding of how the brain operates during these creative processes.

Furthermore, there demands a need to gather further clinical data about the genuine changes occurring in those with dementia.

The concept of consciousness and cognitive capacity is an important issue that often does not get discussed in the ethical and legal implications of Alzheimer’s disease. Geriatric psychiatrist, Gene Cohen, M.D., Ph.D., extensively researched the significance of creativity’s place in brain health, particularly in Alzheimer’s. Cohen championed creativity as an avenue that tapped into the subconscious mind, yet he was well aware of the need for better screening practices in cognitive capacity. A high-profile court case in the U.S. serves as an example of how the lack of cognitive capacity in dementia impacts the quality of care. Cohen testified on the issue of cognitive capability and lucidity on a woman who was suffering from dementia and was being abused (Figure 4). Many important themes were highlighted in the book Sky Above Clouds: Finding our way through creativity, aging, and illness (Miller, Cohen and Barker 2016).


 
(Figure 4) Dr Gene Cohen testifying as an expert physician in Alzheimer’s disease for the Anthony Marshall vs. New York City court case, 2009, pastel on archival canson mi teintes pastel paper, Jane Rosenberg Private Collection, New York, New York
 
Cohen developed a way to assess for cognitive capacity and lucidity based on the three major stages of Alzheimer’s disease: mild, moderate, and severe. Dr Cohen’s evaluation is viewed as a role model of how physicians need to act in patient care, both in social prescribing art programs, and taking the time to thoroughly evaluate their patients (Figure 5).


 
(Figure 5) Dr Gene Cohen talking with a research participant at the Regency House for a 25 year long longitudinal study on a social prescription type of research study for older adults with issues from depression to dementia who were living independently in the community, circa 1981, photography, Robert S. Cox Special Collections and University Research Center of the University of Massachusetts Amherst Libraries, Amherst, Massachusetts
 
This question of ‘What is a lucid moment?’ is difficult to answer and may offer a sense of inner deep reflection.

We may find ourselves asking: ‘What is real?’ For each of us, it also comes down to the same question Dr. Cohen posed, ‘What really is a lucid moment?’

Artist, William Utermohlen, for example, was diagnosed with Alzheimer’s disease in 1995. Despite the disease progression into late-stage Alzheimer’s, Utermohlen painted self-portraits that became more abstract and distorted. He was encouraged to paint as a way to self-express himself when he was unable to use his words. His art became a way for him to communicate as the visual aspect of his brain had not been as affected than his verbal section in the brain (Sharp 2017). In these times of lucid moments, Utermohlen may have appeared cognizant, yet lucidity should not be misconceived as holding cognitive capacity (Hegde and Ellajosyula 2016). Those working close to Utermohlen believed that within these lucid moments there were distinctively fluctuating times happening in his art during the disease progression (Sharp 2017). Studies exploring lucidity and consciousness in dementia cases have found the arts to be of great benefit in supporting self-expression when words cannot be expressed. The University of California at San Francisco (2017) suggests that lucid moments seem to be heightened when persons living with dementia are able to be creative and express themselves, but this does not necessarily mean that those with dementia are able to provide cognitive capacity.  

Conclusion

Understanding the importance of cognitive capacity, lucidity and the arts bring forth awareness that highlights the complexities of dementia. Despite Alzheimer’s, it is important to nurture the mind and spirit, and not to dismiss imagination as nonexistent. Art is a method to stimulate the imagination, help preserve long-term memories and restore quality of life. Art-making may help our perception and awareness of lucidity and help caregivers in the process. Additionally, we as authors believe creativity as therapeutic treatment not only helps the family in these ways, but also informs the stages of lucidity, which further serve as a vehicle for cognitive capacity.

References

Alzheimer’s Disease International, (2017), Dementia Statistics.  Available at: https://www.who.int/newsroom/fact-sheets/detail/dementia [Accessed 12 November, 2020].

American Art Therapy Association, (2020), Becoming an Art Therapist. Available at: https://arttherapy.org/becoming-art-therapist/ . [Accessed: 17th December, 2020].

Chancellor, Bree, Duncan, Angel, and Chatterjee, Anjan, (2014), 'Art Therapy for Alzheimer’s Disease and Other Dementias', Journal of Alzheimer’s Disease, 39, 1-11.
Coates, Charlotte, (2019), Designing Museum Programmes for People with Dementia. Available at: https://www.museumnext.com/article/designing-museum-programmes-for-people-with-dementia/ . [Accessed 17th December 2020].

Duncan, Angel, (2019), ‘Art therapy in neurocognitive disorders: Why the arts matter in brain health’, Surgical Medical Open Access Journal, 2(3), 1-4.

Duncan, Angel, (2018), 'Identity in Memory: Ascertaining Consciousness beyond Dementia', Journal of Neurological and Neurological Disorders, 4(3), 1-6

Flatt, Jason D., Liptak, Amy, Oakley, Mary Ann., Gogan, Jessica, Varner, Tresa, and Lingler, Jennifer H, (2015), 'Subjective experiences of an art museum engagement activity for persons with early-stage Alzheimer's disease and their family caregivers', American Journal of Alzheimer's Disease and Other Dementias, 30(4), 380–389.

Huebner, Berna, Lange, Deborah, Butler, Robert N., Cohen, Gene, Noronha, Avertano, Lazarus, Lawrence W., Sheppard, Jenny Graf, Daly, Timothy, Benson, Jane, Barcus-Slonina, and Robin, Seman, Dorothy, (2011), I Remember Better When I Paint: Art and Alzheimer’s: Opening Doors, Making Connections, Maryland: Bethesda Communication Group and New Publishing Partners.

Graham, Judith, (2020), 'U.S. medical panel thinks twice about pushing cognitive screening for dementia', KHN, 25 February. Available at: https://khn.org/news/u-s-medical-panel-thinks-twice-about-pushing-cognitive-screening-for-dementia/.  [Accessed 27th March, 2021].

Hedge, Soumya and Ellajosyula, Ratnavalli, (2016), ‘Capacity issues and decision-making in dementia', Annals of Indian Academy of Neurology, 2016: Suppl 1, pp. S34-S39.                                                                                                                                                    

Miller, Wendy, Cohen, Gene and Barker, Teresa (2016), Sky Above Clouds: Finding our Way through Creativity, Aging, and Illness, New York: Oxford University Press.

Muller, Jan, Chan, Khin and Myers, Jonathan (2017), ‘Association Between Exercise Capacity and Late Onset of Dementia, Alzheimer’s Disease, and Cognitive Impairment’, Mayo Clinic Proceedings, 92:2, pp. 211–17.  

Schneider, Justine (2018), ‘The Arts as a Medium for Care and Self-Care in Dementia: Arguments and Evidence’, International Journal of Environmental Research and Public Health, 15:6, pp. 1-11.

Sharp, Rob (2017), ‘For Alzheimer’s Patients, Art’s Therapeutic Effects Are Transformative’, Artsy. Available at: https://www.artsy.net/article/artsy-editorial-doctors-making-art-help-combat-alzheimers [Accessed 28th April, 2020].

Suresh, Mahanand, Belathur, Fischl, Bruce and Salat, David (2017), ‘Factors Influencing Accuracy of Cortical Thickness in the Diagnosis of Alzheimer’s Disease’, Human Brain Mapping, 39:4, pp. 1500–15.

Thompson, Rachel, Duncan, Angel and Sack, Jessica. (2021). 'Arts in Mind: A Multidisciplinary Approach to Museum Programs for Persons Living with Young-Onset and Early Stage Alzheimer’s Disease'. International Journal of Lifelong Learning in Art Education, 4, 61-73.

University of San Francisco at California, (2017), hear/say. Available at: https://memory.ucsf.edu/sites/memory.ucsf.edu/files/hear-say_vol1.pdf [Accessed 28th April, 2020].

World Health Organization (2019), Dementia: Key Facts. Available at: https://www.who.int/news-room/fact-sheets/detail/dementia. [Accessed 12th November, 2020]                                                                                                          

Angel C. Duncan

Angel C. Duncan, PhDc, MA, MFT, ATR has an extensive background in counselling psychology, art therapy and Alzheimer's disease neuroimaging diagnostics and clinical research. She currently oversees education and training in Medical Life Sciences at Life Molecular Imaging and serves as the Executive Director for the Cognitive Dynamics Foundation. She is an Adjunct Professor at the University of Tampa and Co-Founder of the Arts in Mind program at the Yale University Art Gallery. Angel speaks on mental health, the importance of creativity on the brain, and dementia forms. She is a widely published author.        

Wendy Miller      

Wendy Miller, Ph.D, ATR-BC, LCPAT, REAT, LPC, BCPC is an art therapist, writer, sculptor, and educator. She taught for over fifteen years in universities throughout the U.S. She is the co-founder of Create Therapy Institute. Wendy is a founding member, and first elected (past) Executive Co-Chair of the International Expressive Arts Therapy Association, where she continues to be on their Advisory Council. She continues in legacy and education of her late husband’s work, geriatric psychiatrist, Gene Cohen, MD, PhD. Wendy researches the relationships among the arts, creativity and health, and co-authored the book, Sky Above Clouds: Finding our way through creativity, aging and illness

Berna G. Huebner

Berna G. Huebner is Co-Director and Associate Producer of the film I Remember Better When I Paint and editor of the book by the same title. She is the President and Founder of the Hilgos Foundation, which supports ongoing artistic creation for those with dementia. Berna serves on the Board of Directors of Arts & Minds, Advisory Council of See Me program at the Smithsonian Museums, and is Director of the Center for the Study of International Communications in Paris, France. She served as the Research Director for Nelson Rockefeller, Governor of New York, later Vice President of the US.