CREATIVE EXPRESSION, DEMENTIA AND THE THERAPEUTIC ENVIRONMENT

By

Dalia Gottlieb-Tanaka

Dip. The Academy of Art and Design, Bezalel, 1975
M. Arch., the University of British Columbia, 1980

A THESIS SUBMITTED iN PARTIAL FULFIMENT OF
THE REQIUREMNETS FOR THE DEGREE OF

DOCTOR OF PHILOSOPHY

In

THE FACULTY OF GRADUATE STUDIES

(Interdisciplinary Studies)

[Health/Education/Arts/Architecture]

THE UNIVERSITY OF BRITISH COLUMBIA
June 2006

© Dalia Gottlieb-Tanaka, 2006



Abstract

This study aims to explore the physical environment in arriving at an understanding of the

administration of and level ofsuccess of creative expression programs that were carried out with seniors

who have mild cognitive impairment to moderate dementia at the L ‘Chaim Centre and at the Margaret

Fulton Centre, two adult day care centres. I am interested in the circumstances that enhance or limit the

seniors’ ability to express themselves creatively. Understanding the physical, cognitive and social abilities

of this population helps establish the foundation for strategies that can manifest themselves in the shape

and form of the physical environment. The physical envelope that surrounds the seniors, spiritually,

emotionally and physically, embodies the reflection of the seniors’ world whether at home, in a

residential setting or in institutional care. This envelope could serve as a therapeutic environment that

fits with one of my long-term goals: To provide opportunities for creative expression activities with

educational components that are supported with appropriate architectural planning and design. This

study is based on qualitative research in which a/r/tography is employed as the overall philosophical

approach and as a methodology for data collection. A/r/tography seeks knowledge through relational

conditions, living inquiry and a commitment from the researcher as an artist and educator to a process of

questioning. It also invites participants to be part ofthe study process and experience an ongoing process

of inquiry. This method fits well with the making of architecture as practice and theory. The research

shows that the physical environment has the potential to attract seniors with dementia to stay in the space

and become engaged in creative expression activities. But the space alone is not enough to engage the

seniors in these activities. Success in implementing a creative expression program is linked strongly with

an understanding of the seniors’ physical and cognitive abilities and with the commitment of the

facilitator to implement aflexible approach to each individual.

II



Acknowledgments

This research was achieved with the help and input of many people and organizations. True to its
interdisciplinary approach to research, this compelling topic on creative expression, dementia and the
therapeutic environment reached across many disciplines.

I would like to acknowledge the many seniors with dementia I interacted with during the last
seven years, especially at the L’Chaim and Margaret Fulton Adult Day Care Centres in Vancouver and
North Vancouver. The seniors were a source of delight, inspiration and deep emotional connection. Many
seniors from my early years of research did not live to see this dissertation or remember they were part of
it.

I would like to thank Maureen Murphy, the Director of Margaret Fulton Centre and Debbie
Cossever, Program Director at the L’Chaim Centre for being such good hosts and wonderful willing
partners in this study.

I would like to mention Sylvia Sinclair, an artist and teacher. Although she was not included in
this study, Sylvia was an incredible source of inspiration to me in my quest to unlock the psychosocial
mysteries of dementia. In a long list of friends and supporters, I would like to acknowledge, Sheila Jones,
a writer and editor, who accompanied me for the last 30 years through all my endeavours. Her solid
support that never failed is one of the reasons for my achievements in this field and others.

I have a special place in my heart for my supervisor, Dr. Rita Irwin, from the University of British
Columbia who, as my steady unwavering guide, managed difficult situations to bring me through to this
moment. Dr. Irwin, as my research supervisor, is joined by Dr. Marlene Cox-Bishop from the University
of Alberta, who worked with me from the beginning of my studies, Dr. Habib Chaudhury from Simon
Fraser University, whose gentle guidance was very much appreciated and Dr. Howard Feldman, from
UBC, who answered my desperate need to include the medical profession in this work. I would like to
add to this group Dr. Jeff Small from UBC, who encouraged me in the early stages of my doctoral
program. A sincere thank you goes to Dr. Annalee Yassi, the Director of the Institute of Health Promotion
(INPR) at UBC and Dr. Jim Frankish, the associate director, for allowing me to use their premises and
enjoy their support along the way. Among the staff at IHPR that helped in many ways were: Julieta
Gerbrandt, Jeanette Hansen and Brenda Kwan.

I would like to acknowledge Dr. Remi Quirion, Scientific Director of CIHR and Dr. Bruce Miller,
Professor of Neurology at the University of California at San Francisco (UCSF), who are probably
unaware of the impact they had on my newly developed career. In the last two years I was fortunate to be
accompanied by David L Brown, a videographer and a dear friend, who documented my work with
seniors with dementia and was always there to help in good times and in bad times.

Other contributors were David Jones, who helped to sort out the formatting, Frank Van de Ven,
who helped search for information no one could find. Thanks from the bottom of my heart to Julie Marez
for her support and great help in using her expertise at AutoCad and producing all the drawings for this
work.

I keep a special place for my family in this acknowledgment. Mineo Tanaka, my husband, knew
when to step in and lend a helping hand - when I needed him the most. I valued his feedback and support
through the whole experience of being a mature student with a family and many other obligations. My
daughter, Carmel, accompanied me with her wonderful musical talent in many of my sessions with the
seniors. With insight, compassion and understanding of this population well beyond her years, she
provided me with a sounding board in many of the difficult, wonderful and exciting situations we
experienced together. I dedicate this work to her, Mineo and my parents who would have been so proud to
see me graduate.

111



This research was supported by the Alzheimer Society of Canada, the Scottish Rite Foundation,
The Lions Gate Research Foundation, The Society for the Arts in Health Care, and The American Society
on Aging. Their financial support enabled me to focus on my work and reach others in an effort to
advance research in dementia care.

iv



Table of Contents

Abstract ii
Acknowledgments iii
Table of Contents v
List of Figures viii
List of Attachments ix
List of Drawings ix
CHAPTER I: INTRODUCTION I
Thesis Organization 1
Foreshadowing I
Overview of the Research Problem 3
Research Questions 4
Objectives 4
CHAPTER II: LITERATURE REVIEW 6
The Therapeutic Environment 6
Current Arts-Based Programs 7

Definiton of Dementia 8
Definition of Everyday Creativity 9

Arts-based Programs in Dementia Care: The Literature on Special Care Units (SCU)
versus Non-special Care Units (non-SCU) 10

Music Therapy 14
Strengths and Weaknesses as Music Therapy Links to Creative Expression Abilities and Dementia 15
Music Therapy and the Arts Room in a Therapeutic Environment 17

Occupational Therapy 17
Occupational Therapy and the Arts Room 19

Art Therapy 19
DaIley’s View on Art Therapy and the Therapeutic Environment 23
McNiff’s View on Art Therapy and the Therapeutic Environment 24
Rubin’s View on Art Therapy and the Therapeutic Environment 25

The Performing Arts 26
Reminiscence Therapy, Life Review, Life Reflection and Storytelling 28
Reminiscence, Life Review, Life Reflection, Storytelling and the Therapeutic Environment 31
Review 31
New Directions for Research and Implications for Practical Implementation 32
Recommendations 33
Emerging Approaches to Creativity Research 34
Other Perspectives on Creativity and Expression 38
The Meaning of Creativity, Gaps in Information 40

Creativity and Aging 41
Why Creativity and Creative Expression Are Important 43

How Seniors with Dementia Experience Everyday Creativity within the Aging Process .. 43
Physiological Changes Associated with Aging and Dementia 45
Cognitive Changes Associated with Aging and Dementia 50
Social Cognition, Aging and Dementia 52

V



CHAPTER III: METHODS .56
Qualitative Research 56
Selecting Qualitative Inquiry 56
AIr/tography 57
Summary of Research Methods 66
Ethics in Research 66
Sites Selected 69

The Margaret Fulton Adult Day Care Centre 69
The L’Chaim Adult Day Care Centre 72

Participants Selected 72
Data Collection 74
Analyzing Data 75
Tools for Collecting Data: Interviews 76

Interviews with Participants at Margaret Fulton Centre 76
Interviews with Participants at L’Chaim Centre 78
Significance of Interviewing Participants at Their Home 79

Tools for Collecting Data: Nr/tography Field Notes 79
Significance of AIr/tography Field Notes and Analysis 85

Tools for Collecting Data: Filming 87
Tools for Collecting Data: The Intervention — The Creative Expression Activities Program 88

Timeframe for the Sessions 89
Selected Sessions from the Creative Expression Activities Program 89
Observed Everyday Creativity 89
Engaging in Creative Expression Activities 90

Tools for Collecting Data: Space Diagrams 91
Example of Video Transcript and Analysis 92
Analysis of Videotaped Session 113
CHAPTER IV: UNDERSTANDINGS DERIVED THROUGH INQUIRY 115
Themes That Emerged from the Literature Review 115
Design Principles for a Therapeutic Environment 115
Applying the Five Design Principles at the L’Chaim and Margaret Fulton Centres 116
General Recommendations 120

Design Principle 6: Provide Opportunities for Different Levels of Participation in
Creative Expression Activities 121
Design Principle 7: Provide Opportunities to Celebrate One’s Ethnicity 122

Physical Changes to the Environment and the Users’ Response to Them 124
Summary of Understandings Based on the Inquiry 127
Furniture Arrangements at the Margaret Fulton and L’Chaim Centres 127
CHAPTER V: DISCUSSION 164
Reviewing the Themes 164
Reviewing the Design Principles 165
Reviewing the Understandings Reached 167

In Dementia 167
In Creative Expression Activities 167
In the Therapeutic Environment 168

Questions for Future Inquiry and Closing Comments 171
The Overall Significance of the Thesis 172

vi



Epilogue .175
Bibliography 179
Appendices 199

A. Samples of Field Notes and Interviews at Margaret Fulton and L’Chaim Day Care Centres
B. A/r/tography Field Notes at Margaret Fulton Adult Day Care Centre
C. Session Planning
D. Samples of Consent and Assent Forms
E. Sample of Interview Questions

vii



List of Figures

Figure 1: Overview of Thesis 5
Figure 2: Selected Approaches to Creativity Research 9
Figure 3: The Conceptual Framework of the Person-Centered Model versus Medical Model 55
Figure 4: Locations of Margaret Fulton and L’Chaim Centres 69
Figure 5: Exteriors of Margaret Fulton Centre in North Vancouver, BC 69
Figure 6: Interior Shots of Margaret Fulton Centre in North Vancouver, BC 70
Figure 7: L’Chaim Centre Exterior Shots 71
Figure 8: L’Chaim Centre Interior Shots 72
Figure 9: Participants at the MFC and LC Centres 73
Figure 10: Margaret Fultori Centre Art Facilitator and a Participant 76
Figure 11: L’Chaim Participants Engaged in Art Activity 78
Figure 12: A Senior with Moderate Dementia at the L’Chaim Centre Designs her Creative Expression

Studio 84
Figure 13: Participants at L’Chaim and Margaret Fulton Centres 85
Figure 14: Participants at the L’Chaim Centre Engaged in Music Activity 86
Figure 15: David L Brown, the Videographer, Sets up the Cameras at the L’Chaim Centre 87
Figure 16: Turning the U Table Around with the Opening Towards the Windows 88

viii



List of Attachments

A: Gottlieb-Tanaka, D. (Producer/Facilitator) & Brown, D.L. (Videographer). (2006). Margaret Fulton
Adult Day Care Centre in North Vancouver, BC. (DVD Video 1 of 2). Canada. Unpublished raw data.

B: Gottlieb-Tanaka, D. (Producer/Facilitator) & Brown, D.L. (Videographer). (2006). L’Chaim Adult Day
Care Centre in Vancouver, BC. (DVD Video 2 of 2). Canada. Unpublished raw data.

C: Gottlieb-Tanaka, D. (2006). Creativity, Dementia and the Therapeutic Environment. (CD 1 of 1).
Unpublished doctoral dissertation. University of British Columbia, Vancouver.

List of Drawings

DrawingLC—1 131
Session One — Music, All tables are arranged into one large rectangular shape

Drawing LC—2 134
Session Two - Repeated Music Activity, Tables arranged in a U-shape with opening facing main entrance

Drawings LC — 3A and 3B 137
Session Three — Friendship
3A — Detached dining tables
3B — Back to a U-shape arrangement with opening facing main entrance

Drawing LC-4 140
Session Four — Bending Wires. Strength versus Weakness, Triangle

Drawing LC—5 142
Session Five — Designing Creative Expression Studio

Drawing LC—6A 146
Hand Sketch of Proposed Floor Plan at L’Chaim Centre

Drawing LC —68 147
Proposed Floor Plan at the L’Chaim Centre

Drawing LC — 6C 148
Proposed Floor Covering Design —Implemented at the L’Chaim Centre

Drawing MF — I (small room in the back) 151
Session One — Friendship, Two tables are arranged into L shape

Drawing ME —2 (art Therapy Room) 154
Session Two — Music, Two tables side by side creating one table (8 feet wide by 8 feet long)

Drawing MF — 3 (courtyard) 157
Session — Music and Drumming, Two round garden tables

Drawing MF —4 (small room in the back) 159
Session Four — Massage and the Walkout

Drawing MF—5 162
Proposed Changes to Floor Plan at Margaret Fulton Centre, Adding a new deck to the back room and
expanding art area and interior wandering path

ix



CHAPTER I: INTRODUCTION

Thesis Organization

This dissertation is composed of five chapters. Chapter one, the introduction, includes a section on
foreshadowing, which explains how I came to work on this topic. It includes an overview of the research
problems and the thesis objectives. Chapter two is a literature review of the therapeutic environment as it
relates to arts-based programs and persons with dementia. In this chapter I review current arts-based
programs, such as music and art therapies, while looking for relevant information on dementia care that
are relevant to my creative expression program. The review is designed to identify the strengths and
weaknesses of each program type, in relation to creative expression abilities and the therapeutic
environment. Chapter three, methods, explains the rationale behind the selection of a/r/tography as a
method for data collection for this inquiry. It includes a thoughtful consideration of the ethical issues of
doing research with this vulnerable population. It provides background information on the selected sites
and the participants. In this chapter I discuss techniques such as interviewing, filming, and conducting the
program on creative expression activities in collecting data. To analyze the data collected I used color
coding throughout the textual material to identify themes and patterns. At the end of the chapter I include
a transcript of one of the 27 videos that were taken as an example, where, again, I used color coding for
analysis. Chapter four, understandings arrived at, discusses the themes that emerged from the inquiry and
applies the design principles to existing conditions at the two facilities as I change the furniture
arrangements and document them in writing, drafting and photographing. At the end of this chapter I
propose architectural resolutions for the two sites, some of which have already been implemented at the
L’Chaim Centre. Chapter five is a discussion that reflects my understanding of the themes and the
application of understandings to dementia, creative expression activities and the therapeutic environment.
Issues raised are examined from an a/r/tography perspective as I apply my multiple roles as
facilitator/architect/artist/educator and researcher. The chapter includes suggestions for further research.
The epilogue returns to the personal note on which I began the dissertation, with my design for stained-
glass connecting doors at the L’Chaim Centre as my gift in gratitude for the love and care the staff and
participants showered on me.

Foreshadowing

I was born into a family of Holocaust survivors. I can count my family members on one hand. Only
one uncle out of many uncles and aunts who lost their lives in the war remain alive to day. It took years to
realize that my family situation was not what would be considered a normal functioning family.
Nevertheless, both of my parents were very creative people and it showed in the way my mother taught
her students, in her lesson preparation, class decoration, in the way she was dressed and how she made
my dress-up costumes.

My father was one of the last carpenters of his era who could still decorate his handmade furniture
with traditional wood inlay. As a child I would spend hours in my father’s shop watching the dance of
creation. I can still smell the glue, the varnishes, hear the screaming sound of the saw, the hurried
instruction of my father to his intern, and the calls ofjoy or disappointment as the work progressed. I
think my father appreciated my fascination with his work. Years later, after I decided to continue my
studies in architecture, he offered his small manufacturing space to me as he was thinking about
retirement. We both knew deep in our hearts it was not a realistic move at that time of my life. Just before
he closed his shop forever, he helped me build a chair that I designed for a school project I would later
take back to Bezalel, a unique school of art and design that followed the Bauhaus tradition.

The school was established by designers who fled Germany at the onset of the war in Europe, and
were later joined by survivors of the war. Throughout my childhood I ached for grandparents, who did not
survive and the sight of older people embracing their grandchildren would pierce my heart with jealousy.

1



And so the Holocaust, with its taxing issues of life and death and the lack of extended family, has been an
invisible extension of self and an active partner in shaping my experiences as I went through life.

From an early age I was encouraged artistically and my efforts always met with great enthusiasm and
approval. Looking back, trying to understand those rare moments of happiness with my mother as we
painted or sewed together, I can see the early foundation for my skills in communicating with seniors with
dementia.

As I grew up, high school was my first encounter with formal education in the design world. The
more the situation at home and the relationship with my mother grew complicated, the more I turned to
the creative aspect of my studies. I loved those moments of searching for the best space solution, the most
suitable colour and discovering the most appropriate materials and techniques to resolve design problems.
It took years to realize that there were multiple approaches to design problems and that many of those
solutions were equally valid.

After high school I served for three years as a draft person in the naval headquarters in Israel. Once
more, as the country struggled to sustain itself, issues of life and death re-emerged from my childhood. I
experienced war after war until the day I moved to Canada and even afterwards, I was caught up in wars
during visits to Israel. The memories of past persecutions and present violence intermingled in a mad,
frenzied dance, threatening to destroy the passion to create. My mother told me that even in the most
difficult times during the war, people still tried to write or paint (if they could find paper and pencil or
walls). They felt a desperate need to leave something of themselves for the next generation. These
paintings were intended to serve as documents recording present events. They were the shortest and most
economical way to describe the horrors of the war.

After my service in the navy I applied to an academy of art and design in the jewellery program, but
that program was already full. Instead I was accepted into the program on industrial and environmental
design. There I found myself designing such products as furniture, cars, pleasure boat interiors, cutlery,
tents, playgrounds and hospital equipment.

In my fourth year I met my Canadian husband, who came on a student exchange program from the
University of British Columbia (UBC). I followed him to Vancouver. I left my country, my family, and a
potentially brilliant career in architecture and substituted it with years of cultural struggle, language
difficulties, being misread and misunderstood. I was uprooted into the unknown and the unfamiliar.
Having to learn everything from scratch, the confidence I worked so hard to build gave way to feelings of
insecurity and self-doubt. And so, to escape the disappointments and harsh reality, I went back to school
to immerse myself in the world of design. I deliberately selected a research topic from a local situation to
help integrate my efforts as quickly as possible into this new environment and its people. Although
integration was a priority, my struggle to maintain my own identity continued. After graduating from
UBC with a master’s degree in architecture, I joined my husband in running our architectural office and
raising our two daughters, now age 18 and 26.

About 7 years ago I was introduced to a wonderful old lady in a long-term care facility who suffered
from dementia. I had no knowledge as to how dementia manifested itself behaviourally or biologically. It
was like stepping into a different worLd; once more having to learn the medical jargon of health service
providers, the terms of social work, of cognitive impairment and the issues of aging. Now, in the midst of
my latest endeavour, I am trying to understand, in depth, the world of people who suffer from dementia.

Long before the decision was made to go back to the academic world, I was intrigued by a new world
I had entered four years earlier: the world of seniors with dementia in a long-term care facility. Nothing in
my 50 years of living prepared me for this complicated experience. In my youth, I was not exposed to
many old people and even less exposed to older people with dementia.

2



I started as a volunteer in a care facility spending time with Ruth, who was 86 years old, frail and
suffering from early dementia. Her health was deteriorating fast. With my limited knowledge I tried to
alleviate the situation and faced many unanswered questions. It did not take long to realize that something
special was happening to me. I needed to understand what was going on. And that is precisely the focus
of qualitative research: it is the quest to understand what is going on in the world of a specific individual
or group of people, to make sense of it and perhaps turn that new understanding into action, depending on
the goals set by the various parties involved in the research. In searching for answers to Ruth’s
deteriorating health, I learned that nothing could cure her; we could only make the best of the situation
with whatever activities Ruth could still manage. At that moment I went back to school to see what else I
could do for Ruth and people like her. Ruth died a year later as have many others I worked with.

I knew right from the start that understanding seniors with dementia and their abilities for creative
expression would not be enough for me. I wanted my direct interaction with them to be meaningful and
bring new knowledge that would benefit all of the stakeholders involved. I needed a way to record the
new information so it would not be lost or forgotten. I was looking for ways to make sense of my
observations, a system that would allow me to go back to it and access specific information, to explore
individuals at different stages of the dementia, events, activities, architectural spaces and myself as a
researcher/artist/facilitator! educator and watch if concepts, patterns or any new information would
emerge from all the data collected.

Although contradicting each other at times, order and a fair tolerance for ambiguity are important to
my style of work. Before beginning my doctoral studies, the direction for my inquiry was based on
common sense, my acquired knowledge and my own analytical way of problem solving. The desire to
understand what was going on by being directly involved with those who use spaces within dementia care
facilities has ultimately guided my inquiry.

Overview of the Research Problem

The aging population in Canada will peak between 2025 and 2045 when the Baby Boom generation
reaches 75+ years of age (Health Canada, March, 2001). Significant pressure will be brought to bear on
the healthcare system and on support services for older people. Various levels of care facilities are
expected to experience higher demand for their services. According to Health Canada, one of every four
persons over the age of 80 will have some form of cognitive impairment. These pressures may threaten
the quality of services to seniors with dementia in the future. Today, most services are geared to serve
basic needs, while existing quality of life programs, such as those based on creative self-expression, have
never really reached their potential. The consensus among researchers is that creativity enhances the
quality of life at every stage in human development from cradle to grave (Runco and Richards, 1997,
Harbet and Ginsberg, 1990 and Holden, 1995). Runco and Richards, who support the idea of everyday
creativity, say that creativity manifests itself in being curious, in an ongoing process of self-evaluation
and personal growth. If we accept the premise that creativity improves psychological health (Robbins,
1994) and contributes to the empowerment process (Cox & Parson, 1993), the ultimate goal is to enable
persons with dementia to maintain and enhance the quality of their lives and to use their remaining
abilities to express themselves.

This study aims to explore the physical environment in arriving at an understanding of the
administration of and level of success of creative expression programs in two adult daycare centres. It is
based on qualitative methods of data collection. I am interested in the circumstances that enhance or limit
the seniors’ ability to express themselves creatively. Understanding the physical, cognitive and social
abilities of this population helps establish the foundation for strategies that can manifest themselves in the
shape and form of the physical environment. The physical envelope that surrounds the seniors, spiritually,
emotionally and physically, embodies the reflection of the seniors’ world whether at home, in a
residential setting or in institutional care. This envelope has the potential to create a therapeutic
environment that fits with one of my long-term goals: To provide opportunities for creative expression

3



activities with educational components that are supported with appropriate architectural planning and
design.

Research Questions

The following questions explore two main themes that focus on the environment and human
behaviour. They cover the built environment, the facilitator/artist, the creative expression abilities of
seniors with dementia and the intervention of creative expression activities.

1. How does the physical setting support, stimulate or hinder the learning environment for seniors
with dementia to express their creative abilities?

2. As an alr/tographer, how does this study influence my perception of educational learning
environments when working with seniors with dementia?

Objectives

The goal of this inquiry is to investigate the physical environment, how it helps or hinders arts
activities and how the space is being used by the participants. In addition, we investigated how the
facilitator’s approach affects the creative expression abilities of seniors with dementia selected
specifically for this project. That approach includes an investigation through the lens of alr/tography
where the facilitator participates and documents the seniors’ activities from the point of view of artist,
researcher and educator.

The results of this inquiry may lead to the following desired outcomes:

(1) To encourage persons with dementia to have a sense of personal control as long as possible; (2) to
help health service providers, formal and informal caregivers, understand the importance of the arts in
maintaining quality of life and as a tool for communication; (3) to offer an additional assessment tool to
help understand the manifestation of neuropsychological problems that arise from dementia in a variety of
functional domains; (4) to provide concrete information for management in making decisions about
facility programs to show that creative activities benefit the seniors, the staff and the overall operation of
care; (5) to help management in making decisions about facility renovation or new construction to include
appropriate spaces for creative expression activities; and (6) to explore applications in other situations
where cognitive and physical abilities may be impaired.

4



Understanding concepts and definitions
through literature review of:

• Creativity
• Expression
• Creative Expression
• Therapeutic Environment

Forming the conceptual framework

• Creative Expression Activities to
be explored in:

Understanding eminent creativity as it expands to
include everyday creativity

Understanding everyday creativity as it expands to
include creativity and aging

4,
Identifying the gap of knowledge

4.
Understanding key issues in everyday creativity,
aging, and dementia as it expands to include the

therapeutic environment

4,
Data collection and analysis using

a/r/tography and participatory action research
methods

4,
Implementing changes to the environment, reviewing

feedback from participants

Figure 1: Overview of Thesis

5



CHAPTER II: LITERATURE REVIEW

This chapter considers the literature about the therapeutic environment as it relates to current art-
based programs for seniors with dementia, such as music therapy, art therapy, the performing arts,
reminiscence therapy,, life review, life reflection and storytelling. At the end of each program outline, I
review the literature about the type of therapy as it relates to the therapeutic environment. In the next
section of this review I explore the meaning of everyday creativity and how seniors with dementia
experience it, with reference to the physiological changes and cognitive changes associated with aging
and dementia.

The Therapeutic Environment

A literature review of 20 references dealing with issues in the therapeutic environment in special care
units revealed a complete lack of information regarding space design for creative expression activities in
long term care facilities for seniors with dementia. As a result, there are no scientifically tested situations
to learn from. However, there is a rich source of information on the institutional therapeutic environment.
From this source we may be able to extract general design principles and apply them to space design for
people with dementia while engaged in creative expression activities. See Lawton & Nahemow, 1973,
Lawton, Fulcomer & Kieban 1984, Lawton, Weisman, Sloane, Calkins, 1997, Lawton 2001, Zeisel 1999,
Cohen & Weisman 1991, Cohen & Day 2000, Day, Carreon & Stump 2000 and Amabile 1990.

By asking what role the physical environment plays in creative expression activities for seniors with
dementia, I look to the desired outcomes I aim to achieve in. linking the environment with the behaviour
of these seniors (Lawton, 2001). I will not know the impact of the environment until I carry out tests
engaging participants in various experimental conditions of the environment, observe their reactions, and
interview a range of stakeholders including the seniors themselves (Lawton, 2001). The physical
environment provides a mirror image of the physical and cognitive needs of seniors with dementia.
Ideally, the physical environment is the final step in a long process of planning and designing a space, a
place and/or an atmosphere.

In this review, I have considered the physiological and cognitive changes associated with aging and
dementia with references that link them to creative expression abilities of seniors with dementia and to
environmental considerations. Those references will assist later in the formulation of a theoretical
approach to space design for these seniors as they engage in creative expression activities.

Four different studies describe the role of the environment and its impact on the behaviour of
different groups of people: Amabile (1990) on creativity and a normal population in the workplace,
Lawton and Nahemow (1973) on older persons, Zeisel (1999) on Alzheimer’s patients and McNiff (1988)
on the concept of a “studio” as a space that inspires artistic activity.

In her article on Motivation and Personal Histories (1990), Amabile found that ranking first in her
interviews was the need for “Qualities of environments that promote creativity” (p. 71). When assessing
environments for older adults with reduced competence, Lawton and Nahemow (1973) argued that the
lower the competence of an aging person, the greater the negative impact of the environment, and the
more likely it was to result in maladaptive behaviour. They quoted Murray (1938) who stated that the
“forces in the environment that together with an individual need evoke a response” and named these
forces “the environmental press” (p. 3). Zeisel’s (1999) article on Life-quality Alzheimer care in assisted
living describes well the importance of the therapeutic environment for seniors with dementia. Zeisel
identifies eight design characteristics: exit control, walking paths, personal places, social places, healing
gardens, residential features, independence and sensory comprehensibility. He lists eight organizational
criteria: personhood, purpose, adaptability, staff suitability, life richness, family responsiveness, real
woridness and responsibility. When the criteria and design characteristics interact, they form the basis for

6



a positive and therapeutic environment. Although there are references to the need for meaningful
activities, no description or space criteria are provided.

The literature review did not deal in-depth with the therapeutic environment because there were so
few sources. However, Cohen and Weisman (1991) in their discussion of institutional environments,
specifically in a special care unit, did outline five design principles for a therapeutic environment. They
report that non-therapeutic environments “can result in frustration and disruptive behavior” (p. 74). They
may also affect policies and programs. Cohen and Weisman recommend:

Principle 1: clusters of small activity spaces
Principle 2: opportunities for meaningful wandering
Principle 3: positive outdoor spaces
Principle 4 other living things
Principle 5 spaces from public to private realms

I will return to these principles and consider them at length in evaluating the work of this inquiry. In
addition, I intend to consider these further elements that Cohen and Weisman (1991, p. 65- 89)
recommended to minimize the negative impact of institutional settings on seniors with dementia, when
they asked that the therapeutic environment allow for:

• regulated stimulation and challenges
• autonomy and control
• ties to the healthy and familiar
• functional ability through meaningful activity
• safety and security
• orientation to space and time
• wandering treated as an opportunity
• social contact
• opportunities for privacy

These elements are discussed in detail in Chapter 4 in connection with the drawings related to
understandings based on physical changes to the environment.

Current Arts-Based Programs

The use of arts-based programs, as therapeutic interventions, is a relatively new concept and is still
evolving. This concept was developed by Shaun McNiff (1992) in his book Art as Medicine: Creating
Therapy of the Imagination. In it he introduced the concept of “multi-arts experimentations” (p. 23). This
approach to arts therapy is based on his work going back to the ‘70s. Of all the publications reviewed for
this paper on various arts-based programs, McNiffs philosophical approach to arts therapy offers the
closest definition of this topic:

Art as medicine embraces life as its subject matter, and separations among the arts are
countratherapeutic. As I work with individuals, Jam open to their poetic speech, stories,
body movements, dramatic enactments, sounds, and other expressions as well as to the
pictures they paint. I try to establish contact with as many aspects ofthe person’s
presence as possible. (p. 22) ... Art itselfbenefits from a community ofcreation that
involves different art forms and incites imagination through diversity. (p. 24)

To identify and describe these current arts-based programs, I conducted a literature review. The
selected programs were based on the parameters established in the revised definition of “everyday
creativity” that was formulated in Question One and on McNiffs approach to creative expression
therapies. These programs include: music therapy, occupational therapy, art therapy, the performing arts;

7



drama, dance/movement and storytelling therapies, reminiscence therapy and life review and poetry
writing, and they are the ones in use with elderly persons with “dementia”. Dementia is the term most
often used to define this population of cognitive and physical impairments; it is my area of interest and
therefore was used as a keyword in this search through the literature. This review focuses on current art-
based programs with brief references to historical developments in order to clarify current points of view
or a specific approach to the arts in health care.

The review covered relevant literature published between 1995 and 2004, including some articles
published as early as 1985, to identify the arts-based programs and the physical environment the programs
operate in, mainly in long-term care facilities, adult day-care programs and recreational centres for
seniors. Although some aspects are extremely important — such as race and gender, medical models of
care, social and economic status of residents and their families — they are not covered by this review.

The initial intention in this literature review was to focus on qualitative studies. However, the
majority of the studies found were based on quantitative research carried out in the field of health care,
mainly by psychologists or scholars in the arts. Therefore, both quantitative and qualitative approaches
had to be considered for their relevance. Relevant literature on the topic was analyzed for its applicability
of theoretical, methodological and practical approaches with some attention to the size of the samples, to
the criteria for subjects’ selection, the measurement technique used, how the data was collected and
analyzed, whether the findings could be replicated in another location with other subjects (reliability) and
whether the findings answered the research question posed (validity). Learning what techniques other
researchers used or didn’t use helped me form my approach and understanding about how to proceed with
the inquiry. I did find out that no matter what methodology was used, almost all researchers mentioned
the difficulties in doing behavioural science research in dementia, and the sensitivity and flexibility that
needed to be exercised.

In the selection of literature I was not concerned with what quantitative research would see as failing
to answer all the requirements of scientifically rigorous research. I was more concern to learn about the
approach and the reasons for selecting it. As in the arts, each situation is unique created by people who
have their own stories to tell, which are influenced by their various abilities to express themselves
creatively. And although the situation may not meet the standards of quantitative research may provide
parts to the puzzle of how to use the arts in the service of health care for the benefit of the people,
especially seniors with early to moderate dementia.

Definition of Dementia

Dementia refers to the development ofmultiple cognitive or intellectual deficits that involve
memory impairment ofnew or previously learned information and one or more of the following
disturbances: 1. Aphasia, or language disturbances. 2. Apraxia, or impairment in carrying out
skilled motor activities despite intact motor function. 3. Agnosia, or deficits in recognizing
familiar persons or objects despite intact sensory function. 4. Executive dysfunction, or
impairment in planning, initiating, organizing, and abstract reasoning. (Agronin, 2004, p. 2- 3,
as published in “The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition)

Dementia is divided into seven subtypes that include over 72 brain diseases. Although, new
medicines have been introduced to alter the progression of the condition, a cure has not yet been found
(Agronin 2004). While the search goes on, people with dementia are in need of special care and constant
supervision wherever they reside, whether at home or in long-term care facilities.

8



/ (1999)

_________

SternbergetaL

Gardner (1982)
• PsychometricNeuropsychological Creativity • Experimental < ‘) \approach based on Research Biographical

< i• Biologicalinguistics
• Contextual E—

/
• Artificial

Behavioural
• Product perspective
• Process • Biology research
‘ Press • Clinical research

• Cognitive research
Eminent creatMty to • Developmental
everyday creativity research

• Economic factors ÷

_________

theories
• Psychometric research
• Social research

Figure 2: Selected Approaches to Creativity Research

Definition of Everyday Creativity

I have proposed this definition of everyday creativity:

Creativity in the context of dementia adds something new and different to the world whether
through intrinsic self-exploration as an individual, or sharing creative expression through
interaction with others. The creative process is demonstrated through creative thinking and
imagination in everyday living and may or may not result in a product. Through creativity, people
with dementia could (can) enjoy meaningful, satisfying and (at times) unpredictable experiences
that may last for only a very short while or as long as memory allows it.

This review focuses on arts-based activities programs and the physical environments they take place
in. Both aspects are addressed through theoretical and practical perspectives, which are tightly

Creativity versus no
creativity

Csikszentmihayi
(1999)
• Added — Public

recognition and
acceptance Creativity versus no creativity

Runco (2004)
• Person

Runco (2004)

9



intertwined. In the theoretical approach I was wondering whether I had the appropriate tools (quantitative)
and observations (qualitative) to measure or observe changes in mood and behaviour of people with
dementia. Which of the interventions are most effective in producing positive changes in the quality of
life of people with dementia? How do we define positive changes, by whose standards? Would pleasures
of the moment count as positive changes, although short lived? Are the people with dementia to be
included in self-reporting and interviews? Can they or should they be included in the various stages of the
research process? The last question is of major interest, since it leads to important ethical issues of giving
consent.

Another interesting question is whether or not arts-based programs play a role in slowing down the
symptoms of dementia and therefore may be essential for individuals of normal aging to be engaged in.
This question is being addressed now in the field of dementia research and there is a definite trend to pay
attention to the arts in the service of health care more carefully. In addition I ask whether or not the
physical environment matters? Could it be that a very capable arts-based facilitator can overcome less
favorable environmental conditions and still achieve positive changes working with seniors with
dementia? In short, does the physical environment really matter?

Arts-based Programs in Dementia Care: The Literature on Special Care
Units (SCU) versus Non-special Care Units (non-SCU)

Arts-based programs in dementia care are often listed in the literature as one activity out of many
others ranging from bath-taking or laundry-folding to drawing. Many times programs that are referred to
are medical care programs, or government initiated programs that have nothing to do with artistic
pursuits. The terminology used by various health care providers is at times confusing. While expecting to
read infonnation on arts-based activities, I was surprised to learn that arts-based activities were many
times lumped together with activities that have nothing to do with the arts. To find information on arts-
based programs for the elderly with cognitive and physical impairments, mainly in dementia care, the
review was expanded to studies on special care units as they are compared to non-special care units in
long-term care facilities. Special care units are believed to be environmentally safer than non-special care
units for seniors with dementia and provide activity programs more suitable to the needs of confused and
wandering elderly people with dementia. While there is an agreement on the safety issue, there are
disagreements on the quality and benefits of arts programs provided in special care units.

The Office of Technology Assessment’s (OTA) 1992 study, Activities in Special Care Units (SCU),
included: “singing, dancing, exercises, painting, crafts, games, parties, pet therapy, field trips, reality
orientation, sensory and cognitive stimulation, reminiscence therapy, religious services, housekeeping,
cooking, gardening, and sheltered workshop activities” (p. 95) OTA reports that the lack of appropriate
activities is a frequent complaint in nursing homes. At the time of the report, OTA was not “aware of
other available data on the proportion of special care units that provide particular types of activity
programs” (p. 96)

One of the descriptive studies reviewed by the OTA’s report in 1992 was an early study conducted in
1985-1986 by Weiner and Reingold and published in 1989. This study found that physical exercise and
music therapy were the activities most used in the 22 SCUs they surveyed and in specialized programs in
other settings, followed by reality orientation and sensory stimulation. In a study of 31 SCUs carried out
by the University of North Carolina and reviewed by OTA, both SCUs and non-SCUs provided almost
the same activity programs for their residents. Studies, such as Leon et a!. (1997), OTA, (1992), Lawton
(2001), where activity programs are mentioned, provide no details as to the structure of the activities, the
philosophical approach, or way of implementation. A study by Itkin Zimmerman, Sloane, Gruber-Baldini,
Calkins, Leon, Magaziner, & Hebel (1997), on various philosophical principles that drive special care in
SCUs, identified “activities that are specifically designed for cognitive impaired” (p. 171) but no details
were provided as to the specific characteristics of the various activities. However, Itkin Zimmerman et al.
(1997) did identify the need to support.self-expression and “a right to dignified care and appropriate

10



mental and physical stimulation” (p. 176). Again, no descriptions are provided as to what constitutes
appropriate mental and physical stimulation. In Sloane, Mitchell, Weisman, Zimmerman, Foley & Long
(1995), researchers were advised to describe the characteristics of the SCU with care, including a
description of program activities. In the 1999 revised publication Guidelines for Care by the Alzheimer
Society of Canada, there is a short section on meaningful programs and activities, which emphasizes the
theoretical aspect and the philosophical approach appropriate for a person with Alzheimer’s disease.
However, no details are provided for the kind of activities or their implementation.

In a review paper by Gloria Gutman (1999), on the physical environment and Alzheimer’s
care, she points out that “various authors recommended that care facilities, through environmental design
and programmed activities, provide opportunities for people to ‘burn-off excess energy” (p. 17). The
paper recommends several physical solutions such as wandering paths, loops and tracks in indoor and/or
outdoor space. However, no details are given as to the kind of programmed activities for people with
dementia and their implementation.

In Gerdner and Beck’s (2001) survey of SCUs and non-SCUs in Arkansas, it was found that “the
types of activities provided in SCUs and non-SCUs did not differ significantly” (p. 293). Examples of
activities included: aromatherapy, social functions, simple exercises, beach ball toss, children and
volunteer visits, church, and sing-a-long. The survey described the state’s proposed regulations calling for
programs that “encompass gross motor, self-care, social, and sensory-enhancement activities” (p. 293).
However, no references were made to the structure of the activities or the implementation. In Marian
Deutschman’s article (2001) on quality of care in nursing homes, she emphasizes the importance of
“search for breakthrough projects” (p. 35) that may produce “options, opportunities, and learning” (p. 35).
She mentioned a facility that introduced 12-hour activity programming in its SCU. No further details were
given of the kind of programs involved. In Grant, Kane and Stark’s articLe (1995), based on a telephone
survey of 436 nursing homes in Minnesota, 31 program features were identified in SCUs and non-SCUs.
Grant et al. (1995) found that SCUs were more likely than non-SCUs to use:

outdoor activities, large motor skill activities, shortened or simphfled activities, music
therapy, art therapy, ordinary task activities, intensive structured programs, programs
using special activities staff occupational therapy, small group activities, pet therapy,
spiritual activities, and sundowning programs. Non-SC Us were more likely than SCUs to
use reality orientation and one-on-one activities. (p. 572)

In addition to comparing these features, Grant, Kane and Stark (1995) concluded that music therapy
was the only program used by a majority of SCUs (55%). They broke down some of the programs into
further descriptions, for example: large motor skill activities were broken into balloon ball, balloon
volleyball, rolling balls or ring toss. Ordinary task activities included cooking, baking, washing tables,
cutting coupons, folding linen or mending clothing. Intensive structured programs included scheduling a
greater number of activity programs on the unit at shorter intervals. Special activities staff included
psychologists or other specially trained activities staff.

The most important finding was that many non-SCUs use similar approaches to SCUs in staff
training, environmental design and programming, which could mean that “some SCUs offer rather meager
specialized features beyond whatever advantages are achieved by a homogeneous population” (p. 575).
Although more detailed information is provided in this article regarding the various features of the
various activities, no description of implementing the activities is provided.

In Kuhn, Kasayka and Lechner’s article (2002), they make behavioural observations and comment on
the quality of life of 131 persons with dementia in 10 assisted living facilities in a Midwestern state in the
U.S. Kuhn et al. examine “the types of interactions and activities taking place among residents and staff
on a given day”. He notes “the lack of purposeful activity .

.
.“(p. 291) for residents in LTC facilities and

the need for structured activities. Kuhn, Kasayka and Lechner compare smaller facilities that are
specifically planned for dementia care to larger facilities that are not dementia specific. This study found

11



that people with dementia in larger facilities interacted less with other residents or staff, while in smaller
facilities, residents were more interactive. The study found that “there were generally few structured
activities in which residents engaged apart from eating and drinking” (p. 297). In all the 10 facilities in the
study it also found “a lack of diversity in terms of activities engaged in by residents” (p. 297).

In the 24 categories of behaviour, the study included a category for expression that was explained as
“Engaging in creative activity” (p. 294). In the breakdown of the time spent by the residents on various
activities, “engaging in expressive or creative activity (code E)” (p. 295) was observed 4 percent of the
time. Kuhn, Kasayka and Lechner (2002) suggested that activities in the smaller dementia-specific sites
“were not appropriate to their (the residents) level of need” (p. 297). No definition was provided as to
what constitutes creative behaviour. However, other categories offered in the list could have been
classified as creative activities if the definition of creativity was clear.

Creativity has the potential to manifest itself in other activities that were mentioned in Kuhn’s
observation such as: participating in a game, craft, intellectual activities and being engaged with media.
Again, with no descriptions, definitions or examples as to how each behaviour manifests itself, it is
difficult to determine whether or not creative behaviour was present and observed.

In Chappell and Reid’s empirical study (2000) on dementia care in SCUs and non-SCUs, residents’
activities are mentioned as resident-relevant activities or individualized care planning and are considered
as one of the “dimensions of care” (p. S23 5) important to quality of care practices. Chappell and Reid
mentioned studies that included the importance of activities in their review of articles written by Morgan
& Stewart, 1997, Grant & Potthoff, 1997 Anderson, Hobson, Steiner, & Rodel, 1992. A quote from Grant
& Potthoffs in Chappell and Reid’s article expresses the frustration of documenting residents’ activities
and overall, perhaps, the reason for the lack of detailed activities in the literature. “The specific type of
activities that should be encouraged is difficult to document, and certain activities may be more suited to
residents of SCUs and others better suited to residents of non-SCUs” (Grant & Potthoff, 1997, p. S236).

Chappell and Reid did not elaborate on resident-relevant activities. They explained that the data
collected on this dimension was limited and therefore did not allow “the development of extensive
categories for this dimension” (p. S238). Chappell and Reid question the efficacy of SCUs in comparison
to non-SCUs. They concluded that SCUs and non-SCUs are similar in care implementations and suggest
that “SCUs are not homogenous and do not necessarily provide better care than non-SCUs” (p. S234).

In a study by Phillips, Sloane, Hawes, Koch, Han, Spry, Dunterman and Williams (1997), it was
found that “no statistically significant difference was observed in the speed of decline for residents in
SCUs and traditional units in any of the 9 outcomes” (p. 1340). This study’s view came from a medical
model emphasizing bodily functions such as, transferring, toileting, eating, walking, dressing, activities of
daily living, bowel continence, urinary continence and weight loss. No other activities were mentioned. A
study conducted in Finland in 1998 by Ulla, Johanna & Raimo, on the effect of respite care of people with
dementia in SCUs, concluded that no deterioration of cognitive functions or mood were observed as a
result of the respite care and that “rehabilitation of demented patients seems to be possible to some
extent” (p. 224). Activity programming is included in the features mentioned, which contribute to positive
outcomes. However, some activities were mentioned indirectly for possible opportunities such as
shopping, visiting a coffee place, restaurants, museums, galleries, kitchen activities, cooking and baking,
gardening and outdoor activities, as well as dancing, singing and reminiscence. The study by Ulla,
Johanna & Raimo (1998) has a different philosophical approach to care than the previous studies
mentioned in this review that advocated for structured activities. Ulla, Johanna & Raimo see a limited
rehabilitation potential by providing an “atmosphere of approval, success and confidence” (p. 227) and by
not providing structured activities at a specific time that could contribute to agitation. They found a 24-
hour supportive atmosphere that “came from the ways of living normal every-day life” (p. 227) was more
effective. This study did not support patients being “pushed throughout the day according to rules and
schedules” (p. 227). No details were provided as to how the activities were integrated into the daily life of
the patients.

12



A non-comparative study by Bober, McLellan, McBee and Westreich (2002) focuses on group
therapy programs in SCUs, led by a social work philosophy to person-centred dementia care, presented a
more developed practical and conceptual framework for art-based activities. This study responds to a gap
in the literature regarding group work with people with dementia. The program, The Feelings Art Group,
was developed “as a stimulus for uncommunicative emotions.” It exposed its participants “to a variety of
sensory stimuli and artistic activities on a series of universal topics including family, work, music,
spirituality, nature, holidays, seasons, and end of life issues utilizing visual, audio, tactile, and olfactory
stimulation” (p. 74). The article goes into a detailed explanation of the theoretical and practical
approaches to the program. This is a clear change from previous studies, which touched upon the topics of
activities in SCUs but did not explore them in depth. This qualitative study presents case studies and
quotes participants to demonstrate their remaining abilities. Bober, McLellan, McBee and Westreich.
(2002) believe that this model of group work could be replicated in other settings. However, at the time of
submission, no replication trials had been undertaken. Bober et al. (2002) stated that “Clinicians, with the
support of researchers, need to explore the efficacy of both individual and group interventions with this
population in order to provide the best possible care” (p. 84).

While the latter approach to art-based activities shows flexible and sensitive understanding of the
cognitive abilities of the participants and tries to minimize a sense of failure, the next study of Seifert
(2000) adopts a research approach reminiscent of a scientific medical approach, which emphasizes the
process of data collection with less sensitivity to the participant’s own needs. This is a case study of one
individual with dementia who expressed a desire to restore a family heirloom. Although the researcher
warns others about the complexity and frustration that was attached to the project, she still went ahead
with the consent of the family and the participant to conduct this study. She also suggests the use of a
psychologist, psychiatrist, or other professionals from related mental health field. The art project is
presented in detail, down to the materials and painting technique. The replication of this study would
depend on a researcher’s comfort level exposing participants to potential failure.

The following study is a valuable review and critique of 33 studies conducted by Marshall and
Hutchinson (2001) on the use of activities with persons with Alzheimer’s disease (AD). They open the
topic by discussing the difficulties in doing research with this population and sum up the current state of
research on activities engaging people with dementia. The study concludes that although “researchers
have demonstrated interest in the use of activities with persons with AD, theoretical and methodological
difficulties, unclear findings and gaps exist

...“ (p. 488). The review, based on the work of about 20
researchers, concluded that activities are valuable to self-esteem, sense of accomplishment, socialization,
communication and pleasure. In several places, Marshall and Hutchinson also point out that “To date the
knowledge, we have about the use of activities with persons with AD is minimal and fragmented” (p.
489). From their own review they found that:

many researchers did not identify a theoreticalframework that influenced their decision
about choice ofan activity, and how they used the activity. Rather, researchers alluded to
a theoretical rationale or embryonic framework ... Theoretical models did not guide the
majority ofstudies reviewed and were used with varying degrees ofclarity and
integration. Theory was never tested in the research, but was used to provide a
theoretical perspective. (p. 490)

In breaking down the types of activities used in the 33 studies, Marshall and Hutchinson found that
music was “the activity of choice” (p. 493). “Music was used alone in 16 studies and was combined with
other activities in seven studies” (p. 493). Marshall and Hutchinson’s review goes on to discuss
methodology.

The literature review on arts-based programs in SCUs versus non-SCUs did not produce detailed
studies that adequately described arts-based programs and the physical envirOnments they occur in. It is
not clear as to why there is such a gap of information. Perhaps there are practical reasons that could
explain the lack of detail, although most of the studies acknowledged the importance of arts-based

13



programs. The lack of detail may have to do with the researchers’ professional background and training.
Many of them come from fields of psychology, social work, gerontology, medicine and nursing, and
unless they have a personal interest in the arts or have been trained in the arts, they seem to ignore the
research that may provide further detailed information regarding arts-based programs. However, in the
absence of detailed information on arts-based programs for people with early to moderate dementia in the
literature reviewed so far, I will further examine individual areas of arts-based therapies such as music
therapy, occupational therapy, art therapy, the performing arts; drama, dance/movement and storytelling
therapies, reminiscence therapy and life review and poetry writing,

Music Therapy

Music as an intervention that contributes to mood changes is not a new phenomenon. “It has been
used throughout history as a healing force to alleviate illness and distress” (Bunt, 1994, p. 2). Leslie Bunt,
a qualified therapist, Director of The MusicSpace Trust and Research Fellow in Child and Mental Health
at the University of Bristol in the UK, gives an historical overview on the changes in the development of
music therapy as a profession. It started as an intervention with mentally challenged adults and with
adults suffering from psychiatric problems, especially schizophrenia. According to her analysis, current
music therapy has its roots at the beginning of the twentieth century when hospitals invited musicians to
entertain mentally ill patients to relieve mental stress. During World War II music therapy experienced a
significant growth and, although it was employed by the medical profession, it always was accused of a
lack of rigor and systematic research to validate the influences music can bring about.

The profession responded to the scientific call and in 1992, the Music Therapy for Older Americans
Act was signed. This act gave public recognition to the power of music to increase cognitive and psycho
social functioning and well-being in areas of working with children with learning and physical
disabilities, with children and adults with visual and hearing impairments, with offenders, with AIDS and
HIV patients, with hospice and cancer patients and with sexually abused people. Music therapy also
provides services to older people in long-term care facilities and in hospitals (Bunt, 1994).

In her historical review of the profession, Bunt (1994) brought forward seven different variations on
definitions of music therapies. Her own definition includes many aspects of what music therapy is about:
“Music therapy is the use of sounds and music within an evolving relationship between client and
therapist to support and encourage physical, mental, social and emotional well-being” (p. 8).

In their articles, researchers like Bunt (1994), Butterfield Whitcomb (1994), Mathews, Clair and
Kosloski (2000), Kneafsey (1997), Aidridge (1993) and Chavin (2002) state that music therapy allows
therapists to observe and assess a range of abilities and behavioral aspects of their clients. In a case study
Bunt described ten different elements affecting behaviour and ability that form the theoretical basis of
music therapy: the ability to observe physical movement, organization of time and space, manipulation of
instruments, making vocal sounds as a response to musical stimuli, level of attention and concentration,
social skills, self expression, feelings, communication and the level of motivation.

Bunt also recognizes the interdisciplinary nature of being a music therapist. She acknowledges the
role of other therapy providers who contribute to a team effort in treating clients. She mentions speech
therapists, psychologists, physiotherapists, occupational therapists, psychotherapists, arts therapists and
social workers.

Music therapy evolved into an intervention that “is not solely a means of occupying people for a short
time with music as a diversionary and entertaining activity” (Bunt 1994, p. 9), but also evolved into a tool
that allows assessments of cognitive and physical abilities. Within the field of music therapy, Bunt
acknowledges four therapeutic models: “a medical model, psychoanalysis, behaviour therapy and
humanistic psychology.” (p. 16). The last model is of a major interest here and will be described in the
next section. Bunt also states that the current trend in music therapy is shifting from the medical model of
patient and therapist relationships, where the therapist is in total control, towards a more balanced

14



relationship where clients have more input into their treatment or at least where the therapists become
aware of the clients’ individual needs, a process which echoes the theoretical approaches of person-
centered interventions in dementia care.

Music therapy as it affects dementia care is considered a relatively new addition to the diverse list of
applications in this field. Among the articles on music therapy and dementia care, or music therapy and
Alzheimer’s of a dementia type, there are studies that explore the influences of music therapy on people
with dementia. Smith-Marchese (1994) explored the effects of participatory music on reality orientation
and sociability in long-term care settings; Sambandham and Schirm (1995) explored music as a trigger for
memory that would contribute to better communications; Johnson, Cotman, Tasaki & Shaw (1998) tested
whether listening to a Mozart piano sonata may enhance spatial-temporal reasoning in people with
Alzheimer’s; Ashida (2000) explored the effects of reminiscence music therapy on depressive symptoms
in elderly persons with dementia; Brotons and Koger (2000) explored the impact of music therapy on
language functioning in dementia; Glynn (1992) looked into using music therapy as an assessment tool
for psychological, physiological and psychosocial conditions; Aldridge (1994) explored how music could
reduce the need for tranquilizing medication, which helps reduce agitation; Gotell, Brown & Echman.
(2002) looked into how background music may impact bathing activity, which is known to create
stressful times for people with dementia and their caregivers; Hope (1998) explored how music
contributes to relaxation in a multisensory environment, also known as the Snoezlen intervention;
Fitzgerald-Cloutier (1993) explored the use of music therapy to reduce the urge for wandering and
therefore reduce the need for restraints.

Strengths and Weaknesses as Music Therapy is Linked to Creative Expression Abilities
and Dementia

The consensus among these researchers is that music has a significant impact on people with
dementia in changing moods, recalling some memories, improving communication and social skills,
helping to relax, to bring enjoyment, and to get in touch with one’s own feelings. In spite of the consensus
and the variety of concerns raised regarding disturbed behaviours and various levels of abilities of people
with dementia, most of the researchers lack outright references to the creative expression of seniors with
dementia and only on rare occasions allude to it as self-expression. Before starting the readings on music
therapy, I assumed that creative expression abilities of seniors with dementia would be discussed
whenever music was concerned; however, it was not so. Depending on the direction the therapy takes, the
activity described may stay only in the listening mode with no purposeful planned opportunities for
creative expression.

Another interesting finding was that the term music intervention or music therapy is not necessarily
limited to certified music therapists. Music is not restricted to one group of therapists. However, the deep
understanding and commitment to provide opportunities for people with dementia to express themselves
creatively was most apparent in literature produced by music therapists and not by healthcare givers, such
as nurses or psychologists. I don’t exclude the possibility that some healthcare givers are quite capable of
conducting interventions based on music activities. However, this realization did not come through the
literature on this topic. As the reading progressed I realized that selecting articles based on their titles
caused confusion since the terminology used by various healthcare givers was not always the same
terminology used by various arts therapists.

For instance, the word program or activity may refer to bathing and not necessarily to artistic activity.
Some authors did make vague references to creative expression abilities or activities but failed to name
them as such. Understanding that various terminologies may become a barrier to finding the bigger
picture of what music therapy is about, I rearranged my approach to reading source material and looked
for concepts and ideas behind the titles and even behind the written text. I started to look more carefully at
case studies and arts programs as they were implemented, while looking for clues and hidden meanings
that may indicate the authors’ awareness of the topic of creativity in dementia care.

15



The following sources were selected based on their deliberate inclusion of creative expression
abilities or activities in music therapy: In their literature review on music and dementia, Brotons, Koger
and Pickett-Cooper (1997) mentioned the positive effect music was found to have on “creative self-
expression” (p. 211). No definition nor explanation of what creative self-expression means was provided.
Halpern and O’Connor (2000), in their study on implicit memory (memory that creeps out after being
exposed to previous experiences), refer to music in connection with Alzheimer’s disease. Instead of using
the words creative expression, Halpern and O’Connor use the terminology “esthetic framework” (p. 395).
Not surprisingly, Halpern and O’Connor both come from healthcare fields — psychology and behavioural
neurology. They also observe that they did not find any studies that explored the ability of Alzheimer’s
patients to appreciate artistic objects.

In a curious observation, Chavin (2002) states that music activity may not be suitable for everyone.
York (1994) attributes to music therapy intervention the ability for creative self-expression. York offers
no definition for creative self-expression; however, she does mention in her quantitative study
“spontaneous singing” and “musical behavior to recorded music” (p. 288).

Butterfield Whitcomb (1994), in her article defending the use of music by other healthcare
professionals and not only by certified music therapists makes several references to the importance of
encouraging creative expression by people with dementia. In her words “Music is a temporal medium. As
it unfolds in a moment to moment flow, it moves us along with it, and we respond in spontaneous and
often creative ways” (p. 67). Aldridge (1993) refers to singing as “an activity correlated with certain
creative productive aspects of language

.. .“(p. 27). Silber and Hes (1995) in Carruth (1997) report on
creative songwriting produced by patients with Alzheimer’s disease.

Although a definition of creativity in these articles is missing or lacking, there is an acknowledgment
of the importance of creative expression as an independent factor that has the potential to improve the
quality of life of seniors with dementia. Bunt’s book on music therapy (1994) stands out in providing rich
information that specifically supports activities that emphasize creative expression abilities, and her
practical approach to music therapy demonstrates her deep understanding of what creativity means.

In her program Bunt (1994) provides “... freedom to improvise and explore.” (p. 23) She is always
ready to change direction to accommodate the needs of the people she works with. She takes account of
changes moment by moment as the activity unfolds and makes sure her clients know that there is no right
or wrong way to play an instrument. She points out that the arrival of her music instruments “attracts
some interest and curiosity” (p. 23), which are some of the attributes that constitute creative behaviour
and which were addressed in Question One. Bunt describes music-making as a “creative process” (p. 29);
she supports it with Jung’s (1922) approach to creativity and quotes him: “The creation of something new
is not accomplished by the intellect but by the play instinct acting from inner necessity. The creative mind
plays with the object it loves” (p. 36). Bunt goes to great length in analyzing creativity, as described by
Freud, Jung and others who laid some of the theoretical foundation to art therapy. Bunt bases her work on
humanistic psychology, which focuses on “helping people realize their full potential ... and growth rather
than treatment.” (p. 42). She also includes issues such as: Respect for individuals and their unique
differences, the notion of ‘wholeness’, development of purpose and personal intentions, freedom of choice,
self-growth, or self-actualization, particular in relation to others, creativity, love, peak experiences, self-
esteem (p. 42).

Bunt reports that after listening to music, some clients were inspired and could imagine “very rich
images” (p. 70). Music has the ability to connect to our inner feelings and it “is very much beyond words,
articulating inner forms beyond language” (p. 73). The structure of some music sessions are described in
detail and are characterized as free floating sessions that start with listening to some music and
improvising on some instruments that may lead to a discussion on various topics. She stresses the
potential collaboration between music therapy and other creative arts therapies such as art, drama and
dance movement. She supports the idea of creating resource centers that would include the various
therapies. Although Bunt’s writing on music therapy stands out among the others in its rich material

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supporting creative expression at all ages, it lacks in-depth analysis on creative expression and dementia.
She does make brief mention of people with dementia but quickly returns to discuss children, young
adults and older adults with mental illness. Although not stated explicitly, she may be linking dementia to
mental illness. In another brief reference to dementia, Bunt suggests indirectly that perhaps people with
dementia revert back to their childhood. This position is acknowledged in the field of gerontology and
dementia care but it is not well supported.

Music Therapy and the Arts Room in a Therapeutic Environment

My original intention was to search for information on spaces dedicated to creative expression
activities programs, especially in the articles selected for their information regarding arts programs.
Surprisingly, space description was scarce, which raises questions as to why the physical environment
that surrounds arts program is totally ignored. Is it because the authors felt it was not in their domain of
expertise to comment on it? Was the environment so unimportant that it was not included in the scope of
research, or was it simply a matter of being unaware of it? Perhaps the environment does not always play
a critical role in some arts programs. Perhaps it is a reflection of the conditions many arts program
facilitators and therapists work under, who have to make do with whatever space is available due to
economic constraints and the prevailing attitude that the arts are expendable and that arts programs are an
item of choice and not of necessity.

Most studies on music therapy mention in general the location of the study such as at long-term care
facilities, recreation centers, or a house in rural Spain. No other details are provided. A quote such as:
“Both experimental and control conditions took place in the dining room with chairs arranged in a circle”
(Olderog, Millard and Smith, 1989, p. 62), may have been mentioned since the furniture became an
important factor in the dynamic that took place between the music therapist and the subjects of the study.

Out of the relevant articles selected on music therapy, only two articles and their authors went into
more detailed description. Mathews, Clair and Kosloski (2000) described the setting for their study in
detail from the size of the day-room and living room to the various items in the rooms such as furniture,
microwave, dining tables and chairs, storage cabinets, telephone and more. They described the shape of
the dining table and briefly mentioned reading lights and the proximity of the dining room and living
room to the nurses’ station and courtyard. Butterfield Whitcomb (1994) utilized her long time experience
working with seniors with dementia and came up with several suggestions to improve the space used for
music therapy. She made a number of suggestions, such as eliminating all auditory stimulation except the
music that was selected, drawing the drapes, providing incandescent lighting, forming the group in a
circle and paying attention to the acoustics of the environment. She also recommended small sitting
rooms or even bedrooms for listening to music.

The word environment carried different meaning to different authors. Authors from the field of
healthcare refer at times to the environment as a symbolic representation for the ambience of a space or
the atmosphere created by the people using it. The ambience is usually created by staff and occasionally
by the designers hired to design those environments. Failing to find information on the arts room linked
specifically to the needs of people with dementia, I turned to literature published on the therapeutic
environment, especially in dementia care, that I have consulted before for other purposes. Surprisingly,
well-known authors such as: Powell Lawton and Kristen Day, do not include details on the arts room in
the scope of their work either, and briefly mentioned space allocations for arts activities.

Occupational Therapy

Stein and Cutler (2002) relate occupational therapy most closely to arts-based programs. Both authors
approach occupational therapy from a holistic point of view and call it Psychosocial Occupational
Therapy. Stein and Cutler consider occupational therapy to be “compatible with the Uniform
Terminology for Occupational Therapy (3rd ed., 1994, p. xii)”, and define it as:

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an applied science and rehabilitation profession concerned with enabling individuals
with disabilities to reach their maximum potential in performingfunctions in daily living,
employment, and leisure, through the use ofpurposeful activities. The occupational
therapist’s treatment goals are to maintain, restore, and develop physical and
psychological functions

... (p. xii)

In a longer version of the occupational therapy definition, Stein and Cutler include creative
expression and arts and crafts, among others, in the description of purposeful activities. They also refer to
the environment as an important factor in assessing treatment outcomes. Occupational therapy started in
the 1 800s and has its roots in treating the mentally ill in hospital settings. Today, occupational therapy is a
combination of two major influences that developed in medical care. One is holistic medicine, focusing
on wellness, which is based on “man’s harmony with nature” (p. 28), while the other influence is the
“moral treatment” (p. 28), which “emerged as a counterbalance to the inhumane care of those with mental
illness

...“ (p. 28). Stein and Cutler identified four theoretical models for treatment that are based on
medicine, psychology, education and sociology.

First is the psychodynamic model, which focuses on interpretation and analysis of personality and
behaviour. Freud, Adler, Jung, Rogers and Erikson are mentioned as major theorists who influenced this
direction. These scholars are referred to repeatedly in arts-based programs and by adopting their
approaches to psychological treatment, there are bound to be some similarities in the various
interventions. Those similarities will be discussed later. The second theoretical model in occupational
therapy is behaviorism, which focuses on changes to thinking, behavior and environment. The third
model is based on the biopsychosocial model, which relates to sequential patterns of growth. The fourth
model, systems theory, is the basis for the holistic approach in occupational therapy. It is an “eclectic
model that focuses on the individual’s daily occupations as a means to master the environment” (p. 114).

At first glance, as Stein and Cutler laid out the theoretical foundation for their profession with
references to creative expression and person-centered care, I assumed that their mandate “to maintain,
restore, and develop physical and psychological functions

... “(p. xii) would change accordingly to
accommodate people with dementia. However, the definition did not change and their mandate continued
to carry overtones of prospective rehabilitation even in the section on dementia. Unfortunately,
rehabilitation is not a reasonable consideration at present, due to the nature of the disease, which is
characterized by a progressive slow decline. On the other hand, no testing was done to prove otherwise —
that increased creative expression activities could halt further deterioration of the brain.

Some scientists, like Remi Quirion, at McGill University and Howard Feldman at the University of
British Columbia, believe that increased exposure to creative expression activities may increase new cell
growth and connections among cells in the brain. Stein and Cutler also linked dementia to mental illness,
although that showed poor understanding of the nature of this disease. According to Agronin (2004),
dementia becomes a mental illness when it is accompanied by other psychiatric disorders such as
depression, agitation and psychosis. It depends on the type of dementia and how it manifests itself.
Seniors with dementia may have reduced memory but still may maintain a global intellectual function
intact and in this case would not be identified as mentally ill. I suspect that if Stein and Cutler had a better
insight into dementia, they would have rephrased some of their statements such as: “... occupational
therapy and psychotherapy are interactive processes that rely on the client’s active participation. In this
process, the client discloses personal information, identifies problems, and tries out new behaviors to cope
more effectively with life tasks” (p. 188). Practitioners in dementia care know that it is extremely difficult
or next to impossible to teach new information that will be remembered long enough to influence changes
in behavior over time. Studies that assess clients with dementia before and after intervention (Brooker &
Duce, 2000) show that changes in behavior are short lived unless the intervention is repeated.

The psychosocial occupational therapy supports an interdisciplinary approach to treatment and
borrows from art, dance, music, poetry, psychodrama and storytelling therapies. It is easy to criticize such
a formidable effort to cover so many areas of creative expression. However, the intentions of meeting a

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client’s needs in the area of creative expression that suits them should be applauded. The concern, then, is
how capable is the occupational therapist in conducting each type of creative expression, and does it
matter? When Stein and Cutler discuss art therapy they see no problem in including artwork analysis as a
diagnostic tool.

Reid and Chappell (2003) raise the issue of activities programs for seniors with dementia in special
care units. Although they found theoretical and empirical evidence in their literature review to support the
value of activities in dementia care, they recognized the importance of how these activities were
implemented and whether the staff was trained and available to facilitate those activities. No details were
provided about the types of programs, nor the physical environment.

It is interesting to read the opinions of various scholars on each other’s field of expertise and the
comparisons between them. From the literature review it is obvious that there is a sense of competition,
and there is definitely confusion about the boundaries between the various programs as they grow closer
and cross over. Rubin (1998), an art therapist, writes on occupational therapy: “All these fields use art as
one of many possible activities, forms of recreation, or ways of being constructively occupied
occupational therapy teaches task analysis — a method of breaking a task into its smallest components
especially valuable for those who are neurologically impaired and/or developmentally disabled” (p. 72).
Dailey (1984), also an art therapist, writes: “Art therapy is not a form of occupational therapy
occupational therapy is concerned with working on a conscious level, with the aim of developing
technique in making products, using methods which are really more compatible with those of teaching

“(p. xxiv).

Occupational Therapy and the Arts Room

Although the environment was acknowledged in the definition of occupational therapy, this subject
was rarely explored. Stein and Cutler’s book devoted less than one quarter of one page to it in a book of
666 pages. In the section on the environment, while three questions were addressed, only two had direct
relevance to the environment — questioning whether lighting, background sound, color, temperature,
atmospheric pressure, visual distractions had an affect on the treatment outcome.

In contrast to the lack of attention to the physical environment — specifically the arts room in Stein
and Cutler’s book — an article by Perrin (1997), a senior occupational therapist at the well-known
Bradford Dementia Group, discusses the possibility that the physical and social environments may not
play such an important role in the lives of people with severe dementia as “commonly imagined” (p. 940).
Perrin goes on to say that for a “severely impaired person ... the environment has ‘shrunk’ to envelop him
in kind of a plastic bubble, which is about 3 to 4 feet in diameter” (p. 940) and that staff have no problem
interacting with this group as long as they are close physically to the clients and within the suggested
‘bubble’. Perrin brings up the notion that if the closeness encourages interaction, it may be an important
factor in space design and the attention given to activities in it. To make her point clearer she writes:

Maybe what is really important is not as much matching the lounge curtains to the
wallpaper, as the smile on our face as we enter the bubble; not so much the TV in the
corner, as the colourful magazine we look through with the client

...
(p. 940)

Art Therapy

J.A. Rubin (1998) in Art Therapy: An Introduction provides a brief historical overview of art therapy.
Art therapy was introduced in 1914 by Margaret Naumberg, who founded a school where the arts were
central. In 1920, Florence Cane, a gifted teacher in New York, discovered that “art had power to liberate
not only the creativity, but also healthy psyches of” The Artist in Each of Us” (1951, p. 4). The field
gained momentum when Victor Lowenfeld, “A sensitive educator, who studied the nature of creative
activity by teaching sculpture to blind children” (p. 5) joined in 1939. Key therapists like Mary Huntoon,
who worked with psychiatric patients in 1935, Adrian Hill, who wrote the first book on art therapy, Edith

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Kramer, who developed a theoretical approach to art therapy working with children, all contributed to the
expanding field. Many art therapists entered the field through the pathway of art education, bringing with
them the understanding of child psychology. Other known artists turned therapists are Don Jones, Hanna
Yaxa Kwaitkowska, Robert Ault, Arthur Robbins, known for his Expressive Analysis, Helen Landgarten
and Shaun McNiff.

The field of art therapy is still going through growing pains and self-examination. Some in the field
believe that the creative process is the main contribution towards healing and named it “art as therapy
Those who felt that art therapy’s primary value was as a means of symbolic communication sometimes
called it art psychotherapy” (p. 61). Art therapy is also called: expressive analysis, clinical art therapy,
psychoaesthetics or expressive therapy (p. 61).

There are about 13 different approaches:

1. Psychoanalytic theory — one of many ways to try to understand how and why people function as
they do.

2. Freudian Psychoanalysis and Jungian Analytical Psychology — based on an understanding of the
dynamics of the patient’s internal world.

3. Humanistic approach — emphasizes the acceptance and development of individuals in the present

4. Person-Centered or Client—Centred approach — developed by Carl Rogers in England.

5. Gestalt approach, emphasizing the here-and-now — based on Gestalt Psychology, which focuses
on sensation and perception.

6. Rudolf Arnheim focused on visual perception and influenced many in art therapy.

7. Human Potential — Erickson Milton, a psychologist, advocated collaboration vs. an authoritarian
model of psychotherapy; pioneered the clinical use of hypnosis.

8. Creative Reframing

9. Phenomeno logical approach — emphasizes the uniqueness of each individual experience of reality
at each moment of time.

10. Existential approach — emphasizes man’s capacity to take charge of his life and use free will.

11. Behavioral approach — examines what can be measured systematically; studies of appropriate and
inappropriate behaviours that provide the base for therapeutic intervention.

12. Cognitive Therapies — focusing on habitually distorted thought processes. Patients are taught new
and more adaptive ways to think and behave. A known Cognitive psychologist, Howard Gardner,
realized the value of making art in cognitive operations.

13. Developmental and adaptive approaches — closely related to cognitive and behavioral approaches,
these are based on the understanding of growth itself. Viktor Lowenfeld, Mary Wood (special
educator), and Geraldine Williams (art therapist) combined the developmental therapy and the
adaptive approach, which works towards normalization (Rubin, p. 158 to p. 180).

Based on my own experience and some of my colleagues’, I use the visual arts as one of many
ways to open communication with seniors with dementia. It is done in an effort to access their memories,
provide an opportunity to express themselves creatively and most of all provide an opportunity for
enjoyment, which in turn leads to improved quality of life.

In examining the role of art therapy in relation to my own work in creative expression activities and
dementia, I selected a sample of authors from several arts modalities as well as occupational therapy in
order to represent the larger community. An exhaustive examination of the full extent of the literature is
beyond the scope of this dissertation. I also contacted the Director of the Vancouver Institute for Arts
Therapy for advice and had numerous discussions with her on the role of art therapy and the population it

20



serves. These discussions helped tremendously to sort out some misunderstandings and brought to light
the similarities and differences between arts therapy and my program on creative expression activities for
seniors with dementia.

Three key books that create the foundation for students of art therapy were selected for detailed study:
T. Dailey (1992), Art as therapy: An introduction to the use of art as a therapeutic technique, S. McNiff
(1988), Fundamentals ofart therapy, and A.J. Rubin (1998), Art therapy, an introduction. These
publications vary in their philosophical approach to current art therapy interventions. Although art
therapists claim expertise in working with a wide range of clients, the following review will bring to light
why there are so few articles on art therapy with a focus on dementia. One example in particular
demonstrates the lack of knowledge of dementia as a disease. Cathy Malchiodi (2003), an internationally
recognized authority on art therapy, lists the people art therapy serves. Among them are “people with
cancer, HIV, or other serious illnesses, older adults with dementia, Alzheimer’s disease, or disabilities
(p. 2). According to medical classifications (Agronin, 2004), dementia is an umbrella name that includes
72 different brain diseases and Alzheimer’s is one of them.

Teresa Dailey

T. Dailey, in Art as therapy: An introduction to the use ofart as a therapeutic technique (1992)
introduces a philosophical approach to art therapy. In the following passages Dailey defines and explains
what art therapy is: Art therapy is the use of art and other visual media in a therapeutic or treatment
setting (p. xii).

Therapy involves the aim or desire to bring about change in human disorder .... Effective
therapeutic procedures are those which result in fundamental and permanent change,
and so, as Ulman argues, therapy is “distinguishedfrom activities designed to offer only
distraction from inner conflicts; activities whose benefits are therefore at best
momentary. (p. xiii)

Dailey states that although painting is somewhat therapeutic to the artist, the final product is an end in
itself, and is exhibited as a work of art; the process of creating it is secondary. ... In therapy, the person
and process become most important, as art is used as a means of non-verbal communication (p. xiii).

However, Dalley recognizes that not all clients can be rehabilitated and she points to “those people
with severe mental or physical handicaps, psychogeriatrics, and the long-term institutionalized” (p. xviii).
With this population she agrees that the arts should be used “for enjoyment, exploration, and
stimulation”(p. xviii). She also places less emphasis on the final product and sympathizes with people in
hospitals and institutions, where “art therapy is probably their only outlet and opportunity for individual
expression, stimulation, and creative occupation” (p. xviii). For them, Dailey suggests a “variety of
sensory and tactile experiences; making things with others help interaction, communication, and
awareness of other people” (p. xviii).

The initial thought of Dailey’s view of art therapy is that there is an expectation of rehabilitation for
clients entering the treatment of art therapy, except for mentally ill people with whom the expectation is
lower in terms of artwork quality and their ability to produce it. Perhaps she is right in her view, but what
is continually disturbing is the tendency to lump the elderly in long-term care facilities together with
mentally ill people without discrimination. The lack of understanding of what dementia is all about is
apparent. Dailey’s book was published in 1992, but must have been written in the late ‘80s, when the new
person-centred approach to dementia care was in its infancy and not yet a recognized force. The
sensitivity and the compassion for the elderly with cognitive and physical disabilities are present, but the
knowledge of dementia as a disease is lacking.

This is most apparent in one chapter in Dailey’s book, written by Suzanne Charlton (1984) who
discusses art therapy with long-term residents of psychiatric hospitals. Charlton states that “[O]lder

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people often develop fixed thought processes with a deterioration in their ability for abstraction and
expression” (p. 19). Such a statement would draw harsh criticism from scholars in the field of gerontology
who would identifS’ it with ageism (prejudice against older people). According to Teague, McGhee,
Rosenthal and Kearns (1997), “Despite the progression of senescence from a biological, psychological,
and social perspective, the aforementioned changes are not universal” (p. 75). As decline in aging is not
universal, so are the symptoms of dementia, which differ from person to person and take on various
cognitive and physical impairments. Not all seniors with dementia suffer from depression and not all
display mental disorder except for forgetfulness and disorientation. It all depends on the stage of the
disease, how much damage has occurred to the brain and where in the brain it happened.

Chariton (1984) also suggests that “too many art materials can add to the confusion of older residents
keep the length of the session short” (p. 19). Based on my experience working with seniors with

dementia, a rich presentation of meaningful resource material was one of the highlights of enjoyment and
delight that contributed towards improved communication, engagement and interaction with seniors with
dementia. It was also a source of inspiration. The Creative Expression Activities Program was planned to
be long enough to allow meaningful socializing, gain trust of the participants, refresh memories or
provide resource information for immediate use, and allow seniors to take their time to digest information
and react to it.

DaIley focuses mainly on children, adolescents, young adults and the mentally ill. People with
dementia are included in the group of the mentally ill. Although there are gaps in knowledge of dementia
as a disease and the care for it, arts therapy still contains many elements that are important for seniors
with dementia. With time and broader education, arts therapy will adjust to the specific needs of seniors
with dementia. It is almost redundant to say that Dailey understands the importance of providing
opportunities for people to express themselves creatively, since her occupation is focused on providing
such opportunities. In her writing she sums up her thoughts about creativity: “Any theoretical approach to
art therapy must take account of the concept of creativity, which has its roots in all art processes” (p. xv).
She also recognizes the important role the therapist takes on in stimulating responses and social
interactions. Depending on the approach to intervention, “Art therapists are participants as well as
observers in the therapeutic process” (p. xx).

The art therapy session is basically divided into two stages: the first stage involves painting or other
creative activities, while the second stage is a discussion that focuses on the art produced, how it makes
the client feel and how it reflects their feelings. Dailey shares some concerns regarding the artwork’s
analysis produced during the intervention: “Even the most experienced art therapist cannot be totally
confident about correct interpretation without active participation and co-operation from the client within
the therapeutic encounter” (p. xx). This statement has implications when interacting with seniors with
dementia: a. How do we define co-operation? b. Would stories based on illusions still be considered as
co-operation? c. How can drawings based on active participation but on no memory recollection be
approached in the process of art analysis? The most critical question that is yet unanswered is: is there a
valid reason why the artwork produced by people with dementia needs to be analyzed psychologically?
What knowledge are we going to gain from it? How relevant is the content in the drawings when the past
may have been forgotten and so is the present? Why analyze the work of seniors with dementia if
rehabilitation is not a serious consideration in a progressive disease with no cure? Charlton (1992) in
Dalley’s book does bring up the issue that art analysis is not always the right thing to do, especially with
long-term residents who just want to paint. In this situation according to Charlton “... therapeutic
interpretation are neither appropriate nor beneficial” (p. 187). It is not clear if people with dementia are
included in this observation. Yet, the emphasis is always to encourage creative expression.

At the beginning of my work with seniors with dementia, I often asked myself whether I was missing
an important source of information by not going into art interpretation for therapeutic reasons. I also
asked myself whether my direction in trying to understand creative expression and dementia should be
explored under the wings of arts therapy. The more understanding I gained about art therapy and about
dementia as a medical condition, the more I realized that there was no point in using the arts for

22



psychoanalytical purposes. I was there to enjoy the moment together with seniors who have dementia. I
had no need to probe into their problematic behaviour or attempt to change it — even though I wished to
improve problematic behaviour, such as restlessness, pacing and shouting. However, the prevailing goal
was to improve the quality of life of seniors with dementia. And so, this approach did not become part of
the creative expression program.

Dailey recognizes that art therapy is an evolving profession that still struggles to gain full recognition.
According to her ‘The ultimate goal must be to establish art therapy as an integral and valued part of
every treatment programme” (p. xxvi).

Dailey’s View on Art Therapy and the Therapeutic Environment

Dailey refers to the therapeutic art room briefly here and there in her book; Chariton actually devotes
a separate title to it: “The art room” for mentally ill patients in psychiatric hospitals. “The art room
provides a setting where residents can experience trust, experiment with different behaviour, exercise
choice, and feel a sense of competence” (p. 175). She states that most hospitals “lack space and facilities
for creative work” (p. 185). She would like to see art rooms where residents are allowed “to get messy, to
experiment, to ponder, or to invent” (p. 185). The art room should include stimulating things such as
books, pictures and other interesting objects. Charlton (1984) would like to see a variety of space,
including spaces for one-on-one intervention and for group activities. She even suggests specialized areas
individuals can claim as their own, doing activities such as “pottery, weaving, and printmaking” (p. 186).

Shaun McNiff

McNiff is another key scholar in art therapy whose work was recommended by Lois Woolf, in
particular his book Fundamentals ofArt Therapy (1988). Out of the three publications recommended, it
was the writing by McNiff that caught my imagination and became a source of inspiration. As a result, I
have been reading most of his writing; his philosophical approach to arts therapy and to the engagement
in the arts in general is very relevant to creative expression in dementia care. Although I differ with him
on several issues, the overall concept of going with the flow fits within the program on creative
expression activities for people with dementia:

McNiff defines and describes art therapy as: The engagement of both materials and emotions (p.
8).. .Art therapy is an expression of our desire to know more about images and people and to do more
with them ... whether in words or images, they are concerned with exchange and opening to whatever
presents itself (p. 6). McNiff also states that art therapy is about contradictions, “[T]he Psyche is not as
predictable as the highway ... It is not fixed in material forms” (p. 7). He also tries to reassure therapists
who feel the need to be in control by planning every detail in advance and advises them not to be “...
afraid of chaos ... looking for themes and messages . . .“(p. 7). This statement is actually the theoretical
foundation for qualitative research, such as ethnography and grounded theory, and may lead to beneficial
observations in a clinical setting. Although the overall themes in the creative expression activities
program are pre-planned and the first segment of each session is directed through visual and verbal
stimulations, the rest of each session is free flowing and ‘spontaneous’ as McNiff calls it (p. 5). By having
all sessions planned in advance, Lisa, an art educator who became an art therapist, commented in a dialog
with McNiff that advanced planning to reduce risks of chaos in the classroom might have jeopardized the
flow of creativity (p. 7).

McNiff believes that children in unstructured lessons do not need much to start drawing. However, in
my experience, seniors with dementia need to be stimulated and provided with information to initiate the
process of creative expression. Pre-planned sessions versus spontaneity raises very interesting questions
that are worth exploring in future research. Would seniors with dementia initiate art work if: a) art
supplies were displayed in view and in easy reach? b) Would they start drawing if a facilitator was not
present? In short, c) What would it take to engage seniors with dementia to become involved with art
work?

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McNiff does not limit himself to the visual arts only. He believes in endless possibilities within the
media. He is interested in what other colleagues are doing with other materials and likes to integrate them
in his own work, such as rhythmic expression, storytelling and the performing arts (p. 29). He sees the
motions of dance when helping a person hold a brush and he likes to talk during the intervention. Unlike
Dalley, McNiff does not feel comfortable in therapeutic art interpretation alone for the following reasons:

The use ofdiagnostic labels is actually one of the most anti-therapeutic things we can
do... The label serves the purpose ofkeeping people in their designated places. This can
be catastrophic with psychopathological labels. Even positive and illustrious labels, titles
and degrees can become serious obstacles to change and imaginative transformation. (p.
97)

MeNiff finds it is more important to approach clients in a comprehensive way through interaction, to
find out what they want and meet them where they are at that moment. As stated before, he is not worried
about unpredictable situations that may not fit “within the confines of the psychopathological diagnostic
drawing test clichés because we fear what we can be, what we are not” (p. 20). He continues to explain
that “Interpretation is both intuitive and intellectual, verbal and non-verbal. Art interpretation is sensual
and imaginative ... For me it includes both cognition and perception” (p. 46).

Interestingly, McNiff reveals that art therapists don’t participate in the art activity with their clients.
They act more as observers:

Art therapists ... rarely communicate through their medium because their artistic values
are not based on interactive process, and this makes it unnaturalfor them to work
together with clients ... If images are generated by the patientfor the purpose of
diagnostic assessment, then it does lead to role confusion when the therapist paints.
(p.41)

McNiff raises an interesting question as to what makes an act an artistic act. According to him “Art is
whatever manifests itself’ (p. 28) and needs to include the soul of the person.

Art is a matter of intent. What is perceived as art depends upon the attitude and values of
the person. Anything, afound object, or a series of lines can become art. The only limits
are the range ofthe artist’s perception, available materials and imagination. (p. 28)

He does not see the products produced during psychological testing as art, but rather as graphic
exercises, since no soul was attached. Occasionally someone manages to produce an artistic product.

McNiff’s View on Art Therapy and the Therapeutic Environment

McNiff sees a link between the environment, health and creative activities. He focuses on the
importance of a designated space for artwork—the studio. However, no other details are provided:

I emphasize the studio because we need it more right now. I know that I desire the studio.
There is not enough of it in my lzfe. Two decades ofworking with graduate students and
art therapy colleagues has shown me that they hungerfor it too, and the phenomenon of
art therapy needs the studio. 1ff walk into a medical environment with its chemical and
antiseptic smells, my soul is aroused only to the extent that I want something else. The
medical environments can sometimes be the antithesis ofart. The studio summons the
artist in me and the artist in art therapy. (p. 135)

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J. A. Rubin

In Art Therapy: An Introduction (1998), J. A. Rubin’s book is the third publication recommended by
Lois Woolf as an excellent resource with a detailed overview of art therapy and its history. In this book,
the focus is on children and young adolescents. Rubin’s clinical vignettes did not include seniors with
dementia. Here is Rub in’s definition and description of art therapy:

combination ofgenuine expressive art activity with some kind of thoughiful reflection on the
process ... In fact, it is what distinguishes it most clearly from related disciplines. In almost all
approaches to art therapy, there is an image-making time and a reflection time. The proportions
may vary, and the thoughtful component may be silent. Art therapy, however, is the involved
doing p1us the relaxed reflection ... Creating art can indeed be therapeutic, and verbal therapy
can be very effective. But there is something about the Iwo together that is really spectacular. (p.
xxi)

Rubin states that all art therapists understand the importance of the creative process: Equally central
in effective art therapy is knowing how to observe another’s creative process acutely, sensitively and
unobtrusively. Becoming aware of all the temporal, spatial, and other non-verbal aspects of people’s
behaviour with materials takes time and practice (p. 135). Rubin then quotes Robert Ault, one of the key
figures in the art therapy field, who wrote in an unpublished 1983 manuscript, “a picture may be worth a
thousand words, but to observe the making of a picture is worth ten thousand words” (p. 135). According
to Rubin, the best way to understand what art therapy is all about is to observe an actual session, and even
better is to participate in it.

Rubin brings to light a debate within the art therapy community regarding the multi-arts therapy or
generalist approach, as some prefer to call it. Unlike McNiff and his colleague Paolo Knill, Rubin seems
reluctant to support the multi-arts therapy approach and she states:

It is easy to tell the difference between art therapy and close relatives like music,
movement, dance, drama, or poetry therapy — at least when each is offered separately.
But there is considerable confusion about approaches, which use multiple modalities.
Multimodal approaches are usually called by names like “expressive (arts) therapy” or
“creative (arts) therapy”. Although there are afew individuals with the ability to evoke
andfacilitate expression in more than one artform, such people are rare. More often, a
therapist has training in one creative art modality, along with an openness to and
comfort with others. (p. 73)

Although she has some concerns about the multimodal approach, she realizes the growing interest in
it. It is evident in Britain (p. 78) and in Canada (p. 80). In Canada she mentions Stephen Levine and Ellen
Levine, who co-direct a training program in expressive arts therapy in Toronto (ISIS-Canada). “Although
most art therapists are still trained and skilled primarily in the visual arts, there seems to be a greater
openness to the use of other art forms than in the past” (p. 80). Rubin also differentiates between what is
therapy and what is therapeutic, “If the primary purpose of the activity is learning and/or fun, it is
certainly therapeutic, but it is not art therapy” (p. 63).

Rubin’s View on Art Therapy and the Therapeutic Environment

There is a brief comment in Rubin’s book regarding the therapeutic environment: “Regardless of what
is done, there are a series of necessary steps ... They begin with setting the stage, a major element in
promoting expression in art therapy. A well-prepared environment can inspire creativity, whereas a
confusing or uncomfortable one can have [a] most inhibiting effect” (p. 280).

25



D. Fausek

D. Fausek produced A Practical Guide to Art Therapy Groups (1997), whose title promised an
interesting look at the subject. Some of Fausek’s suggestions seem to fit less well with seniors with
dementia. Although the guide is planned for them, the need to focus on task completion and choice—
making activities for low functioning clients, some of her suggested activities do not fit her own
classification of abilities. One example is a suggestion for rubber cement glue to be used with low-level
clients. I am puzzled by this suggestion, since low-level clients may end up taking it in their mouths or
spreading it on their clothes or hands. There are better substitutes for rubber cement, which is a toxic glue.
On the other hand I do agree with Fausek about using written comments around the artwork. The artwork
serves here as a tool for communication and therefore as a platform for non-verbal communication. She
also has no problems helping hand-over-hand if needed. Fausek likes to display the artwork for enjoyment
and stimulation.

The Performing Arts

I have combined the discussion of the two therapies of drama and dance/movement for two reasons:
The literature on drama and dance/ movement with a focus on therapy is so new that hardly any material
has been written on them. And, as the two are linked together under the title of the performing arts, they
share many characteristics. If anything surprised me in the process of reviewing literature on creativity
and dementia, it was the literature on therapeutic performing arts. I was not expecting to see it linked to a
research inquiry for assessments purposes and outcomes. Perhaps, like many others, I assumed that the
performing arts are there to draw on our emotions and provide artistic experiences. But to try and measure
the impact on people with dementia is an interesting concept. Is it then measurable? Do we have the tools
for it? If not measuring, then how are we going to describe drama, dance and movement? Do we even
have the language to describe them? And what are we going to describe? It is clear to me more than in
any other form of artistic therapy that this research needs to be conducted by the artists themselves. They
need to be an integral part of it, intimately immersed in it, fused with the process and with the clients
involved.

Dance/movement therapy dates back only as recently as the 1 950s. The dance/movement therapy was
started by several women who used dancing to interact with people who suffered from severe
psychological disturbances (Levy, 2001). The new field got organized under the American Dance
Therapy Association (ADTA) in 1966 “to establish and maintain high standards of professional education
and competence.” (http://www.adta.org) ADTA is a member of the Creative Arts Therapy Coalition that
includes other associations of music, art, poetry, drama and expressive arts (Wadsworth Hervey, 2000).

Here is a definition and description of dance/movement therapy. “Dance/Movement therapy is the
psychotherapeutic use of movement as a process, which furthers the emotional, cognitive, social and
physical integration of the individual. Dance/Movement therapists work with individuals who have social,
emotional, cognitive and/or physical problems. They are employed in psychiatric hospitals, clinics, day
care, community mental health centers, developmental centers, correctional facilities, special schools and
rehabilitation facilities. They work with people of all ages both in groups and individually. They act as
consultants and engage in research.” (http://www.adta.org).

Research on this topic reveals only a handful of publications. According to Wadsworth Hervey (2000)
“there is no scholarly dialog on the subject in professional publications” (p. 43). Two articles were found
that discussed dancing. One article by Milchrist (2001) is an autoethnographic narrative on the
relationship between the author and her mother who has dementia. The author initiated dancing with her
mother over a period of 5 years until she could not dance any longer due to advanced Alzheimer’s.
Dancing was very much a part of the author’s mother’s life and the ability to dance lasted long into the
disease. Milchrist tells us how her mother enjoyed the dance and how they could continue to
communicate although verbal communication was almost impossible. It is a wonderful first-hand story
that had many moments ofjoy in spite of the limitation imposed by the disease.

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The second article is by Palo-Bengtsson and Ekman (2002), who discuss social dancing with people
with dementia residing in a nursing home in Stockholm. It is a phenomenological study that explores a
dancing activity that has taken place in that nursing home for 10 years. The study was carried out in 1995.
The results of the study suggest: “that dance music was a good stimulus for making social contacts. The
earlier-trained social patterns, old social habits, and general rules seemed to awaken to life in the persons
with dementia” (p. 101).

Palo-Bengtsson and Ekman (2002) also observed that the people with dementia would wait for their
caregivers to initiate the invitation to dance and then would follow them. The study concluded that it was
important for caregivers to show “individual creativity, spontaneity, and supportive nursing care” (p.
101). Although the authors observed “response to rhythm, attention to dance music, and joy and
amusement” (p. 101) demonstrated by the people with dementia, creativity was not included in the list of
observed behaviour. I wonder why creativity was important enough to be linked with the caregivers but
was omitted when describing the people with dementia. Was it because of low expectations that people
with dementia were not capable of creative expression? Or did the authors have a different understanding
of what constitutes creative behaviour? The physical environment is described with very few words: “The
dances took place ... in a large hall which was used for several activities for elderly patients, relatives,
and caregivers” (p. 103).

The main scholar on drama therapy is Dr. Davis-Basting, who is Director of the Center on Age and
Community and an Associate Professor in the Department of Theatre and Dance at the Peck School of the
Arts, University of Wisconsin-Milwaukee. Her creative work includes nearly a dozen plays and public
performances. Davis-Basting, who received her Ph.D. in Theatre Arts and Dance from the University of
Minnesota in 1995, continues to direct the TimeSlips Creative Storytelling Project, which she founded in
1998, and makes numerous presentations on creativity and aging across the United States. TimeSlips is an
innovative method of group storytelling by seniors with dementia. In the training materials for the
program, she writes:

Creativity is: adding something new to the world, how we know ourselves, how we grow
ourselves, how we connect to others ... through creative expression, we share ourselves
and connect to others. Creative expression is importantfor everyone, but it is even more
importantfor those with dementiafor whom other avenues ofself-expression can be
severely limited. (p. 8)

As in other therapies, Davis-Basting combines several creative activities such as storytelling,
reminiscence and drama. In a visit to Milwaukee to meet with Karen Stobbe, who facilitates TimeSlips
under the direction of Davis-Basting, I observed the interaction between Karen and her seniors with
dementia. The stories that were produced in a collective effort by as many as 20 seniors with dementia
brought joy, laughter, sadness, jokes, and even slight criticism of peers and staff.

Besides Davis-Basting’s work in drama therapy, I found only two qualitative articles on drama
intervention. In one by Lepp, Ringsber, Holm and Sellerjo (2003), the authors, who are mainly from the
nursing profession, refrained from calling it drama therapy. The focus of their study was on the
caregivers. Two categories emerged from the analysis: interaction and professional growth. What was so
interesting in this article was the fact that the caregivers were surprised at the level of expression
demonstrated by their patients with dementia. Although reluctant to join the program, the caregivers
found the program personally rewarding while their patients bettered their quality of life; they “showed
their feelings, both joy and sorrow, more openly, their self-confidence grew and they showed greater
interest in their surroundings” (p. 873). Drama intervention for therapeutic reasons is so new that the
authors in this article had to rely on the defmition of drama in education: “. . . defined as the dynamic
embodiment of events involving human beings, is described as a valuable tool for intellectual and
emotional growth” (p. 875).

27



In another publication by O’Toole and Lepp (2000), they add: “Drama is both a method and a subject,
seen from an holistic perspective, and integrates thoughts, feelings and actions” (p. 875). Lepp, Ringsber,
Hoim and Sellerjo (2003) found that a combined program of dance, rhythm, song, storytelling and
conversations, designed especially for seniors with dementia, worked well. There were no references to
the physical environment.

Drama programs, drama therapy, drama intervention — whatever name is adopted in the future — is
such a new area that empirical literature on this topic is next to nonexistent. Anecdotal reporting from
practitioners in the field of creative expression programs is rich in stories of interesting experiments using
a host of activities including drama. It is difficult to isolate drama from other creative expression
interventions when it contains so many elements of others. Based on the literature review so far, there is
undoubtedly a great deal of overlap among the various models of creative expression interventions. Many
try to box combined interventions under the roof of one discipline or another, but in reality it is the mix of
interventions that appeals so much to so many of the facilitators who work with seniors with dementia.

Reminiscence Therapy, Life Review, Life Reflection and Stoiytelling

Reminiscence, life review and storytelling are all ways to communicate with others and express
ourselves verbally. A literature review revealed a wide range of publications that focused mainly on these
topics in regard to people of nonnal aging. However, specific literature on reminiscence, life review and
storytelling in regard to people with dementia is less available. Ten articles and two books were found to
be relevant to this discussion in the pursuit of creative expression abilities demonstrated by seniors with
dementia and the environment associated with these activities. Although the literature differentiates
between reminiscence, life review and storytelling, based on my experience, these elements are
interchangeable when facilitating discussion sessions with seniors with dementia. However,
understanding the fine differences is important in this relatively new area of research, started in the 1 960s
by Robert Butler (1963). The fine differences are important because they are linked directly to the
qualifications and training a facilitator may need to acquire to handle the analysis part of life review or
life reflection. Reminiscence therapy and storytelling could be left at the first stage of expression without
going into depth of evaluation and explanation of one self (Staudinger, 2001). Ursula M. Staudinger
(2001), a prominent researcher in human lifespan development at the Dresden University of Technology,
Germany, defines reminiscence and life review:

Reminiscence is defined as the remembering of life events, and flfe review is defined as
the remembering of events plus the further analysis ofthese events. (p. 149)

the distinction refers to the extent and sophistication of the further analysis and
possibly also the intentionality ofsuch analysis ... Reminiscence is defined as
reconstructing life events from memory, and lfe review is conceptualized as
reconstructing life events from memory plus further analysis (explanations and
evaluation) of the materials. (p. 150)

The function ofeither of the two processes, reminiscence and life review should be
determined only in a second step ... for instance, establishing intimacy could be achieved
both by sharing memories and by uncovering insights about one life. Reminiscence, in
particular, may be linked to functions such as boredom reduction, oral history, or
conversational pleas ure. Functions specflc to lf’e review may include, for instance,
alleviating depression, teaching others, solving a problem, enhancing life insight and
wisdom. (p. 149-1 50)

In her literature review on this topic, Staudinger finds that the aim of life review is “to repair and
return to normal levels of functioning ...“ (p. 154), while remembering the past usually follows a
chronological timeline. She felt that a new term needed to be introduced to capture “single life events and
sequences of events” (p.1 54) and named it life reflection. In an empirical study of life reflection versus

28



life review, Staudinger (2001) found that older participants engaged in life reflection to “balance and
integrate their life as lived” (p. 157).

Although Staudinger does not refer directly to creative expression abilities in discussing life
reflection, she does bring up elements that follow the definition of everyday creativity such as growth in
self-understanding and finding the meaning of “life as lived”. To encourage the process of life review,
Butler (1974), in Kasi-Godley and Gatz’s article (2000) on psychosocial interventions for individuals with
dementia, used triggers such as: written or taped autobiographies; pilgrimages, either in person or through
correspondence; reunions; construction of a genealogy; creation of memorabilia through scrapbooks,
photo albums, collection of old letters; verbal or written summary of life work; and preservation of ethnic
identity (p. 760).

Although literature on reminiscence in normal aging is growing, KasI-Godley and Gatz concluded
that “little attention has been given to how dementia might affect the ability to reflect . . .“(p. 760).
According to Butler (1974), brain damage should not prevent health service providers from using life
review therapy with people with memory impairment. On the contrary, Kasi-Godley and Gatz refer to
Cook (1984) and Kiernat (1979):

that reminiscence may be particularly importantfor demented individuals’ psychological
health given that the progressive deteriorating nature ofthe disease erodes the ability to
achieve present successes and makes individuals increasingly dependent on past
accomplishments for a sense of competency ... demented individuals retain much of the
capacity to recall and integrate the past because remote memory is spared through most
ofthe disease process. (p. 761)

Although the memory of factual details such as dates, names and locations may be affected with
seniors with dementia, other aspects of memories may still be intact. In my interactions with seniors with
dementia I have witnessed numerous similar situations, for example, one may remember learning how to
ski, but may not remember where and when it took place. One may remember being married, but have
forgotten to whom and if children were involved. Comments such as “I must have been married at some
point, aren’t we all?” are common. This fascinating behaviour has been observed by researchers and
practitioners in the field of dementia care and was discussed in depth in Question One. Understanding the
fine differences of how memory manifest itself in people with dementia is most important, especially
when facilitating sessions on creative expression activities.

Until I read Patrick Colm Hogan’s (2003) book, The Mind and its Stories, Narrative Universals and
Human Emotions, I struggled with finding literature that would support my approach to creative
expression activities where fabricated stories told by seniors with dementia were as important and
meaningful as those perceived to be true stories. One could never be absolutely sure whether a story may
also include experiences of others to be claimed as their own. Hogan compares this behaviour to
children’s storytelling and supports it with quotes from Miller, Hoogstra, Mintz, Fung and Williams
(1993), “a child might appropriate and use for his or her own purposes someone else’s experiences,
someone else’s story. Framed in this way, any story has the potential to be personalized story” (p. 91).
Hogan sees this behaviour in adults as well and states:

it seems likely that this sort ofthing occurs with authors all the time. It seems likely
that authors incorporate autobiographical material even in entirely nonautobiographical
works (for example, in filling out characters in historical novels) through just such a
process ... retellings supports not only our account of aesthetic responses, but parallel
accounts ofartistic creation.” (p. 69)

So, according to Hogan (2003), we are all capable of incorporating experiences of others into our own
storytelling intentionally or unintentionally. Although Hogan does not discuss dementia, he does discuss
the link between literature and the human mind, which includes storytelling and memory and which he

29



calls “verbal art” (p. 3), where people share their “ideas, perceptions, desires, aspirations, and ... emotions
It is an activity engaged in by all people at all times ... something people do, and always have done, in

all parts of the world
...“ (p. 3). Verbal art is a form of creative expression. While Hogan calls it verbal

art, Cheston (1996) describes the action of storytelling as a “new shape and form to the present” (p. 582).
Yen-Chun Li Yu-Tzu Dai and Shiow-Li Hwang (2003) define reminiscence “as a mechanism for
adapting to stress” (p. 298). All of these authors support the definition of everyday creativity that was
discussed previously. Bernie Arigho (1997) summarizes very well the relationship between reminiscence
and creativity:

The success ofreminiscence work is measured in terms of the extent to which it enables
people to participate in meaningful and enjoyable activities. The focus is on being active
and creative in the here and now, though the inspiration is derivedfrom the there and
then. (p. 188)

From medical observation, we learn that people with dementia suffer from illusions and that
fabricating stories is considered a common symptom of the disease. From a medical point of view this is
problematic behaviour, less tolerated and in need of being treated. From a societal point of view, there is a
perception that these people may have lost their minds, they may be considered unreliable and living in
their own world, one that is disconnected from reality. However, if we accept their reality, we can help
remove the stigma attached to their behaviour. The change needs to occur in our attitudes towards people
with dementia. By creating a friendly and accepting environment, we allow the persons within the disease
to continue to live their life to the best of their remaining abilities. Cheston (1996) in his article Stories
and metaphors: talking about the past in a psychotherapy group for people with dementia reacts to the
common perception that people with dementia are engaged in meaningless talk, “their memories are
defective, and their reminiscences are of little importance...” (p. 598). He argues “that there are other
stories to be told about the talk produced by people with dementia if we can only allow ourselves to listen
to the poetical, the metaphorical aspects of language” (p. 598). He also sees:

Self-narratives and stories ... as a mean of communication and as a focus for
exploration. They can permit a rich world, a place ofre-membrance, a re-creation of
people, ideas and images so positioned and constructed that they lend new shape and
form to the present. The creation ofa story permits a world in which present dilemmas,
uncertainties and hopes can be lived through. (p. 582-583)

Since we cannot, at the present, change dramatically the progression of the disease, we might as well
work with it instead of against it. The question is then, how do we go along with realities experienced by
seniors with dementia? How does reality manifest itself in the physical environment and in human
relationships? The answers lie in our services, interventions, planning and in design solutions for people
with dementia. For example, in a documentary Memory Lane (2003) on architectural design for people
with dementia, one solution provided was very imaginative. Given the average age of seniors with
dementia today, we can trace back to the 1950s and l960s when these people were in their prime.
Through research we can recreate old streets, neighbourhoods, colors, furniture, fashion, ice cream
parlours, cars, music, dances, food, customs, and so on. In this documentary, a Long-term care facility
recreated a section of a street along its property that was designed to replicate the 1 950s in a typical North
American urban setting. The ‘neighbourhood’ provided opportunities for seniors to sit in coffee places and
purchase their own ice cream as they used to in the past.

For normal aging people it may look like a Hollywood movie set, however, it is real to seniors with
dementia who can still remember some of their past. Speakers at an American Society on Aging
conference on generation gaps in Denver, 2001, commented that about every ten years, there is a
significant shift in the western society’s taste in clothing, music, customs and so on. If that is true, then the
present generation of Baby Boomers could adjust the make-believe street to include Elvis Presley, Bob
Dylan, mini-skirts, portable phones, fat-free foods, photos of known citizens and politicians and more.

30



This approach is the exact opposite of reality orientation as developed by Dr. Camp Cameron in Ohio
(discussed earlier) for seniors with dementia, which is still being practiced in various facilities. Instead of
constantly repeating information that may sound foreign, meaningless or hard to retain, seniors with
dementia would be less stressed if we did not confront them or try to train them in the hope they may
change. A study by Woods (1992) on reality orientation has shown that long-term memory retention was
not very successful or significant after the interventions were completed. KasI-Godley and Gatz (2000)
also concluded that reality orientation as an intervention has “little to no effect on behavioural
functioning” (p. 769).

In comparison to reality orientation that focuses on training individuals to be more aware of the time
of the day, the month, meal times and room finding, reminiscence therapy, according to Yen-Chun Lin,
Yu-Tzu Dai and Shiow-Li Hwang (2003), focuses on developing “new relationships [that] meet
psychosocial and developmental needs” (p. 299). Still, reminiscence therapy is not appropriate for
everyone and may have dangerous consequences (Thorgrimsen, Schweitzer and Orrell, 2002). Careful
consideration needs to be exercised. If facilitators are not qualified to handle crises, there is a need to
arrange backup professional help in case of emergency.

Reminiscence, Life Review, Life Reflection, Storytelling and the Therapeutic Environment

In the articles on reminiscence as it is linked to dementia care, very little attention is addressed to the
environment. The source for reminiscence therapy by Joyce L. Harris (1998) mentioned the physical
environment:

A conversational grouping in a small, quiet, well-lit area is idealfor a reminiscence
group. A small area is likely to have better acoustical properties which creates a better
listening environmentfor everyone. A small area also creates a feeling ofgreater
intimacy among group participants (p. 46)

Harris also points out that furniture and seating arrangements are very important contribution to
successful reminiscence sessions.

Review

Only seven years ago when I started to look for practical ideas to implement in my work with seniors
with dementia, I was struck by the lack of information. What I did find was inappropriate, comprising
child-like activities that did not reflect the seniors’ cognitive and physical abilities. Nor did I find detailed
information that made a link between seniors with dementia, their abilities to express themselves
creatively, and the physical environment to accommodate these activities. Today’s literature offers a wide
variety of arts-based programs for seniors with dementia; however, there are still major concerns to be
dealt with. The literature review revealed the following outstanding issues:

Lack of understanding. Dementia as a medical condition is misunderstood due to misinformation,
lack of education, lack of experience working directly with seniors with dementia.

Some scholars from medical backgrounds lack deep understanding and first-hand experience of what
creativity is all about. They may understand it intellectually, but depending on their definition of
creativity, they may fail to see how creativity manifests itself in spite of the disease.

Artists who are also researchers have a tendency to rely on the medical model for psychological
assessments of seniors with dementia.

Expectations. There is a tendency to lump people with dementia with the mentally ill without
discriniination.

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There are lower cognitive and physical expectations of seniors with dementia.

There is a tendency in the literature to agree on minimizing the sense of failure when interacting with
seniors with dementia. However, some may enjoy an appropriate challenge that may reflect respect and
appreciation of their remaining abilities.

Programs. Most articles focus on methodological aspects of art-based programs while very few
discuss how those programs are implemented.

There is a shortage of meaningful programs, with purposeful and diverse activities. There is a need
for structured activities that allow the seniors to set the pace that suits them.

The consensus among researchers is that music has a significant impact on people with dementia in
changing moods, recalling some memories, improving communication and social skills, helping to relax,
to bring enjoyment, and to get in touch with one’s own feelings. At the same time, some consideration
may be given that music may not be suitable for everyone.

A strong pattern is emerging that a mix of arts-based programs is the most popular intervention
among facilitators who work with seniors with dementia. However, there is definitely confusion about the
boundaries between various programs.

Facilities. In reviewing the literature on special care units (SCUs), an important finding was that
many non-SCUs use approaches similar to SCUs in staff training, environmental design and
programming. This could mean that some SCUs offer rather meager specialized features that SCUs are
not homogenous and they do not necessarily provide better care than non-SCUs.

An approach is developing that perhaps residents in long term care facilities should not be pushed
throughout the day to follow rigid rules and schedules, but rather enjoy a calmer pace.

People with dementia in larger facilities interacted less with other residents or staff, while in smaller
facilities, residents were more interactive.

One observation made by Perrin (1997) may have a great impact on the architectural design and
communication with seniors with dementia. Perrin found that people with dementia respond best when
other people and objects are placed within 3 to 4 feet diameter around them. In Perrin’s words, the
environment has ‘shrunk’ to envelop the person with dementia in kind of a plastic bubble and that staff has
no problem interacting with this group as long as they are close physically to the clients and within the
suggested ‘bubble’. Perrin brings up the notion that if the closeness encourages interaction, it may be an
important factor in space design and the attention given to activities in it. In other words, the “bubble’
concept may have an impact as to how physically we interact with seniors with dementia, display our
stimulating objects such as art materials, furniture arrangements, locations of easels, strategically placed
instructors and so on.

New Directions for Research and Implications for Practical Implementation

Numerous articles stated that doing research with seniors with dementia presents many difficulties.
The population is frail and vulnerable and usual research methods may not be practical. Researchers need
to take these limitations into account.

Lack of understanding. Need for programs that educate medical personnel, potential caregivers and
arts-based program leaders about dementia — differentiating mental illness from mental deterioration and
considering the implications for care and activities.

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Expectations. Need for research on seniors with dementia to study their reactions to programs in care
situations. Are expectations appropriate to their cognitive and physical abilities?

Programs. Need for research on successful programs with emphasis on practical applications.

Facilities. Need for research on the effect of facility design on the well-being of seniors with
dementia, on caregivers and medical personnel as it is linked to creative expression activities.

Recommendations

The literature review revealed that there is a strong need for a multidisciplinary program of creative
expression activities for seniors with dementia. In order to achieve it there is a need for educational
programs to train facilitators that would combine expertise in dementia care with programs on creative
expression activities in a comprehensive way. In addition, architectural schools need to include courses on
designing for the elderly with a focus on dementia.

There is a need for forums where researchers and practitioners from various arts-based programs can
meet to exchange ideas and create new alliances. Ideally, such forums would include input from the
medical community.

A strong pattern is emerging that a mix of arts-based programs is the most popular intervention
among facilitators who work with seniors with dementia. There is a great deal of overlap among the
various models of creative expression interventions. As they grow closer and cross over, many try to box
combined interventions under one discipline or another, but in reality it is the mix of interventions that
appeals so much to so many of the facilitators who work with seniors with dementia.

Clearly, much more research is needed in the area of creative expression and dementia, especially
with a focus on what works and what does not work with these seniors. There are no studies that explore
the ability of Alzheimer’s patients to appreciate artistic expression. This is, potentially, a new area for
research.

Researchers should be encouraged to cross the boundaries of their own fields and expertise. They
should be allowed to stretch their imagination and develop fresh new ideas without being constrained in
the name of science. I believe that every bit of new information has the potential to spiral into new
adventures and trigger additional new thoughts. Working with seniors with dementia is full of
opportunities to learn about them and about oneself. It is a mutual journey where the researcher and the
seniors being studied can learn from each other through layers and layers of rich information.

This section of the literature review covers the meaning of everyday creative expression and how
seniors with dementia experience it. The recent literature on research in creativity focuses on the work of
several prominent scholars. It contains their definitions of creativity to further develop an understanding
of what creative expression means and how it manifests itself (fig. 2, see page 9). It is based mainly on
the Handbook of Creativity (1999) that describes the work of Sternberg and his 30 colleagues, on
Creativity, Mark Runco’s (2004) most recent work, and on Art, Mind and Brain: A Cognitive Approach to
Creativity by Howard Gardner (1982).

Following this review, I will provide selected definitions of creativity followed by a discussion of
how they follow or contradict the assumptions and approaches to research on creativity and dementia I
have pursued. These definitions may derive from quantitative or qualitative studies and from less rigorous
studies due to the complexity of this topic and the difficulties arising from conducting research in this
field. Gaps in the understanding of the two domains of creativity and dementia and in the combination of
them will be identified to provide the base for a new definition that may be more appropriate to research
on creativity with seniors with dementia. The new definition will provide a fresh starting point and will
continue to evolve as the inquiry progresses.

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Eight models were reviewed for their appropriateness to tackle research on creativity and dementia
and although no one specific model was definitive, many of these models provided important information
as the backbone for this study. The eight models cover the six approaches in Sternberg’s (1999)
Handbook of Creativity, along with Runco (2004) and his colleagues’ approach in his review article
Creativity, and Gardner’s (1982) cognitive approach. Although Sternberg and Runco’s work are more
recent, I found that Gardner’s approach fills in gaps of information missing in the others and appears to be
more relevant to research on creativity and dementia.

Emerging Approaches to Creativity Research

Robert Sternberg (1999) introduces the work of 30 scholars in the field of creativity and identifies six
approaches to creativity research:

a. Psychometric: “creativity ... as a measurable human factor or characteristic” (Mayer, 1999).
Sterneberg and O’Hara (1999) were looking for multiple answers “as opposed to one single
correct answer” from their subjects. The answers were quantified and rated for creative
abilities based on comparative scoring of creative versus non-creative persons. Psychometric
assessments take place in a controlled environment. This control may limit the ability of
creativity to be expressed spontaneously and in an unpredictable manner.

b. Experimental: the study of creativity in which subjects are engaged in creative thinking
through solving problems. The aim is to identify factors that improve or inhibit creative
thinking. As in the psychometric approach, the experimental approach utilizes quantitative
measurements in controlled environments while analyzing tasks prepared in advance that
were administered to the subjects. The aim of this approach is to identify the various phases
in creative thinking a person goes through. According to Ward, Smith and Finke (1999),
research on differences between creative and non-creative thinking in experimental
observations found two kinds of cognitive processes: first, generative processes based on
existing knowledge and which are part “of ordinary minds” (p. 190); this knowledge may or
may not inhibit creativity. Second, processes that are of an exploratory nature and, based on
potential function, can be untested proposals that are marked by “originality and
appropriateness” (p. 191). Ward, Smith and Finke report on examples of exploratory and
generative processes experienced by a writer (Ward et al., 1995) or by an inventor (Finke,
1990). The two processes may happen independently or be combined and operate under
various restrictions. They may be generated with a specific goal in mind or for an open-ended
situation (Ward, Smith and Finke, 1999, p. 192).

c. Biographical: A qualitative, richly detailed narrative study (Gruber & Wallace, 1999) of a
creative person through a single case history or through a comparison between creative
persons. The biographical approach can also be studied through quantitative analysis of a
group of creative people (Simonton, 1999). The aim of this approach is to identify factors in
life events that foster creativity. A positive aspect of this approach is that the subject is
studied in a personal authentic environment, in contrast to the controlled environments used
in psychometric and experimental approaches. The down side of this approach is the concern
that the findings of one case study may not be applicable to another case. However, this
approach is useful in combination with other approaches as a rich source for qualitative data.

d. Biological: The study of creativity through cognitive neurosciences that examine brain
activities as the subjects are engaged in creative thinking (Martindale, 1999). None of
Sternberg’s 30 colleagues in the Handbook of Creativity discusses how biological
impairments impact creativity.

e. Contextual: The study of creativity in a social and cultural context. Collins and Amabile
(1999) examine intrinsic and extrinsic motivations and their effects on creativity. Based on
empirical studies, they concluded that intrinsic motivation is “conducive to creativity” (p.
299) and is generated by the individual for enjoyment. Extrinsic motivation is defined as

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having to meet external requirements such as awards and competitions. This motivation is
harmful to creativity. Csikszentmihalyi (1999) uses the “systems perspective” to explain the
creative process and its external variables. Csikszentmihalyi concludes that in order for
creativity to be considered valid, it must be accepted and recognized by the community.

f. Artificial creativity: This approach seems to be irrelevant to the topic of creativity and
dementia and was omitted.

In the review chapter Fifty Years of Creativity Research in Sternberg (1999), Richard Mayer analyzes
the various approaches to creativity research and comments on the gaps and challenges that still exist in
the pursuit of answers to questions such as: Can creativity be measured? Which cognitive processes are
involved in the creative process? Do life experiences matter? What motivates creative people? What role
do biological and evolutionary factors play in creativity? How do social and cultural contexts affect
creativity? Can creativity be enhanced? He also sees a need for “new and useful methodologies” to study
creativity. He suggests that some of the discussions lean towards “speculation that is only loosely related
to empirical data,, by sweeping generalizations that are not tightly supported by research evidence, and by
a level of theorizing that is too vague to yield testable predictions” (p. 459).

Mayer’s comments on the state of research on creativity resonate with some of the thoughts,
questions and difficulties that impede the process of gathering relevant information on creativity and
dementia. Providing empirical evidence to support the assumptions of scholars’ statements on creativity
can be a formidable task. The literature is short on empirical studies, and the ones provided do not offer
an appropriate approach that can capture the essence of creativity in formation. Publications in general
cover views that are so widely spread that the focus on creativity and dementia is rarely addressed. It is
clear that scholars in this field are grappling with understanding creativity and how to conduct appropriate
research that would fit multiple situations. One clear message from Mayer’s review is that there is a need
for a multidisciplinary approach to creativity research.

One approach some scholars (Gardner, 1982 Redfield Jamison, 1997) find attractive is to focus on
people who are already known for their creative powers, since their creative abilities are obvious and easy
to access for quantitative evaluation or qualitative observations. Perhaps understanding acknowledged
creative people could assist in analyzing what makes these people think or act creatively. What external
(environmental) and internal (personal) conditions promoted their creativity? Could these findings be
replicated elsewhere in a quest to understand creativity and dementia?

Adopting the biographical approach that has been applied to known creative people to understand
creativity, it might be possible to study a creative person who has dementia. However, if we use the
biographical approach to research creativity, we indirectly adopt the notion that not all people are creative
and therefore everyday creativity may not be an accepted concept. But if we adopt the opposite
assumption that all human beings are creative, (Ward, Smith & Finke, 1999, p. 189) it could be possible
to study any human being.

The question is then what kind of creativity are we looking for? Are we looking for exceptional
creativity or everyday creativity — one or both? Perhaps we will need to reconsider, readjust and redefine
what creativity is. The following section reviews the existing definitions of creativity put forward by these
scholars. I am aware of the scientific aspiration to meet rigorous academic standards, but I also respect
years of experience and wisdom accumulated in this complicated field of inquiry. Therefore, some
definitions will be backed by empirical findings and some will be based on theory. Acknowledging the
difficulties and the lack of rich empirical evidence should not prevent continuing efforts to pursue
creativity research. Perhaps some untested thoughts may lead to a new direction for others to follow that
will result in more rigorous tests in the field. There are many factors to be taken into consideration when
researching creativity and perhaps utilizing one approach to creativity research at this time is not
appropriate and trying to prove the existence of creative expression through empirical research is only one
factor in a much more complicated undertaking.

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In his most recent review article on creativity, Runco (2004) faces the same complicated task as
Sternberg did in trying to sort out the various approaches to creativity research and advance the
understanding of it. Runco claims that more than ever people need to use their creative abilities in a fast
moving technological society, which he describes as a “cultural evolution” (p. 658). He states that his
review of the research is based on a framework suggested by Rhodes (1961,1987), which is divided into
four categories of creativity research:

a. Person. “Research on personal characteristics” (Runco, p. 661), such as a person’s broad
interests, intuition, or a “firm sense of self as ‘creative” (Barron & Harrington, 1981, p. 453).

b. Product. Outcomes “that result from the creative process”, such as “publications, paintings,
poems, designs” (Runco, p. 663). Most research that uses this approach deals with artists
well-known for their talents as opposed to ordinary people. Runco also states that
“productivity and creativity are correlated but not synonymous” (p. 663).

c. Process. A description of a process over a long period of time. Usually involves “divergent
thinking and problem solving” (p. 661).

d. Press. Was introduced for the first time by Harry Murray (1938) and continues to be used. It
refers to “pressures on the creative process” (Runco, 2004, p. 661). For instance, Amabile
(1990) refers to the physical environment as a source for influences on the creative process.

Runco felt that the four categories of person, product, process and press were not sufficient for a
comprehensive approach to understanding creativity and added information from specific disciplines that
were “organized by behavioral, biological, clinical, cognitive, developmental, historiometric,
organizational, psychometric and social perspectives” (p. 663): Let me describe each in turn.

Behavioral perspectives. Runco supports Epstein (2003, in press) in connecting creativity with
“insight and novelty” (Runco, p. 664) Epstein, Runco suggests, tested participants in a pre-arranged
setting, to see how previous experience could contribute to creative behavior in problem solving. Epstein
explains “Insight” as a result of “spontaneous integration of previously learned response” (p. 664).

The biology of creativity. Based on medical findings, Runco suggests that creativity research from a
biological point of view leans towards “... behaviors and aptitudes” (p. 664). Studies that were based on
past medical surgeries to inhibit seizures referred more to the skills of the patients and not to their creative
abilities that are defined as “... originality and appropriateness, intuition and logic” (p. 664). Based on
empirical evidence, Katz (1997) discovered that the creative process does not limit itself to one
hemisphere but requires the collaboration of both sides of the brain. Other researchers, such as Hoppe &
Kyle (1991), used electroencephalography (EEGs) to detect brain activity in a group of patients with
bisected hemispheres and in a control group. They found that both parts of the brain are engaged when
verbal and emotional expression is concerned.

Clinical research. Runco sums up creativity research in this category to be focused mainly on mental
disorders such as schizophrenia and other disorders such as alcoholism, suicide and stress. Realizing the
limitations in past research Runco, Ebbersole and Miraz (1990) turned to a new direction, in which the
definition of creativity was expanded to include self-actualization within the context of health promotion.
Runco, Ebbersole and Miraz conducted a study with 84 university psychology students. They
administered three questionnaires that measured “creative traits, preferences, and attitudes” (Runco,
Ebbersole and Miraz, 1990, p. 267). They used the Self-actualization Scale (SAS) developed by Jones and
Crandall (1986). To their disappointment they could not establish cause and effect between creativity and
self-actualization. However, they did conclude that “Creativity may allow individuals to become self-
actualized, or self-actualization may lead to creative behavior” (p. 271). Runco, Ebbersole and Miraz, also
make the connection of creativity and self-actualization with “coping and adaptive skills” (p. 271). This
connection is also supported by Rhodes and his theory (1990, p. 247) that creativity rises from
“deficiency needs for love, acceptance and respect” (p. 251), which in turn lead to self-growth, self

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expression and self-actualization. Runco also emphasizes the importance of research in this category for
the understanding of the individual’s subjective experience.

Cognitive research. This category is often studied for creativity by using tests for divergent thinking
(providing several answers to a problem), fluency (number of solutions), originality (uniqueness), and
flexibility (variety) (Runco, 2004, p. 668). Runco sees these tests as predictors only that may indicate the
potential for creative thinking. Although the definition of creativity was expanded to include all of these
factors, the solutions for problems provided in the various tests needed to demonstrate that they are
appropriate solutions as well. And so appropriateness was added to the definition of creativity that looks
for novelty, innovation, flexibility and fluency.

Developmental research. Most of the research in this category, according to Runco, is applied to
children and adolescents, although research on creativity and adulthood is mentioned here with reference
to the latest work by Lindauer (1992). Runco did not look at the work of other scholars with expertise on
creativity and aging, like Gene Cohen (2000) or Howard Gardner (1982).

Economic factors and theories. According to Runco, this category lacks empirical validation.
However, he considers some suggestions that hard times may stimulate creative thinking.

Educational and historical research and organizational perspective. While these approaches to
creativity research were described by Runco, they were too far removed from the topic on creativity and
dementia. Although educational research is rich in studies on creativity, it mainly focuses on children and
adolescents.

Psychometric research. In this category, creativity is tested for its potentiality through “paper-and
pencil” tests, which usually are administered to ordinary people as opposed to eminent persons. This
approach to creativity research is involved in comparative studies and their ratings. Psychometric testing
is relevant to the topic of creativity and dementia, since people with dementia often go through
neuropsycho logical testing, such as the diagnostic test of drawing a clock, to evaluate memory capacity,
which indirectly may or may not indicate creative abilities. This category lacks appropriate tests for
seniors with dementia to determine the level of their remaining creative abilities.

Social research. Runco reminds us that early creativity research was focused almost entirely on the
individual until scholars like Amabile (2000) shifted some of the attention to social influences on the
creative process. In these situations, depending on external factors, creativity could be discouraged in the
case of competition and criticism, or enhanced by working with other people. There is no mention of
creativity, aging and dementia. However, understanding how creativity manifests itself within a social
context is very applicable to people in institutional care, such as seniors with dementia in long-term care
facilities.

In his conclusions, some of Runco’s comments on the state of creativity research and its findings may
provide support directly and indirectly to the importance of research on creativity and dementia. Runco
concludes, “that creativity is beneficial. Creativity facilitates and enhances problem solving, adaptability,
self-expression, and health” (p. 677). He suggests that “creativity research is best understood by
considering various perspectives” (p. 677) and that researchers need to stay flexible in their approach
when studying the subject. He recommends taking into account the person and their environment. Runco
sees the importance of the interplay between clinical work and cognitive perspectives and between basic
research and applied research. He makes us aware that creativity is expressed in many ways and in many
domains.

He recognizes the need to study everyday creativity, which is the ability to cope with everyday
problems that does not call for what he calls “high-level achievement or expertise” (p.678). Runco applies
his concept of everyday creativity mainly to children. He is disappointed that the field of creativity
research is still far from understanding the “mechanisms that underlie creative capacities” (p. 679). A

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major concern of his is that creativity per se is not really researched, but novelty, insight, productivity and
behavior are; he considers these factors the products of the creative process. He agrees with other
researchers that “originality is necessary but not sufficient for creativity” (p.679) and yet he misses the
connection Czikszentmihalyi (1999) makes that society has the final say as to what makes a thought or a
product creative, which leaves originality in question.

Of note in particular in Runco’s article is a report of the results of his survey asking 143 individuals in
the field of creativity research to rank the importance of research topics, ranging from the most important
to the least important. In a list of 36 items, mental health was 16, while neurobiology, mental illness and
therapy were at the bottom of the list. Testing and measurement got very low priority as well, while
creative behavior topped the list. Which brings us back to the question posed in this paper: what does
creative behavior mean? What does creative expression mean? Based on this survey it seems that people
in the field of creativity research do not see a strong need to explore the connection between health and
creativity. Although Runco did not elaborate on the reasons, it is possible that the pressure to produce
empirical findings in the health services domain discourages research known for its difficulties and
complexities. To reinforce this possibility testing and measurements also got a low priority. Perhaps the
results of this survey may indicate the gap between those who see creativity as a personal trait of eminent
artistic talent and those who see creativity manifested in daily routine. It may indicate that any less than
eminent talent deserves less attention.

These two publications, Runco’s Creativity Research Handbook and Sternberg’s Handbook of
Creativity, are considered to be milestones in creativity research; they bring together the work of many
scholars in an effort to identify major approaches to creativity research. Mumford used these two
handbooks as a starting point for his research on creativity. By studying their content, he concluded that
there is a need for “critical comparative tests contrasting the merits of different methods and theories,
elaboration and extension of our traditional samples and our traditional measures, and more attempts to
develop integrative models” (p. 107). He also concluded that there is a need for more research on topics
such as: “practical innovations, cross-field differences in the nature of creative thought, and the effect of
creativity on people and social systems” (p. 107). Like other scholars, Mumford’s definition of creativity
is still evolving; however, he states that “creativity involves the production of novel, useful products”
(p.11 0) Understanding Mumford’s background and expertise in the field of industrial and organizational
psychology makes it clear why the link between creativity and a product is an important indicator of
creativity for him.

In response to Mumford’s definition of creativity, Runco agrees that creativity involves the
“production of novel and useful products”; however, he argues that the potential for creativity, which
precedes the actual performance, does not bring forth a product to evaluate. Therefore, “creativity may
sometimes not involve any productivity whatsoever”... Productivity, then, is an objective indicator but
only sometimes indicative of creativity” (p. 138). Runco’s response opens the arena of creativity research
to new directions, which potentially may help support research on creativity and dementia.

Other Perspectives on Creativity and Expression

Creativity. According to the Random House Webster’s College Dictionary (1995), creativity is “the
ability to create meaningful new forms, interpretations, etc; originality,” while being creative “result[s]
from originality of thought; imaginative,” and create is to “evolve from one’s imagination, as a work of art
or an invention.” This definition still leaves the reader with insufficient explanation, which leads to the
next question: Does creativity always need to result in an invention? Is any deviation from inventiveness
considered less or non-creative? In Sternberg’s handbook scholars such as Mayer, Gruber & Wallace,
Martindale, Lumsden, Feist, Lubart, Boden and Nickerson (1999) make strong connections between
creative abilities and products that can be evaluated for their creativeness. Gruber and Wallace (1999)
define creativity as “novel and value: The creative product must be new and must be given value
according to external criteria” (p. 94). If there is an agreement in most definitions that creativity involves

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the creation of original and useful products, who decides what is original and useful? What evaluative
systems do we have for assessing originality and usefulness? According to Csikszentmihalyi, (1999) even
if an idea or an act resulted in a product, it would not be considered creative unless society accepted and
recognized it as such. As he states:

Originality, freshness ofperceptions, divergent-thinking ability are all well and good in
their own right, as desirable personal traits. But without some form ofpublic recognition
they do not constitute creativity. In fact, one might argue that such traits are not even
necessaryfor creative accomplishments. (p. 314)

Csikszentmihalyi’s definition helps redefine creativity and opens it to new possibilities that may lend
themselves to research on creativity and dementia. According to Csikszentmihalyi, creativity only exists
when it evokes some form of public recognition. But public recognition can exist on different levels
within specific contexts. For eminent artists, public expectation is high. For seniors with dementia, the
entire context changes and so do public expectations. Two years ago, I mounted an art exhibition by
seniors with dementia as an event exhibiting creativity. More than 4,000 visitors attended, many of whom
left comments showing their surprise at the level of creativity on display. They were expecting much less
from these seniors. In this instance the community showed their positive support of the exhibit based on
the level of expectation.

Not all scholars in the field see the end-product as a necessary element in defining creativity.
According to Ward, Smith and Finke (1999) creativity may or may not result in generative expression and
may stay just in the exploratory phase in the form of an idea or creative thinking. Feist’s definition of
creativity (1999) still supports the notion of inventiveness but broadens the definition to include the
ability to be flexible as well, through “novel and adaptive solutions to problems” (Feist, 1999, p. 274).

Expression. In Webster’s New World Dictionary (1986) Expression means, “a putting into words or
representing in language. A picturing, representing, or symbolizing in art, music, etc. A showing of
feelings, character, etc. (laughter as an expression ofjoy). A look, intonation, sign, etc. that conveys
meaning or feelings (a quizzical expression on the face)” (p. 495). This definition is sufficient to cover the
various modes of verbal and non-verbal expression that will be discussed later in more detail.

Based on these definitions, it is possible to develop a new definition of creativity that could be more
inclusive, embracing expressions exhibited by people who may not be considered by society to possess
creative abilities, such as seniors with dementia. If creating is an act of expression, it may be original or
not, yet it brings something into being — perhaps a line drawn on a blank paper, a song, a thought, an idea.
In other words, expression changes the existing status quo and creates new situations. Therefore, a new
situation may be considered equal to a creative act.

In Art, Mind and Brain, a Cognitive Approach to Creativity (1982), Gardner admits that he knew very
little about adults with brain damage when he first began to work with them. He describes how he came to
appreciate the “person” within the individual. Working with these individuals he realized how much they
varied from one another and how they still were able to make the best of their remaining abilities.
Gardner’s work in the US and his appreciation and positive attitude towards brain-damaged people gained
recognition in the 1 980s, about ten years before Tom Kitwood in England introduced the concept of
personhood. Personhood stands for an approach that relates to the person within the individual with
dementia as opposed to the medical model, which treats the symptoms of the disease. It is possible that
the two scholars did not know about each other’s work, since both were situated in different countries and
came from different fields of expertise; Gardner from education and Kitwood from social work.

Gardner’s main interest in working with brain-damaged adults came from a desire to understand
“better the nature of human artistry” (p. 267), which would shed light on impaired cognition as well as
normal cognition. Gardner based his work on neuropsychological studies that focused on language
disorders such as aphasia. He studied gifted artists who had suffered brain damage and “normal

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nonartistic individuals” (p. 267). Both groups were observed working in three art forms: painting, music
and literature. It should be noted that Gardner did not question what is considered creative. He did not
elaborate on how he decided who was considered a highly artistic person, and who was not. Although
Gardner seemed to divide individuals into artists and non-artists, he still believed that “nearly all of us
have attained some modest artistic skill. We can sing a song, make a drawing, tell a story” (p. 320).
Gardner was more interested in the abilities of brain-damaged people to express themselves and refrained
from discussing the quality of the expression.

The Meaning of Creativity, Gaps in In formation

The overarching definition of creativity, as these various researchers present it, seems to concur that
ideas and products are creative as long as they are new and useful. In addition, they cite the ability to
adapt, maintain flexibility and fluency and be valued by society. None of the researchers discussed the
issue of creativity and dementia. Sternberg’s handbook ignores the subject of creativity and aging
altogether. Runco’s article on creativity does bring up briefly the issue of aging and creativity but not
creativity and dementia. Gardner discusses how creativity manifests itself in people who have suffered a
stroke, bisection of the brain, and other damage. While Gardner makes it clear that not all individuals with
brain damage are mentally ill, other researchers (Eisenman, 1997) actively associate creativity with
mental illness or other exceptional personal traits. All researchers in these publications agree that
creativity is a complicated subject and there is a need for more research. Many researchers agree that one
approach to the study is not sufficient and that research should consider studying creativity from several
approaches, including interdisciplinary approaches that would provide empirical findings (Gardner, 1982,
Mayer, 1999).

Based on creativity definitions reviewed here, I came to the conclusion that none of them are relevant
in their entirety to the study of creativity and dementia and none reflect the situation in which seniors with
dementia operate. Some parts of the definitions may apply, such as the need to be able to adapt to new
situations, flexibility, fluency, everyday creativity and society’s acknowledgment of the creative idea or
act. What is missing is literature on aging that may provide information on how creativity manifests itself
in later life with a possible focus on dementia.

Opening up the definitions from eminent creativity to everyday creativity allowed researches like
Runco and Richards (1997) and Runco, Ebersole and Mraz (1990) to further develop this concept and its
contribution to the quality of life at every stage in human development. They say that creativity manifests
itself in being curious, in an ongoing process of self-evaluation and personal growth. Quality of life in
adulthood is defined by the level of physical, social, mental health and role function (Anderson, 1997).
Teague, McGhee, Rosenthal, and Kearns (1997) defined quality of life as “a dynamic process in which
each adult has unique or different health needs” (p.3 5). Their understanding of the quality of life of older
people supports Runco, Ebersole and Mraz (1990) in defining the concept of everyday creativity, which
values the social, emotional and spiritual aspects that contribute to the notion of what makes a person
whole. In his (2003) response to Mumford (2003), Runco elaborates further on how he sees everyday
creativity manifest itself:

Everyday creativity may be involved in the problem solving that occurs when an
individual drives to work and decides what attire is bestfor a particular day ‘s schedule,
improvises while cooking or decorating the home, decides the best way to entertain
guests or children, and in countless other fairly mundane ways. Without recognition of
everyday creativity, we will overlook individuals whose creativity is not manifested in art,
science, or some professional fashion. (p. 139)

Following this train of thought, Runco and Richards (1997) state:

Everyday creativity is the originality of everyday lfe, the doing ofsomething new in the
course ofone ‘s activity at work or leisure ... In every case, the activity involves

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innovative elements which are also meaningful to others — two common criteria for
creativity” (p. 97). [Creativity] “emerges unpredictablyfrom the richness ofour
diversity — both within our own minds, and between all of us in this multipotentialled
world. We should cherish this diversity, preserve, and enhance it, for it may help us in
ways we cannot imagine now.” (p. 449)

Based on these definitions and explanations of creativity, we can now investigate further how
creativity manifests itself in later life and examine the qualities valued the most at this stage. To
understand creativity in later life, I will describe three studies. The first, a qualitative study done by Fisher
and Specht (1999), concerns seniors in normal aging. The second is a quantitative study by Smith and
Van Der Meer (1997) that is included to provide contrast with the two qualitative studies. The final
qualitative study by Davis Basting shows how creativity manifests itself in seniors with dementia.

Creativity and Aging

In Successful Aging and Creativity in Later Life (1999), Fisher and Specht conducted a qualitative
study over a period of two months, was to examine the link between successful aging and its relationship
to creative activity as older people see it. The study included thirty-six seniors, men and women, ages 60
to 93. These seniors participated in an art exhibit and were interviewed for their understanding of
successful aging and creativity. Two independent interviewers asked closed and open-ended questions
from a survey questionnaire. The interviews lasted from 45 to 60 minutes. Using content analysis, six
topics emerged as important for successful aging: “a sense of purpose, interaction with others, personal
growth, self-acceptance, autonomy and health” (abstract, p. 1). Reports of the participants’ opinion on
being involved in creative activities showed that it contributed to “a sense of competence, purpose and
growth” (p. 1). Artistic creativity encourages “problem—solving skills, motivation, and perceptions”, (p. 1)
all of which enhanced the quality of the seniors’ “everyday lives” (p. 1). Fisher and Specht found that
participants identified adaptability, flexibility and coping as important elements to successful aging; these
are the same elements that other researchers in creativity describe as essential factors in the creative
process. Fisher and Specht also found that their participants valued their artwork, the opportunity to use
their skills, express their thoughts and use their imagination. Most participants expressed joy and
satisfaction in being involved in a creative process. They also referred to these activities as an opportunity
to forget their health problems and to become absorbed in their work. The activities encouraged a positive
outlook on life and provided an opportunity to engage in social interaction. Fisher and Specht found it
intriguing that the participants put more emphasis on the creative process than on the product itself, and
on using the same “dynamics, motivation, attitude and imagination” in other areas of their lives. It
appears that these dynamics allowed them to “express a sense of self and manage everyday life” (p. 1)
Fisher and Specht link their findings on creativity and aging with the definition of creativity by Lubart
and Sternberg (1998, pp. 25-26): “Creative performance involves the intellectual processes of defining
and redefining problems, choosing appropriate problem-solving strategies, and using insight processes to
solve problems”.

With this study the definition of creativity and aging can be expanded to include the ability to define
the problem, choose appropriate strategies and use insight to meet challenges in life. As one of their
participants put it: “I’m not done with life. In some ways, I think I’m just beginning to see what it’s all
about” (p. 13). Fisher and Specht concluded that life itself is a creative expression. Their findings
represent the core of how many old people approach their lives. Anecdotal reports and personal
experience working with elderly people serves to support this observation.

Smith and Van Der Meer in Creativity in Old Age (1997) provide an example of an empirical study
on creativity in old age. Although not put forward in a clear way, the underlying assumption is that not all
people are creative. The aim was to explore how old people handle health crises, aging and death. Smith
and Van Der Meer concluded that creative people face aging, death and illness in a less negative way than
non-creative people.

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The group under study included subjects between 67 and 86 years old. The control group had people
between 70 and 72 years old. The control group was tested over a period of one year while the group
under study was tested all in one day. Three instruments were used, all following a pre-planned, time
sensitive method. The instruments included the Meta-Contrast Technique (MCT) that measures anxiety
and defence against anxiety by using various themes of visual images, the Identification Test (IT) that
examines the subjects’ own projections of meaning on vague images, and the Creative Functioning Test
(CFT) that presents ordinary and non-threatening images. This study is an example of some of the
difficulties researchers face in carrying out projects that involve an older population. Several flaws were
evident in their research design: a. The two groups were not comparable in age. The age span from 67 to
86 is too large. b. The testing period was not comparable. The group under study was tested in one day
while the control group was tested over one year. c. The time-sensitive testing approach is not appropriate
for this age group. The literature is rich in findings (see below) on physiological and cognitive slowing
down with aging. Does that mean the older person who needs more time to process information is less
creative? d. The interview questions concentrated on highly stressful issues such as fear of illness and
death that may have primed the responses of the participants and may have played a factor in their
responses. Older people, encountering stressful topics where they were required to respond within pre
determined time limits, may find they have no opportunity to reflect, to come up with spontaneous
answers, or time to think creatively.

The approach to neuropsychological investigation described by Una Holden (1995) is much more
applicable in situations involving older subjects. Holden recommends: setting a relaxed atmosphere;
making sure the tasks are suited to the participant, the situation is friendly and encouraging; giving the
subjects the opportunity to succeed as much as possible; keeping the interview short and presenting
questions a little at a time — an approach that is better than too much at once — and introducing interests,
social skills, experience, and personal standards to be discussed at the beginning and through the
interview (p. 35). For her part, Amabile (1990) reports that external evaluative processes of one’s creative
abilities are harmful to the creative process itself. Of the two studies, Fisher and Specht’s appear to have
taken the more appropriate approach to examining how older people perceive creativity and how they use
it to face life experiences.

To continue the evolution of definitions of creativity, I have moved from creativity of eminent
individuals to everyday creativity as a trait of ordinary people, to creativity as an expression of life, with a
focus on creativity in old age. The next step is to examine creativity in old people with dementia. There
are very few empirical studies on this topic and the ones found are limited mainly to single abilities such
as singing, dancing or painting. The topic needs study from an interdisciplinary perspective delving into
the richness and complexity of what it means to be old and creative while being physically and
cognitively impaired.

The next qualitative study is unique since its author’s philosophical approach to creativity and
dementia fits within the topic of this study and is one of the few studies available on this topic in the
literature. Looking back from loss: Views of the self in Alzheimer’s disease by Anne Davis Basting
(2003) is based on three narratives or autobiographies as they were written by persons with dementia.
Davis Basting does not present these autobiographies for their literary quality, but rather to point out the
preservation “of selfhood in the midst of its perceived loss” (p. 89). She supports her work with Tom
Kitwood’s (1997) approach to personhood, which treats people with dementia as “whole beings”
struggling to cope with their disease. Davis Basting finds the three authors maintaining their social
identity (how others perceive us) intact and comments on the amazing self-awareness they have of the
deterioration of their personal identity (our sense of who we are). Davis Basting’s authors are aware of
their problems, they are coping with the disease as well as they can and finding ways to express
themselves creatively through writing. All authors would like to leave a legacy behind that may be useful
one day for others; this shows the ability to plan for the future. Davis Basting’s authors demonstrate
qualities that are included in definitions of creativity: the ability to identify a problem and apply a solution
to it, the ability to have the motivation to produce a useful product, the ability to have a vision and plan
for the future with the help and recognition of the community, family and friends and of Davis Basting

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herself, who as a leader in the field sees their writings as very valuable. TimeSlips, a program she
developed, is an innovative method of group story-telling by seniors with dementia. In the training
materials for the program, she writes:

Creativity is: adding something new to the world, how we know ourselves, how we grow
ourselves, how we connect to others ... through creative expression, we share ourselves and
connect to others. Creative expression is importantfor everyone, but it is even more importantfor
those with dementia for whom other avenues ofself-expression can be severely limited” (p. 8)

Davis Basting’s definition covers just about all the key elements discussed so far on creativity by
other scholars in the field of creativity research. However, for a definition that embraces dementia more
closely, I suggest adding a few more key elements to her definition: Creativity in the context of dementia
adds something new and different to the world whether through intrinsic self-exploration as an individual,
or sharing creative expression through interaction with others. The creative process is demonstrated
through creative thinking and imagination in everyday living and may or may not result in a product.
Through creativity, people with dementia could (can) enjoy meaningful, satisfying and (at times)
unpredictable experiences that may last for only a very short while or as long as memory allows it.

Why Creativity and Creative Expression Are Important

Based on this literature review ,inquiry in the field of creativity and dementia provides some evidence
that support what anecdotal observations have claimed for a long time — that when given meaningful
opportunities and encouragement, seniors can express themselves creatively until they reach the advanced
stages of the disease, in spite of their physical and cognitive limitations. Providing an outlet for creative
expression gives seniors with dementia an opportunity to be heard and to be valued. Creative expression
is a general term that includes visual and performing arts activities, verbal and written expression,
interpersonal communication and forms of self-actualization. We know from experience that through
creative expression activities we can communicate with seniors with dementia. We listen, respond and
interact with them through these activities. In this way we can learn about the seniors’ past life, which
may include their ethnic background, occupation, hobbies and family. We can learn to respect their world,
treat them with dignity, and start to have a positive influence on their quality of life.

How Seniors with Dementia Experience Everyday Creativity within the
Aging Process

Opportunities for engaging in creative expression are numerous and they vary from visual and
performing arts such as painting, listening and making music, dancing, singing and reminiscing to
activities in daily life such as cooking, dressing, planning and gardening. The main question that arises is
which opportunities are appropriate when we interact with seniors with dementia and what are the
environmental circumstances that affect them.

The explore the main question concerning changes associated with aging and dementia I turned to a
theoretical model in gerontology that combined the biological, psychological and social aspects of aging.
This theoretical model helped “explain why we do what we do and may alert us to some of the currently
unforeseen implications of unselfconscious assumptions about age. It may also provide conceptual tools
to interpret complex events and critically evaluate the current state of aging.” (Biggs, Lowenstein &
Hendricks, 2003). Age-related changes in physiological, cognitive and social aspects take place in several
domains. The interrelationship of the changes is supported by numerous researchers (Davis Basting 2003,
Agronin, 2004; Dannifer & Perlinutter, 1990; Schneider & Pichora-Fuller, 2000; Staudinger, 1999;
Stuart-Hamilton, 2000; Teague, McGhee, Rosenthal and Kearns, 1997). For example, Staudinger states
that “to understand human life, we need to study thinking, wanting, feeling, and doing conjointly ... In
fact, it may be exactly this combination of an elementaristic and holistic approach that makes room for
new insights into psychological functioning” (p. 352). Biological, psychological and social aspects of

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aging “do not occur independently of each other ... changes in the physical state of the body (and the
brain in particular) can have profound effects upon psychological functioning”, as Stuart-Hamilton (2000,
p.43) states in his publication, The Psychology ofAgeing. Stuart-Hamilton is a professor of psychology at
the University College in Worcester in the UK.

Staudinger and Davis Basting focus on changes that take place in each domain that affects creative
expression abilities and opportunities for engaging in creative expression in the older population from
normal aging through to aging persons with dementia. This population of older people, from the age of 65
to 100 years and over, is diverse in age, health and abilities. Growing older and experiencing
physiological decline does not necessarily result in diseases and/or in cognitive and physical impairment
that stem from a medical condition. It is more appropriate to talk in terms of mild decline in normal aging
rather than in terms of significant impairments that can be diagnosed as cognitive disorder (Agronin,
2004, Osterweil, Brummel-Smith, Beck, 2001). Researchers like Schneider and Piehora-Fuller (2000) and
Lindenberger and Baltes (1994) indicate that some deterioration in memory functioning such as
inattention, processing speed and accuracy may occur, but the overall intellectual function is intact.

To support a biopsychosocial model, we draw information from existing literature relevant to aging
and dementia with a specific focus on its relevance to creative expression activities. Case studies from the
literature will be drawn for support wherever possible. However, due to the lack of appropriate empirical
studies that make specific connection between practical manifestations of creative expression, dementia
and the biopsychosocial model, I will turn to the closest qualitative studies of researchers like Policastro
and Gardner (1999). Both Policastro and Gardner came to the conclusion that psychometric standardized
testing failed to fit everybody’s abilities, especially those of exceptional creative individuals. Policastro
and Gardner also struggle with the difficulty of how to approach creativity studies. Although this
explanation could belong at the beginning of this paper, it has its special place in this section. Because of
its relevance to this question, I will rely mainly on their work. Policatsto and Gardner developed a new
cumulative approach to creativity study, which was based on a progression of steps ranging from
phenomeno logy, the study of known creative individuals, to a search for emerging patterns in comparison
with other similar individuals. They accumulated a large database that allowed more patterns to emerge
and contributed to generalization and explanation for deviations.

Age related changes do not have to be associated with cognitive and physiological impairments.
There are always older individuals who enjoy good health until very late in life, who use everyday
creativity to adapt to the changes in their lives. A good example of creative adaptation is the well-known
choreographer, Twyla Tharp, (2003) age 62, who appropriately named her autobiography, The Creative
Habit: Learn it and Use itfor L/è. Twyla Tharp represents what is known in the gerontology literature as
‘successful aging’ (Fisher & Specht, 1999). Gene Cohen’s (2000) book, The Creative Age, is full of
examples of people he met during his 30 years’ working with elderly patients as well as a rich selection of
stories about well-known seniors from Mother Teresa, who received a Nobel Peace Prize at age 87, to
Jacques Cousteau, the French oceanographer, who popularized the study of the ocean environment and
worked until his death at age 87. Stories about such exceptional individuals are the data usually collected
in qualitative research that may also promote understanding of everyday creativity (Policastro & Gardner,
1999).

Although not tested in any systematic way, personal anecdotal stories, which are similar to Cohen’s
qualitative descriptions, can help delineate many of the questions that propelled this research topic on
creativity and dementia. Ignoring this practical experience will only mask a world that exists in dementia
care and may stifle reality for thousands of persons who could benefit from being acknowledged while
their cases only later contribute towards more rigorous scientific research. The anecdotal examples help to
identify a problem, and build towards a theory that needs to be tested. However, I realize they may simply
present fascinating snapshots, moments in time rather than the whole picture. Their use is not intended to
provide empirical evidence except as individual cases, which limits their generalization.

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Although most of us experience aging, it is still shrouded in scientific mystery. Most people refer to
aging from a biological perspective. Dr. Gene Cohen, Professor of Health Care Sciences and of
Psychiatry at the George Washington University, explains the process of aging as “a simple case of wear
and tear ... an internal erosion that weakens cells, organs, and organ systems from head to toe, limiting
their functioning” (p. 43). Stuart-Hamilton (2000) lists several theories of aging from “programmed
theory of ageing (i.e. that cell death is in effect planned)” to an “autoimmune theory of ageing ... that
ageing may be attributable to faults in the body’s immune system” (p. 24).

Defining aging is almost as difficult as defining creativity. Aging is a word that describes a process
that takes place in several domains. As in creativity, aging does not have “one single reliable measure”
(Stuart-Hamilton, 2000). For most people aging is defined by its social construct, which is marked by
retirement and the so-called typical behavior that a specific society expects of its aging people (Baltes and
Reese, 1984).

“Dementia refers to the development of multiple cognitive or intellectual deficits that involve
memory impairment of new or previously learned information and one or more of the following
disturbances: 1. Aphasia, or language disturbances. 2. Apraxia, or impairment in carrying out skilled
motor activities despite intact motor function. 3. Agnosia, or deficits in recognizing familiar persons or
objects despite intact sensory function. 4. Executive dysfunction, or impairment in planning, initiating,
organizing, and abstract reasoning” (Agronin, 2004, p. 2- 3; The Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (DSM IV TR).

Dementia is divided into seven subtypes that include over 72 brain diseases. The seven subtypes are:
1. Alzheimer’s type, 2. Vascular dementia, 3. Viral dementia, head trauma, Parkinson’s disease,
Huntington disease, Pick disease, Creutzfeldt-Jacob disease, 4. Due to a general medical condition, 5. Due
to substance abuse, 6. Due to multiple etiologies, 7. Unspecified dementia. Of the dementia diseases,
Alzheimer’s is the most common type, accounting for 50% to 70% of all dementias, while vascular
dementia accounts for more than 20%. Causes for Alzheimer’s disease are still being investigated. Recent
research points towards two contributing factors to the disease: “extra neuronal deposition of I—amyloid
and intraneuronal destabilizing of tau protein” causing plaque formation, which destroys neurons in the
brain and induces inflammation that causes further damage to the cells. Damage to the areas of the
entorhinal cortex and the hippocampus causes impairments to short-term memory in early symptoms of
the disease. (Agronin, 2004, p. 72). Agronin, Director of Mental Health Services, at Miami Jewish Home
and Hospital for the Aged, reports that some people may have more than one type of dementia. It is
important to diagnose the type of dementia, since it may be of a reversible type. Risks factors are
associated with “advancing age, menopause, brain injury, lower education, and the presence of the
apolipoprotein E4 (APOE4) genetic allele” (p. 72).

Physiological Changes Associated with Aging and Dementia

Physiological age-related changes relevant to creative expression abilities take place in the nervous,
sensory, cardiovascular, respiratory, skeletal, and muscular systems. All systems are interconnected and
when one system fails, it affects the other systems as well (Teague,, McGhee, Rosenthal and Kearns,
1997).

The nervous system and the sensory processes in normal aging play a role in regulating and
integrating information and in internal communication (Deck & Asmundson, 1998). The nervous system
is divided into the central (CNS) and peripheral (PNS) nervous systems. “The CNS consists of the brain
and the spinal cord, while the PNS consists of the neurons connecting the CNS to the rest of the body”
(Stuart-Hamilton, 2000, p.3’7) An age-related decrease in blood flow to the braift and to the nervous
system may contribute to the following changes: a) “Tremors, slowed reaction time, short-term memory
deficits, personality changes and depression” (Dudek, 1993, P. 326). “Reaction times become slower and
the velocity of nerve conduction slows by 10 to 15% by age 70” (Spirduso, 1975, p. 435), b) Slowing in
speed of information transmission, c) Reduced functioning of autonomic nervous system, d) Sleep-related

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changes, e) Aging eye - “The lens undergoes a yellowing and, in some cases, lens opacity occurs
(cataracts). The iris does not open as much as a younger person (Heath, 1993). Loss in visual acuity,
“Ability to see in low light”, “distinguish color intensities and depth perception” (Dudek, 1993, P. 326), f)
Loss of hearing - “Mechanical and neurological changes” impact the auditory system and lead to a
“decrease in sound discrimination” (Heath, 1993), g) Loss of balance, h) Olfaction changes - lead to a
decreased ability to smell, i) Decrease in taste sensation (Rawson, 2003).

To express ourselves creatively we rely on the senses that allow us to see, hear, taste, smell and touch.
Through these senses we receive information from the world around us; we then process the information
in the brain in combination with our accumulated knowledge, based on memory and life experience
(Coren, Ward & Enns, 1999). If our nervous system is impaired, so is our communication with the world
outside. It will take longer to process information and longer to react to it. Missed information may cause
confusion and decreased self-esteem; it may contribute toself-imposed isolation, loneliness, mood
swings, anxiety, anger and aggravation (Una Holden, 1995). It is important to note that creative
expression abilities may continue to function internally in spite of physical limitations. However, those
abilities need the opportunity to be expressed, recognized, validated and appreciated. If the opportunities
are not provided, those physical limitations may become mental problems, which in turn may result in
further physical deterioration. This cycle needs to be broken in order to provide opportunities for healing
of the mind and spirit and for creativity to continue to survive (Tiki, 2000).Davis Basting’s definition of
creativity underscores how important creative expression can be for seniors with dementia if they are to
continue to maintain cognitive and social contact with others.

Age-related visual impairment can be most noticeable when dedicated artists experience changes in
the style of their artwork late in their career. The normal aging population, who may not be engaged in the
visual arts, may never notice some changes in their visual abilities. Following the rationale of Policastro
and Gardner (1999) and their cumulative approach to research in creativity, we may learn about the
exceptional abilities of well known artists and through comparative studies reach an understanding of
what is normative and what is not and apply it to people with everyday creativity. There is a long
standing debate in the art world as to what constitutes a change in artistic style — is it due to an artistic
decision, made from free choice or is the change due to physical, cognitive and perceptual limitations?
The debate over de Kooning’s artwork in later life is a good example. After being diagnosed with
Alzheimer’s, he continued to produce a large body of work that was exhibited and analyzed with some of
these questions in mind. Perhaps, such artists were aware of their limitations and found satisfactory ways
of adapting to them. We have some clarification that artists suffer from visual impairment in Marmor and
Ravin’s book, The Eye of the Artist (1997). In it, Monet is quoted as commenting on his painting of water
lilies:

IfI regained my sense of color in the large canvases I’ve just shown you, it is because I
have adapted my working methods to my eyesight and because most of the time I have
laid the color down haphazardly, on the one hand trusting solely to the labels on my
tubes ofpaint and, on the other hand, to force of habit, to the way in which I have always
laid out my materials on my palette. (p. 248)

Monet suffered from cataracts, where the “lens becomes so sufficiently opaque that vision is
compromised” (page 2 1-22). Cataracts also contribute to a “progressively more yellow world” (Marmor
& Ravin, 1997, p. 21-22) and, as a result, may alter the colors of the art produced. As Marmor & Ravin
state, “What cannot be seen cannot be matched and therefore cannot be made” (p. 30). Other well-known
artists may have suffered from visual impairment, including El Greco from astigmatism, when “images
are focused more strongly in one direction than another” (p. 16), Edgar Degas from blindness, and
Georgia O’Keeffe from blurred vision. O’Keefe suffered from macular “degeneration of the central part of
the retina” which can cause “images (to become) hazy, fragmented and distorted” (p. 216). Regardless of
the other types of impairment, presbyopia, an optical age-related problem that affects nearly everyone,
can change how we see objects and how we draw them. In presbyopia, the “lens becomes less elastic, and,
as a result, we lose the ability to focus over the whole range from infinity to near” (Marmor & Ravin, p.

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16-17). Another age-related impairment is the diminishing ability to pay attention to fine details and a
“decline in contrast sensitivity” (p. 30). As the pupil decreases in size, so does the amount of light
absorbed by the eye, decreasing the ability to distinguish detailed images against their background (p. 29).
Older people may experience higher threshold sensitivities to “light and movement and color
discrimination” (Coren, Ward & Enns, 1999).

Understanding aged-related visual impairment has significant implications for how art topics, art
supplies, educational materials and studio arrangements should be considered when presented to older
people. More specifically, visual information may need to be less detailed, high in contrast, appropriately
task lighted, located at eye level, whether for a sitting or standing person, and presented at an appropriate
distance from the eye. Other solutions may be as simple as providing a pair of glasses, or medical
intervention.

Adults over the age of 80 run the risk of developing dementia-related impairments in addition to the
normal age-relatcd decrease in abilities. A person with dementia may have the mechanism of seeing intact
but suffer impairment to the perception system, which reduces the person’s ability to recognize the objects
they see. To make matters worse, if parts of the diseased brain affect memory, they also affect their ability
to recognize objects from memory. This explains why some seniors with dementia cannot identify objects
in front of them and have difficulty drawing them, or — more amazingly, they are able to draw the objects
but fail to recognize what they have just drawn. This phenomena is described in Margaret Livingstone’s
book, Vision and Art (2002). Livingstone is a Professor of Neurobiology at Harvard Medical School. She
quotes a stroke patient saying to his doctor: “I can see the eyes, nose, and mouth quite clearly, but they
just don’t add up ...“ (p. 64).

Stroke patients may exhibit similar symptoms to dementia, but unlike people with dementia, their
condition may improve as time passes. Strokes also account for vascular dementia, the second most
common form of dementia (Agronin, 2004). In addition to object and color identification, people with
dementia may experience difficulties in depth perception. Our eyes allow us to see in two dimensions but
the brain must convert the information into three dimensions. The conversion is automatic and is
“happening well before conscious perception” (p. 101). Any disruption to the visual system in the brain
diminishes the ability of a person with dementia to recognize spatial depth.

In my work with seniors, I have seen seniors who did not select the colors of the objects they were
looking at. For instance, one senior painted a tree all in one color, green, although a large variety of colors
were available. Was it a deliberate decision not to bother changing the pens to reproduce the correct color
of the object? Was it an artistic choice? Was it the loss of color recognition that caused this behaviour?
Perhaps it was a mental condition or the age-related decrease in attention to details.

In spite of reduced abilities, creativity finds multiple ways through which it can be expressed.
Although the tree was drawn completely in green, the senior explained its shape and location on the
drawing paper by stating that the apples were still green and so was the foliage that covered everything
almost to the ground. This verbal explanation, which went along with the visual image, made the whole
session very special and meaningful to the artist/senior with dementia and to the other participants who
were amused by it.

In another situation a senior with moderate dementia, who had been a well-known artist in the past,
could paint richly colored pictures in an abstract style, but could not reproduce the objects displayed in
front of her. Still, her need to stay engaged with the arts was fulfilled. Was she aware of her impairment?
Did she consciously adjust her style of painting? Did she really see in her mind what she was drawing?
Although she had lost her ability to recognize familiar objects and project them on to paper as she had in
the past, she still maintained her technical ability to mix paints, select the right brush for the right task,
hold the brush and apply the color in the most interesting and tasteful way. Although her artistic
expression was affected by the dementia, her language abilities stayed almost intact. In searching for an
explanation, Gardner (1982) is the only one I found who makes the connection between artistic abilities

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and language and how they are manifested. Gardner reports the claims of other researchers who had
similar experiences, although there is little evidence of more research in this direction. In his chapter on
the breakdown of the mind, Gardner describes this interesting phenomena:

• .painters with right-hemisphere disease — whose language has retained unaffected —
often exhibit bizarre patterns in their paintings: they may neglect the left side of the
canvas, they may distort the external forms of objects, or they may portray emotionally
bizarre or even repulsive subject matter. Apparently painting and linguistic capabilities
can exist independently of one another. (p. 274)

Although the changes to the artwork may result in bizarre images, the main idea, suggested in the new
definition of creativity and dementia I propose, is to continue to encourage creative expression as long as
possible. According to Davis Basting, these bizarre images may be the only avenue left for self-
expression and through it for connections to others.

Hearing impairment affects 15% of all people over the age of 65, and about 75% of people over the
age of 70 (Coren, Ward & Enns, 1999). Hearing loss may prevent a person from understanding speech (p.
494). A decrease in verbal communication may have a profound impact on the elderly. It may increase
their feeling of isolation, and can even “result in psychiatric disturbances ... delusional thinking” (Teague
et al., 1997). This observation is also supported by Weinstein (2003): “Untreated, hearing loss has
significant social, cognitive, and emotional consequences” (p. 15). In hearing less the elderly are less
exposed to external stimuli that could activate their memory and prompt the internal creative process. For
example, Aldridge (1993), a professor of clinical research in the Faculty of Medicine at the University of
Witten Herdecke in Germany, found that music therapy programs for seniors with dementia activates
their memories.

Hearing loss should not affect creative abilities that are not sound-based. “Fortunately, a variety of
interventions and technologies are available to help older people overcome these communicative and
psychological effects” (p. 15). In addition to hearing loss, the elderly run the risk of increased imbalance
due to age-related changes to the inner ear. This change may contribute to “dizziness, instability, and
falls” (p.15).

Internal creative processes benefit from external stimuli, which in turn give birth to new ideas,
renewed energy to explore and stay engaged with the world around us. In the case of hearing and creative
expression abilities, we refer most often to music, speech, and the sounds we hear from the world around
us, whether it is a barking dog or traffic noise. The question arises: What may the impact be for a person
with dementia whose hearing impairment is not detected, or for whom hearing aids are not used all the
time? The impact of hearing loss on creative expression abilities or the opportunities to be engaged in
them depends very much on the person with dementia. Some people are affected less than others and the
sounds of music may be more important to one person and not so important to another. The literature is
rich in studies of people with dementia and their positive response to music, whether actively
participating in music activity or becoming less agitated (Aldridge, 1994; Brown, Gotell, & Ekman, 2001;
Bruscia, 1991; Carruth, 1997; Chavin, 2002; Gotell, Brown, & Ekman, 2002; Johnson, Cotman, Tasaki,
& Shaw, 1998; Kneafsey, 1997; Mathews, Clair, & Kosloski, 2000; Olderog-Millard & Smith, 1989;
Sambandham & Schirm, 1995).

Amy Horowitz, M.S.W, in a peer reviewed article Depression and vision and hearing impairments in
later life (2003, p. 36) found that “hearing-impaired older adults are approximately twice as likely as their
nonimpaired counterparts to have clinically significant depressive symptoms” and that these symptoms of
“sadness, loss of interest and/or pleasure, feelings of worthlessness or inappropriate guilt, loss of appetite,
sleep disturbances, psychomotor agitation or retardation, fatigue or loss of energy, trouble thinking or
concentrating, and thoughts of death. Hearing impairment may limit the selection of possible expression
activities but adjustments can be made so that hearing impaired seniors with dementia can enjoy related
creative activities. In addition to behavioural modification, listening to familiar music is another form of

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auditory stimulation that is beneficial in autobiographical memory recall (Foster & Valentine, 2001).
Recalled memory may provide opportunities for story telling, reminiscing and socializing — to be heard,
to express and feel alive.

Taste and smell are quite noticeable in age-related changes. “Odor sensitivity is greatly diminished,
although the reduction is not uniform across all stimuli or individuals” (Cain & Stevens, 1989, in Coren,
Ward & Enns, 1999. p. 494) In a test done by Schiffiman and Pasternak (1979), it was noted that elderly
subjects could best distinguish fruity odors compared with other types of odors. In a test done by Stevens,
Cain, and Demarque (1990), it was found that elderly people had a shorter span of odor memory
compared with younger adults. In addition to smell reduction, the ability to taste is reduced as well.
Schiffman (1977) reports that younger subjects are twice as accurate as the elderly in recognizing
common foods in pureed form. Also, while seniors show a reduced sensitivity to touch, their sensitivity to
pain remains (Coren et al., 1999). Although taste, smell and touch impairments are not considered as
profound as impairments to seeing and hearing, they yet rob the older adults from experiencing fuily the
world around them in comparison with a younger population. It is important to note that older people are
at risk when taste, smell and touch are impaired, since they may be exposed to toxic substances, overlook
important ingredients in their diet (Coren et al., 1999) or touch dangerous surfaces, which are too hot,
cold or sharp.

The literature revealed that impairments to taste, smell and touch reduce the sensitivity to external
stimuli that might otherwise provide access to recall memories. As a consequence, a facilitator for
creative expression activities needs to take into consideration that older adults, especially seniors with
dementia, may need enhanced flavors, especially in salt and sugar (Coren, Ward & Enns, 1999), while
engaged in creative cooking and baking. A facilitator needs to be aware of food products that may not
evoke any reaction since they may appear tasteless to the senior. Exposing seniors to smells may remain
unnoticed, unless the facilitator focuses on fruity smells. In a study by Larsson (2000) it was found that
women perform better in olfactory tasks than do men. In addition, Pause, Ferstl, and Fehm-Wolfsdorf
(1998) found that individuals with a high emotional level would excel in olfactory ability. These findings
are important in understanding gender differences, personality traits and the need to accommodate
creative expression activities that are meaningful by tapping into the strongest abilities still left to work
with. In selecting objects to be touched by seniors, the facilitator may need to be aware that feather-like
touches may not be noticeable and that extreme temperature and sharpness would need to be monitored
for safety reasons.

The cardiovascular system is based on the heart and blood vessels. Cardiovascular disease is common
in old age and it increases as age progresses. At age 70, about 10% of the population have cardiovascular
diseases and at age 85, the percentage rises to around 50% (Fahiander, Wahlin, Fastbom, Grut, Forsell
and Hill., 2000). In addition to fatigue and hypertension, which is not an inevitable consequence of aging
(Schulman & Gerstenblith, 1989), a study by Fahlander et al. (2000) found a relationship between signs
of cardiovascular deficiency and cognitive performance in normal old age, which is “seen most clearly”
(p. 259) in vascular dementia, especially in episodic memory and visual and spatial skills. Episodic
memory is defined as “specific episodes in one’s life” (Reisberg, 2001, p. A4). We need to take into
account the risk factors in increased physical activity and tailor the activities to the elderly, especially for
cardiac patients (Schulman & Gerstenblith, 1989). The intensity level of physical activity needs to be
taken into consideration, in consultation with the seniors’ healthcare providers. Although these activities
should be taken with care, “regular physical activity and exercise can also assist older adults in enhancing
their quality of life, improving their capacity for work and recreation, and altering their rate of decline in
functional status” (Frontera & Evans, 1986). However, dementia does produce a decline over time in the
seniors’ functional status and with it the opportunities to engage in various movement activities, such as
dancing. If a senior with dementia also suffers from congestive heart failure, that condition may restrict
the level of activity recommended for that person.

Due to the direct relationship between cardiovascular deficiency and cognitive performance, high-risk
individuals may need to be identified prior to an activity to make sure the activity is appropriate for their

49



energy level and cognitive ability. Creative expression activities may include physical work such as
dancing, clapping, using drums, acting, painting large images that may require standing, gardening and
planting and so on.

The respiratory system “provides oxygen to all cells in the body as well as serving to excrete carbon
dioxide, a waste product of metabolism” (Deck, 1998, p. 63). Any disturbances to the oxygen supply may
cause heart problems and pneumonia, which in turn reduce the level of activity of the elderly. Care should
be given at any age and at any place to protect against environmental toxins. Elderly people run the risk of
emphysema and pneumonia. They are also very vulnerable to air pollutants (Spence, 1989). Respiratory
problems may restrict the senior from taking part in some of the creative expression activities. Art
products should be screened for their toxicity and for their use; they may pose problems if taken into the
mouth. Creative abilities are not necessarily affected unless the senior is too frail to take part in any
activity.

The skeletal system supports “all the soft tissues of the body, it protects internal organs, it stores vital
minerals, and it plays an integral role in the formation of blood cells.” (Deck, 1998, p. 73). Changes to
this system have a “profound effect on the life style of the elderly” (p. 73). Osteoporosis is a “skeletal
disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with
consequent increase in bone fragility and susceptibility to fracture”, which are common in the “hip, spine
and wrist” (Kendler, 1996, p. 262). Symptoms of impairment to the skeletal system and osteoporosis
contribute to stiffjoints, pain, restricted movements, frailty and deformity. Other impairments are due to
the deterioration of cartilage, changes to the spine, and rheumatoid arthritis. Although impairments to the
skeletal system are not connected to cognitive abilities or creative abilities, they have the potential to
restrict mobility and cause significant pain that would prevent a person from fully enjoying creative
expression activities.

A combination of carefully planned programs and appropriate therapeutic environments will
contribute to a safer environment. Some thought is needed to address the kind of art supplies, location of
the art supplies in relation to the artist, drawing position, whether sitting or standing. Many frail elderly
people have difficulty holding brushes, standing up at their easels, bending, raising their anns and lifting.
Elderly people fall more often and are more likely to break their fragile bones (Newton, 2003). On many
occasions, I adjusted easels, improvised work surfaces, suggested painting with fingers instead of holding
a brush, and ripping paper instead of using scissors to avoid putting pressure on finger joints.

This system is closely associated with the skeletal system and is important to the “functional ability
and lifestyle of the elderly individual” (Deck, 1998, p. 79; Spence, 1989; Heath, 1993). Physical activity
is necessary for successful aging and can bring “physiological and psychological benefits” (p. 79). Aging
contributes to loss of muscle mass; 20% of muscle strength is lost by the age of 65; this loss can also be
attributed to “disuse” or inactivity and which contributes to significant limitations in flexibility (Heath,
1993). Deck (1998) comments that “boredom, inactivity, and expectations of illness contribute
substantially to the decline of physical capacity in elderly individuals” (p. 79). Impairments to the
muscular system may increase the resistance of seniors to participate in creative expression activity with
more physical involvement. Working with seniors with dementia, the author noticed how pain associated
with muscular and skeletal impairments discourages older people from wanting to move. Combined with
symptoms of dementia, physical movement would keep these seniors from participating in creative
expression activities.

Cognitive Changes Associated with Aging and Dementia

To understand “how the brain works, what is involved in various mental processes, and how the brain
makes these achievements and processes possible” (Reisberg, 2001, p. 2), we need to combine knowledge
from cognitive psychology and cognitive neuroscience. However, our focus here is on intellectual
functioning and how it manifests itself in cognitive functioning or, more specifically, in creative
expression abilities. Neuroscience will be mentioned briefly only to clarify how it relates to dementia and

50



the parts of the brain responsible for impaired behaviour in an attempt to identifS’ why certain behaviour
and abilities are the way they are.

Cognitive neuroscience is associated with the medical model of care based on illness. It is criticized
by those who wish to dissociate their work from it and focus on the person inside the disease (Kitwood,
1992). But no matter what approach is adopted in providing care, the process needs to be inclusive,
comprehensive and realistic to respond to seniors with dementia and their many needs.

To address the issue of cognition and creative expression abilities we need to delve into the strong
relationship that exists between the cognitive system (intellectual functioning) and the perceptual system:
“the conscious experience of objects and object relationships” (Coren, Ward & Enns, 1999, p. 571). Since
creative expression touches on both systems of cognitive functions and perception, we will concentrate on
an in-depth review chapter by Schneider and Pichora-Fuller (2000). In the literature on cognition and
perception in aging, this study is remarkable for its depth, breadth and comprehensiveness. It supports our
need to tie together several fields in understanding how elderly people react to external stimuli, and then
express themselves creatively. In explaining the processes that contribute to learning, knowing and
expressing, Schneider and Pichora—Fuller (2000) write:

The coexistence of these two kinds ofage-related changes raises important questions
about the relationship between early and later stages in information processing, that is,
between perceptual and cognitive processes, which have now been shown to have “a
powerful inter-systemic connection” (Baltes & Lindenberger, 1997, p. 16). In this
chapter, we argue that perception and cognition must be considered as parts ofan
integrated system fwe are to understand how they are affected by age. (p. 156)

As reviewed by Schneider and Pichora-Fuller, Lindenberger and Baltes (1994) found a strong
correlation between changes in hearing and the “speed of processing in the older adult” (p. 162).
Schneider and Pichora-Fuller concluded that “anatomical and physiological changes would have multiple
consequences for perceptual function” (p. 173) The main concept of their theory as it applies to the link
between cognition and perception is explained very clearly in the following:

“... age leads to sensory organ deterioration that affects the kind and quality of
information delivered by the perceptual system to the cognitive system. Ultimately, a
reduction in both the quality and quantity of input would result in cognitive deterioration
due to atrophy.

“
(p. 203)

In their conclusion, Schneider and Pichora-Fuller recognize the importance of testing the perceptual
status when doing cognitive research with the elderly. By doing so, the researcher can define the
perceptual loss and its effects on cognitive abilities. Schneider and Pichora-Fuller and other researchers
found evidence of degeneration in normal aging. It affected auditory functions: in detecting signals in
noise; visual acuity: the ability of the eye to resolve details (Coren et al., 1999) and contrast sensitivity:
the difference between light and dark (Coren et al., 1999) occurring in normal aging.

The following description aims to connect the location of dementia in the brain, as it affects brain
functions, with cognitive and perceptual impairments that determine the level of creative expression
abilities.

The information on neurological and cognitive impairment is based in large part on a recent book,
Dementia: Practical Guides in Psychiatry (2004) by Dr. Marc Agronin. Agronin brings together issues
that pertain to dementia disorders and dementia care. He successfully combines various approaches to
dementia care, including the Kitwood approach, which emphasizes the person inside the medical
condition. He responds to the mounting criticism from gerontologists and social workers regarding the
way seniors with dementia were treated and still are to a large degree. Recent neurological research

51



findings from Ropper and Adams (2001) and Nutt & Weizman (2001) are described in Agronin’s
publication:

1. Damage to the Frontal Lobe can result in: impaired executive functioning, impaired immediate
memory, slowed cognitive processing, slowed activity, poor concentration and attention, impairments in
judgment, insight and behavioral control, personality changes, apathy, preservation of words, sounds or
behaviors, disinhibited reflexes, impulsivity, aphasia, language disturbances, and impaired task-follow-
through (Agronin, 2004). Impaired attention translates into decreased alertness, being distracted, not
being able to separate relevant from irrelevant information, not being able to handle multiple sources of
information at the same time (Mcdowd & Shaw, 2000). Anatomical changes in the frontal lobe due to
dementia can impair the processing of information and the ability to react to it. Interestingly, the same
damage may reduce barriers to behaviour control that result in encouraging artistic expression.

Dr. Bruce Miller, of the Department of Neurology and Psychiatry, University of California at San
Francisco School of Medicine, discovered with his colleagues, Cummings, Mishkin, Boone, Prince and
Ponton (1998) and Ponton, Benson, Cummings and Mean (1996), that patients with frontotemporal
dementia (FTD) “developed new artistic skills” and “became accomplished painters after the appearance
of frontotemporal dementia. Three patients in a study group improved their skills during the onset of the
disease and through the middle stages of it. One patient in particular, with no interest in the visual arts in
the past, continued to paint for about 10 years from the time of the diagnosis with increased “precision
and detail”. He used bright colours and painted his first paintings fast, slowing later and paying more
attention to detail. As his disease progressed he started to draw “bizarre doll-like figures.” These figures
became an important key in examining artwork done by seniors with dementia. Gardner (1982) also
brings up a similar description of artwork done by brain-damaged patients.

2. Damage to the Occipital Lobe may cause: visual agnosias, deficits in recognizing people and
objects, reading impairments, cuts in the visual field, illusions and hallucinations of shapes and colors,
visual inattention (Agronin, 2004). Damage to the occipital lobe reduces the ability to process incoming
information and, therefore, responses to the external stimuli may not always be appropriate. However,
illusions and hallucinations may become opportunities for creative expression, when the person with
dementia cooperates and the facilitator is aware of the situation.

3. Damage to the left hemisphere of the Panetal Lobe, the dominant side, may cause:
impairment in reading and writing, right—left confusion, impaired tactile recognition. Damage to this part
of the brain will reduce the ability to respond to stimulus through touch, poem writing, story reading and
writing, and instructions that use left-right orientation.

4. Damage to the right hemisphere of the Parietal Lobe, the nondominant side, may cause:
visuospatial and visuoconstructional impairment and neglect of the left side. These impairments more
profoundly affect the ability for expression in visual arts.

5. Damage to the Temporal Lobe may cause: impaired memory and hearing, changes to emotional
and behavioral expression, apathy, and oral exploratory behaviors.

Summary

Researchers like Gardner, Miller, and Schneider and Pichora-Fuller provide the groundwork for
neurological understanding that translates into practical information about what to expect when
interacting with seniors with dementia who engage in creative expression activities. Dr. Miller’s patients
were diagnosed using magnetic resonance imaging (MR1) to veri1y the degree of atrophy in the brain and
the location of the damage. It would be beneficial if all dementia patients had this procedure, however, it
is costly and most dementia patients do not undergo such procedures. In the absence of this diagnostic
tool, artwork could become an inexpensive substitute with the potential of explaining some behaviours.

52



Social Cognition, Aging and Dementia

Social cognition in aging is defined by self-identity, social interaction and social perception (Hess, &
Blanchard-Fields, 1999). Ha.zan (1994) describes aging as:

Knowledge about ageing is peculiar; alongside matters of lfe and death it embraces
notions about dependency and autonomy, body and soul, and paradoxes emanating from
irreconcilable tensions between images of the old, their own will and desires, and the
facilities offered to them. (p. 1)

Hazan sees people in old age trapped socially by the language of separation, by a culture that
separates them, by their image as perceived by the rest of society, and by their own self-image. Further,
he says that this separation is “a form of social segregation which defines the aged as non-humans and
humans as non-aged ... detached from their previous lives and from social frameworks of the non-aged”
(p. 18). He also criticizes the notion that older people need to adapt and “conform to the demands of
society” (p. 21). The whole socio-cultural construct seems to be afflicted by fear and anxiety of old age,
where old age is perceived as a social problem that needs to be resolved.

Hazan sees the concept of death as the main divider between “those on its verge and those desperate
to avoid it” (p. 5). For him, words such as “aged, old, older person, senior citizens, elders, old age
pensioners — all serve to stigmatize the aged” (p. 13). The recent popular concept of ‘successful aging’
implies that older people need to be instructed on how to live their lives to the fullest. Yet society dictates
when a person should retire from the work force. Entering retirement is based on a bureaucratic decision,
which is driven by economic reasons that favor younger people. The decision to retire affects older people
economically, “their relationship to others, their self image” (p. 16). Overnight, retired people lose their
status as viable and contributing members of society. Aging becomes equivalent to illness, dependency,
powerlessness, dehumanization, eventually leading to institutionalization away from all that was familiar
(Hazan, 1994). Treating older people in a discriminatory way was named “ageism” (Cohen, 2001, Levy,
2001; Palmore, 2001). Cohen (2001) quotes Butler (1975) as saying:

Ageism can be seen as a process ofsystematic stereotyping ofand discrimination against
people because they are old, just as racism and sexism accomplish this with skin color
and gender. Old people are categorized as senile, rigid in thought and manner, old-
fashioned in morality and skills.... Ageism allows the younger generation to see older
people as different from themselves; thus they subtly cease to identfj’ with their elders as
human beings. (p. 576)

Creative expression abilities are based most strongly on “the interface between personality and
intelligence” (Staudinger et al., 1997). Those creative traits may or may not be expressed through social
interaction and a quest for self-identity. Older people may refrain from expressing themselves if the
society they live in refuses to support them emotionally. According to Hazan (1994) older people suffer
particularly from stereotypes that are socially constructed when they are treated as a homogeneous group
without regard to individual differences. Staudinger (1999) stresses the importance of the individual and
their life experiences. These individuals have a past and make plans for the future. In her research, which
is supported by Lindenberger and Baltes (1994), Staudinger found that when older adults are engaged in
life review and life planning, they “do not show the usual declines identified in cognitive functioning of
the mechanic type ... Rather, stability and sometimes increases in performances are observed” (p.351).
Hazan comments on how society views aging and creativity, explaining the stereotypes that brand
ordinary old people as “incapable of creativity, of making progress, of starting afresh” (p. 28). He
continues “only in art and the domain of the spirit are they licensed to continue to be creative” (p.28).

Ryan, Hummert and Boich (1995) share the opinion of Hazan and Staudinger that older people
become stereotyped as incompetent and dependent (p. 146). In 1986 Ryan introduced the Communication
Predicament of Aging, which demonstrated how caregivers change their verbal and non-verbal

53



communication with an elderly person. This model presents several stages from the first encounter with
an older person to changes in speech and behaviour of a patronizing nature, which reinforces stereotyping
and causes the older person to avoid interaction. To support this cycle, Smith & Van Der Meer, in Runco
and Richards (1997), point out that “older people, because of negative social stereotypes about aging,
often become isolated from their own emotions and filled with doubts about themselves, all of this being
detrimental to creative functioning” (p. 352). McMullin and Marshall (2001) suggest that age
discrimination is widespread in western societies and that it “occurs within families and households,
government agencies, healthcare systems and wage labor markets” (p. 112).

The relevant finding is that older people are “denied resources and opportunities that others enjoy”
(Bytheway, 1995, p. 14). It seems that these research findings of western social attitudes towards normal
aging become more accentuated with older people, who are sick with dementia. Aronson (1999) makes it
very clear that older people, who become sick and move from being independent and in relatively good
health to total dependency, are at the mercy of others for care.

Older people with attributes that signal their potential dependency —for example, being
ill or disabled, poor, or female — are especially exposed to these oppressive practices and
are, coincidentally, those most likely to enter the orbit of long-term care, thus, ofsocial
workers. ... These organizations and the cumulative practices ofservice providers within
them play critical parts in both distributing resources and in shaping images and
vocabularies about older citizens ‘ entitlements and the signflcance of their needs. (p. 47)

Aronson joins the voices of other researchers in the social sciences (Corley, 1999; Cox & Parsons,
1999; Fulimer, Shenk and Eastwood, 1999; Hancock, 1990; Hooeyman & Gonyea, 1999; Kitwood, 1992;
Kitwood, 1997; Neysmith, 1999; Sabat & Harre, 1990) who view their work with older people from a
postmodern and feminist perspective that focuses on the social construct and issues of empowerment.
This viewpoint opens the door to criticism of some practices in dementia care. As Tilki (2000) observes:

The damage caused by not enabling older people to occupy their time in a meaningful,
enjoyable and challenging way was dramatically underestimated (Goodwin, 1988).
Recreation according to Goodwin was not a luxury, but a starting pointfor excitement,
meaningful diversion, adaptation and creative activity. Crump (1991) went so far as to
suggest that the absence of meaningful activity could be interpreted as abuse. (p. 113)

The following is a conceptual framework (fig. 3) that illustrates how therapeutic environments may
bring positive changes in behaviour and self-image when the medical model of treating seniors with
dementia is enhanced with the person-centred model as identified in the field of gerontology. Although
the reduced abilities are a fact, responsive environments may help alleviate feelings of isolation and
breakdown in communication.

54



L From a Biomedical Model to a Person-Centred Model Within
the Context of Creative Expression Activities

• Understand patterns of behaviour
and the causes for problematic a
behaviour to reduces anger and
agitation. Provide opportunities
for decision-makmg as long as
possible, however small: art
projects, meal preparation,
moving objects, collecting things.

Therapeutic Environment
• Positive change in behaviour
• Promotes independence

preservation of the self and
dignity

• Improves socialization and
communication.

Figure 3: The Conceptual Framework of the Person-Centered Model versus Medical Model

‘Jr
Is it an opportunity

opportunity

person-centred model
supporting and adjusting

to gradual deficits

• Release of inhibition may encourage
creative abilities

• Long-term memory may stay intact.
Opportunity for: Life review,
reminiscing & reconnecting with
loved ones

• Use of non-verbal activities: music-
making and listening, art-making
and viewing, use of tactile activities.
Encourage seniors to relive times
still remembered.

F’

• Reduced memory & emotional
control

• Loss of short-term memory
• Reduced speech and language

control
• Loss of time awareness

• Free movement indoor & outdoor to
maintain muscle strength as long as
possible

• Provide meaningful activities and
spots of interest along the
wandering routes.

• Continue to work with remaining
abilities, assist and support as
needed.

-I0-

• Restrained with wheelchairs,
geriatric chair & bed rails to
control perceived problematic
behaviour leads to loss of
muscle tone

• Wandering
• Reduced range of movements

• Loss of reasoning leads to loss
of the right to control personal
life, to frustration, agitation, &
problematic behaviour

Non-responsive environment
• Institutional feel contributes

to confusion, agitation,
isolation, breakdown in
communication.

I

55



CHAPTER III: METHODS

Qualitative Research

Manning, Algozzine and Antonak (2003) define qualitative research as: “Inquiry designed to discover
meaning by intensively studying representative cases in natural settings using analytical approaches” (p.
56). John Creswell (1994) explains that in qualitative research:

researchers interact with those they study, whether this interaction assumes the form
of living with or observing informants over a prolonged period of time, or actual
collaboration. In short, the researcher tries to minimize the distance between him- or
herselfand those being researched. (p. 6)

According to Creswell, key issues in qualitative research are: a) the admission and recognition of the
researcher’s biases that are embedded in his or her woridview and life experiences, b) the qualitative
researcher waits for categories to emerge from the process of inquiry that may lead to patterns or theories,
c) qualitative researchers take the risk of including possible ambiguity in their research with unknown
variables.

According to Roger Grainger (1999), qualitative research “indicates such a wide field of enquiry
within a single project, it involves a great deal of organization and the ability to orchestrate its effects so
as to present its conclusions as powerfully and convincingly as possible” (p. 38). He also sees the
qualitative research role in describing situations that are difficult or even impossible to measure. For
example “things that are concerned with the quality of human relationships and what happens between
people. It concerns itself primarily with investigating how things happen rather than trying to be
scientifically accurate about why they do” (p. 40).

Selecting Qualitative Inquiry

The decision to use qualitative inquiry was made deliberately to focus on detailed descriptions and
address research questions that allow for new understandings rich in information. As Springgay, Irwin
and Wilson Kind (2005) noted in their essay:

It is often an anxious life, where the a/r/tographer is unable to come to conclusions or to
settle into a linear pattern of inquiry. Instead there is a nervousness; a reverberation
within the excess ofthe doubling process. Living inquiry refuses absolutes, rather it
engages with a continual process ofnot-knowing, ofsearchingfor meaning that is
dfjIcult and in tension. Tension that is nervous, agitated, and un/predictable. (p. 5)

As Irwin and Springgay (2005) explain:

Whereas many forms ofresearch are concerned with reporting knowledge that already
exists or finding knowledge that needs to be uncovered, action research and a/r/tography
are concerned with creating the circumstances to produce knowledge and understanding
through inquiry laden processes. (p. 7)

A/r/tography was selected as the overall methodology and philosophical approach to lead this inquiry.
A/r/tography as a method helped me tackle the various components of the research questions; it fit my
values, beliefs, experiential knowledge and goals. AIr/tography seeks knowledge through living inquiry
by “creating the circumstances to produce knowledge and understanding” (Irwin & Springgay, 2005, p.
7). It draws the researcher into an intense, personal and interactive relationship with the topic being
researched. Irwin and Springgay (2005) used Carson and Sumara’s explanation of action research and
applied it to alr/tography in saying that interpretations of action research and alr/tography practices “. . . are

56



always in a state of becoming and can never be fixed into predetermined and static categories” (Carson &
Sumara, 1997, P. xviii). A/r/tography calls on the artist inside the researcher to seek an understanding of
self and the larger world through an artistic process. The researcher in a/r/tography acts as a facilitator
who intentionally selects a situation in order to bring on social and/or political change with the help of
concerned stakeholders.

I acknowledge that working with seniors with dementia has its drawbacks, considering that they may
not have the capacity for full blown participation in a traditional academic sense. However, this research
proved that even with various levels of memory impairment, from mild memory impairment (MCI) to
moderate dementia, seniors were capable of expressing their wants and ideas for a space to be creative in.
Their participation was subtle in comparison to revolutionary and dramatic acts, yet their input was very
significant in the world of dementia care, where changes are so small that, sometimes, an untrained eye
may miss a brief moment of brilliance. Through the arts and the search for any meaningful gesture by the
participants, a/r/tography helped bring out those precious moments that unfolded in between “language,
images, materials, situations, space and time” (Irwin & Springgay, 2005, p.2). By documenting the
responses of the participants through a/r/tography, I allowed the seniors with dementia to be heard,
appreciated and to be included in the process of design.

Air/tography

A personaljourney. By using a/r/tography as a “living inquiry” which is explained as “visual and
textual interpretations of lived experiences” (Springgay, Irwin, and Wilson Kind (2005, p. 5), I was able
to devote the same level of attention to self-reflection as I did to the participants in the study. Ar/tography
invites the researcher to become aware of his or her multiple roles through artistic and educational
endeavors. A/r/tography also introduces an emerging qualitative method called relational inquiry and
which is supported by researchers such as Gergen and Gergen (2000) in Denzin and Lincoln’s Handbook
of Qualitative Research (2000). Gergen and Gergen describe relational inquiry as research based on
relationship, as oppose to the traditional way of conducting research based on an individual approach.

As our methodologies become increasingly sensitive to the relationship ofresearchers to
their subjects as dialogical and co-constructive, the relationship of researchers to their
audiences as interdependent, and the negotiation of meaning within any relationship as
potentially ramifying outward into the society, individual agency ceases to be our major
concern. We effectively create the reality ofrelational process. (p. 1042)

Irwin and Springgay (2005) use relational inquiry within a/r/tography, which is based on multiple
views as an educator/learner/artist/researcher. Architects struggled for ages to be recognized for their
theoretical approach to design while doing their practice. A/r/tography and its understanding of relational
inquiry fits perfectly with the process of designing in architecture. The three forms of knowing (theoria),
doing (praxis), and making (poesis) which are fundamental concepts in a/r/tography (Irwin, 2004) are also
the structural pillars of architecture.

In the past architecture was perceived as a profession that was dominated and driven by a few
politically and socially influential clients with very little or no input from the public as users. Structures
were built in celebration and adoration of the developers as an expression of power. Architecture today is
more liberal and exercises democratic approaches to hear and listen to the users. The architect of today
assumes the role of a learner who is sensitive to the social, political and economic issues of the situation.
Only then can the architect bring in the technical expertise required to create architecture just as the
alr/tographers are expected to learn, change, understand and interpret (Irwin & Springgay, 2005). Each
time I work on an architectural project I add another piece of information to my repertoire, not only from
a building technology aspect, but by understanding the psychosocial aspects of the users. Each new
awareness brings new ideas and new ideas turn into shapes, and forms and the cycle never ends.

57



It needs to be pointed out that architecture is not always about a real geographical place. Sometimes
architecture is defined by the use imposed on the place. For example, a group of people may use the
beach as a place to party and sleep. For that specific short time, the beach is transformed to contain the
activity imposed on it. Irwin and Springgay allude to it by stating that the definition of what a “site”
means “needs to be re-defined not through physical or local terms, [but] as a complex figure in the
unstable relationship between location and identity” (2005, p. 12).

As I approached this study, I thought it would be simple to explain the transitions I went through
from my work in architecture to my work in gerontology. As I began to make sense of my recalled
memories, I realized that I was dealing with a continuous transformation with multiple and overlapping
processes that could not be contained easily in separate boxes with well-defined boundaries, starting at
one date and ending at another. As I “opened” one area, I quickly discovered that I needed to turn to
earlier memories to make sense of recent events in my life. I was compelled to go back and forth and
unravel the meaning of what creative expression, architecture, research and dementia meant to me. In this
case, the act of opening was of a personal nature; however, openings according to a/r/tography can be also
applied in relationships between alr/tographers and the others they work with. As Irwin and Springgay
suggest (2005, p. 19) “Another purpose of a!r/tography is to open up possibilities for alr/tographers as
they give their attention to what is seen and known and what is not seen and not known”. Openings also
refer to losses and discomforts (Springgay, Irwin & Wilson Kind, 2005, p. 9), as Wilson Kind refers to
her own losses and difficulties in life. So are the losses seniors with dementia experience and the need to
mend the environment to accommodate physical, mental and cognitive impairment.

The process was not always easy or pleasant as I faced situations and asked questions about why
things happened the way they did and where I was going with them. Through this process I found
relevance in a/r/tography and in its six renderings: “contiguity, living inquiry, openings,
metaphor/metonymy, reverberations and excess” (Springgay, Irwin & Wilson Kind, 2005, p. 1). These
renderings explore the process of discovering new meanings in difficult situations due to the tension,
ambiguity and resistance I encountered along the way. At various times I would compare this process of
discovery to dance, the strokes of a brush, playing ping-pong, giving birth, writing a poem, designing a
building, listening to music, having meaningful conversations — and working with seniors with dementia
in the creative expression program I developed. In short, living life.

I also thought how easy it would have been if I could express myself, metaphorically, in white colour.
What do I mean by white colour and how does it relate to metaphor and metonymy in a/r/tography? Isaac
Newton (1642-1727) discovered “that white light is broken by a prism into a full spectrum of colors”
(Marmor & Ravin, 1997). Each colour represents different wavelengths and energies. It is one single
phenomenon that combines many colours at the same time and produces a new colour, seemingly so pure
and colourless that it presents a clean slate on which artistic activity can begin. Amazing. Although we
now understand the mechanics of this phenomenon it still puzzles our minds. Going back to the multiple
roles of the researcher/educator/artist/facilitator, we know it takes time to explain who we are through
verbal and textual expression. Unlike the efficient presentation of white colour, our ability to perceive in
one singular act who we are is limited. To make matters even more puzzling, the objects we think we see
are really the light that is reflected back from them in combination with the way we perceive through our
visual system. This activity of seeing and not seeing, even if we are aware of the phenomenon, creates
duality and dichotomy, making us unsure and uneasy. It fits the understanding of alr/tography where, by
displacing the self with white colour, we may clarify the position of multiple roles and the changes we go
through while producing a new self, like the new white colour.

Inquiry into renderings of u/r/tography. My overarching goal in providing a creative expression
program was to give an opportunity for growth, reflection, and discovery; in alr/tographic terms, to allow
some renderings to play themselves out. While I was going through my own reflections, I was hoping the
group of seniors with dementia would too. We were in this journey together, exploring the possibilities
for new situations. Although one can never be sure of what to expect while working with these seniors,
the uncertainties are constant —just like alr/tography itself— as a process of inquiry. Symptoms of the

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medical condition keep shifting. There may be good days when the seniors are just as able as those with
no dementia, or bad and difficult days when they can hardly concentrate or participate in any activity.
Difficult days and moments such as this, when intertwined with my own uncertainties, produce situations
that de Cosson (2002) calls “Aporia”.

My own “Aporia.” Alex de Cosson (2002) explains Aporia as a place/concept of difficulty, a fluid
entity in between places/ideas that is ever-changing, as the various players discover or rediscover the
known and the unknown. Aporia is a process of making meaning in the context of a present moment. As I
was preparing the outline for one of the selected sessions for the study on friendship, my own thoughts
started to infiltrate my planning given the fact that I am Jewish. In exploring memories of the participants’
younger days, I was wondering where the seniors in Margaret Fulton came from originally. Were they
involved in the war in Europe, were they victims, were they fighting with the allies or on the enemy’s
side? I worried how it would impact my study and how I would react to the possibility that one of the
seniors may have been a soldier in the German army fighting for his country. As it turned out there were
no men in the group at Margaret Fulton and my anxiety subsided. This is my Aporia, as I try to come to
terms with a past that has no words to explain what happened. The more I try to make sense of it, the
more I get entangled in this sticky web — wanting to believe in the goodness of mankind and yet aware of
the painful realization that mankind is capable of inflicting the most horrendous crimes on neighbours and
friends, with no discrimination. Yet, regardless of their past, they are now old, frail with limited memory
and in need of help. But so were my grandparents when they were killed. This is my Aporia, my private
torment of making sense of this world as it relates to my work with seniors with dementia. Like the
seniors, I may want to take refuge in the present and unlike them, I am still able to be selective as to what
to remember.

There is no question in my mind that some changes are taking place in my own perceptions of life as I
work with these seniors. As Irwin (2005) describes the subtle changes that take place in her life when
walking around the UBC Campus and enjoying a fall day: “Each image holds different meanings for me
though they represent the same day and time period. Each image teaches me something fresh and alive
through every new encounter. Each image was birthed as I was created” (p. 3). I too, feel the urgency to
enjoy life to the fullest; every minute counts. And while the seniors are going through life assessments, I
go through them too. Although I am not afraid of getting old, I find myself delighted that I still have time
to do things. And when I come into a room full of frail seniors, I count my blessings and feel guilty
thinking that way. And yet, I mingle with them and I discover precious moments of knowledge, wisdom,
humour, kindness, lessons to learn, stories of pain, suffering and of good times, traditions, history —
stories I will never hear again directly from the source. While appreciating the value of older people in
society, I cannot help thinking how the society they helped build is ready to discard, waste and ignore
them. In rendering Excess, society could spare this vulnerable population and recognize their worth in
searching for deeper and different meanings.

One of the difficulties in linking my artistic aspirations through architecture, research and dementia is
in understanding who is an artist? Is it the person who declares himself an artist? One who is perceived to
be an artist by society? One who makes a living by selling paintings? One who does not sell but paints,
writes music or sings for the love of it? Who decides if what is being produced is art? What is art?

When I look at my life as a whole, I see that art touches just about everything I do. I live art. There is
no aspect in my life that does not go through the lens of aesthetics, form, shape, coordination, tension,
focal points, physical and emotional perspective. I am thinking who is my audience, who is using my
buildings, are they still going to like them in one month or years from now? I see art when I cook, do
gardening, sew, knit, give haircuts, design buildings and their interiors. Architects need to consider
material selection, aesthetics, compositions of form, colour, and balance whether on paper or on “real”
sites. I select art to fit my designs, my clients and their budgets. I see art selection as an extension of my
own designs. I create. This act of creation spills over into other areas and continues to change, influence,
agitate, comfort and heal not only my clients but myself as well. Designing a building does not differ
from creating a painting, a sculpture, a play for the theatre, a dance. The architect, the artist, the dancer —

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all are trying to express themselves through a creative process that takes in information through the
senses, then digests it while searching for meaning, and delivers it in multiple ways. Each drawing may
lead to another and each dance may inspire another. None of these forms of expression are limited,
isolated and contained.

I also enjoy the opportunity of designing stained-glass windows and furniture to satisfy the “real”
artist in me. As I try to understand what attracts me to work with seniors with dementia, I think it may
have to do with the fascination I feel working in situations and with materials that appear to the eye very
fragile, such as glass, and yet have hidden and surprising qualities of strength. It is in this paradox that I
find my most creative moments born. It is the tension between opposites that intrigues me. I am always
curious about what may transpire and I look forward to challenges that will inspire new ideas. Not every
road leads to success but I learn as much from failures. When I got interested in designing stained-glass
windows for the buildings I designed, I was told by experts that there were limitations to how glass would
respond to cutting and this would limit the scope of the design. Although I understood the limitations, I
wanted to break away from the traditional design approach and be open to whatever might come my way.

I have been ridiculed for being naïve, for venturing into a field where I did not pay my dues. But what
some did not understand was this: the sheer fact that I was not trained meant that I was not boxed in. I
could look with fresh eyes at how to use glass in different ways, for partitions, windows, roofs and even
floors. I have come to appreciate glass art by doing it. Living it. Like everything else in my life, it seems
that my practical experiences propel me into new endeavors. Trying to understand how things come about
and where they are going, I explore the rationale for their being. This back and forth is an effort to make
sense of the world, and at the same time be aware of new possibilities. It fits within the six rendering of
Reverberations described in alr/tography (Springgay, Irwin, Wilson Kind, 2005).

As the glass was breaking away from the pieces I needed for various projects, I became aware of the
accidental shapes of the broken glass. I was drawn to create new compositions, using different techniques
and making a deliberate effort to leave the accidental pieces as they were. I found myself checking each
excess piece, for its shape, colour and how I could continue to use it. All of a sudden, the leftover broken
pieces were more exciting than the projects I had already designed. At this point, the renderings of
Opening and Excess came into play, inspiring the creation of three-dimensional glass sculptures I call my
accidental projects. As I write about it, I realize that I use the same approach in my work with seniors
with dementia. I try to chip away at the obstacles that prevent the seniors from using their remaining
abilities. As I do that, I am aware that their responses may be unpredictable. And like the sharp edges of
the broken glass, I may need to smooth the rough edges so we can continue to work and minimize the
harm.

As I walk into the workspaces allocated for art activities in most long-term facilities I have visited, I
feel so discouraged. The artist in me shrinks at the gloomy prospect of having to pretend that space is
unimportant in the creative process. The facilitator in me takes over to mediate the circumstances and do
the best I can under these conditions. The architect in me wants desperately to design the state-of-the-art
studio that would take into account all physical, emotional and artistic needs of seniors with dementia.
The researcher in me is already busy collecting data, searching for the right methodology that will explore
whether or not it is important to provide an appropriate space and atmosphere that may or may not be
conducive to creative expression activities.

I very much liked McNiff’s description of space and function in what he calls “the studio”. Architects
who design therapeutic environments will find this description of great interest.

I emphasize the studio because we need it more right now. I know that I desire the studio.
There is not enough of it in my life. Two decades ofworking with graduate students and
art therapy colleagues has shown me that they hungerfor it too, and the phenomenon of
art therapy needs the studio. IfI walk into a medical environment with its chemical and
antiseptic smells, my soul is aroused only to the extent that I want something else. The

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medical environments can sometimes be the antithesis of art. The studio summons the
artist in me and the artist in art therapy. (p. 135)

Irwin joins McNiff’s desire to work in a studio situation and be inspired by the ambience the space
offers. As she states in her article, Walking to create an aesthetic and spiritual currere, “Whenever I walk
into this space, I become acutely aware of my need to create, my need to care for the urge to create” (p.
3).

And so, the architect in me becomes vety practical and sets to work within the rendering of Excess,
trying to find solutions from a wasted situation. Working within the rendering of Reverberations, I find
myself pushing against the administration and their resistance to any change in the status quo. The
architect in me asks: how can I change the conditions, improvise, use skills and knowledge, use
innovation and creativity? And so, I find temporary solutions in various situations, such as these. I was
lining up seniors to paint on a glass partition wall in a long-term care facility where I was conducting
creative expression activities. I knew the glass was tempered, easy to clean, safe and a novelty. The
results were exciting. The seniors wanted to draw and produced many of the artworks that were displayed
later in an art show on creativity and dementia. On another occasion, I lined up seniors in front of a glazed
exterior wall facing into the garden. As the sun was coming around and shining through the drawing
paper posted on the glass doors, I was in awe of the beauty of the light, the shadows on the wall and floor,
the seniors painting and loving the warmth of the sun. I grabbed a brush and started to paint. When I came
home, I wrote down every detail that would help me understand what happened that day. At that time, I
shot a whole roll of film that now helps to demonstrate the importance of having an appropriate space for
creative activities.

AIr/tography also stresses the role of the researcher as an educator. As Irwin explains in her
philosophy of teaching:

Art pedagogues become involved in their own continuous learning while recognizing the
personal knowledge, interests, experience of the students in their care. Pedagogues wish
to nurture the growth of their students’ emotional, intellectual, spiritual and intuitive
powers in a cooperative learning environment. Learningfor the sake of learning is not
enough. Importance must be placed upon translating understanding into action,
empowering students to be active creators and potential transformers of their material
and cultural world ... (Irwin, 2005)

http://cust.educ.ubc.ca/faculty/irwin.html

Although I do not call myself a teacher as the result of formal education in that profession, I do think
of myself as an educator/learner. I have taught Hebrew for many years to young children and adults, I
have home schooled my children, taught interior design to university students and served as a mentor to
university students over the years. In education terms, I consider myself a facilitator. I facilitate a
situation in which the people I interact with are encouraged to express themselves. Working with seniors
with dementia, I find myself learning from them as well. I am there to release what they have already
known for a long time and may have forgotten. I am there to provide information that may be new to
them at the moment, but which I know they knew once before. And so I borrow from psychology that
claims that familiarity is an automatic inherent human quality — seniors with dementia may feel familiar
with a situation or an object although the memory of it was destroyed. For example, seniors may not
remember me as Dalia, the person who comes in once a week to work with them on creative expression
activities, but they may link my presence with something that is pleasant and enjoyable and perhaps with
food, since I often bring homemade desserts or food to most sessions.

Concluding thoughts on architecture and a/r/tography. There are two issues that come to mind
when discussing architecture and alr/tography. One is the unquestionable link between the visual

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expression of architecture and the text that comes along with it. The second issue is the opportunity that
alr/tography opens up for the acknowledgement of architecture as practice and as theory.

AIr/tography is described as “a coming together of art and graphy, or art and writing” (Springgay,
Irwin and Wilson, 2003, p. 4). Since architecture is a form of artistic expression, I can substitute the word
architecture for “art”. To test the notion of architectural drawings without text we need to ask the
following: could a building stand on its own merit without a name, an address, without occupants or the
name of the designer? Could the building be understood without asking why it was built and what for —
when it was built, what was the cultural context, and what materials were used? Without this information
would we understand the full meaning of its purpose? I would say, no, we would not understand the full
meaning of its purpose.

We should not forget the reams and reams of drafting papers, trails of sketches, meshing art and
technology and text together. What about the historical written information of negotiations for permits
with various authorities? When we understand that the building is also a product of local and national
building codes, do we get the full picture then? Looking at a building without knowing its context is like
trying to read Egyptian hieroglyphics. Yes, we can see them, but can our minds make the necessary
connections to make sense of them?

Then I wondered: if we separated the text from the drawings, could we count on the text alone,
following the same specifications, to guide us towards the same exact building design. I believe that in
spite of working from the exact specifications, the design would vary from one designer to another. The
individual architect’s ability to perceive, analyze and produce would be reflected in each interpretation.
This observation is based on many years of architectural practice and comments from colleagues in the
field. To support this observation, there is an interesting example about how text alone fails without the
adjunct image. Although very detailed plans of Noah’s Ark or the Holy Temple in Jerusalem were
described in the Old Testament, we cannot know for sure what they looked like. In artistic interpretations
of the Temple and the Ark, we witness several versions. All claim to be the closest interpretation of the
biblical text.

The second issue that deals with architecture as practice and as theory refers mainly to architecture
that focuses on therapeutic environments. Architects do theorize and contemplate through their ideas and
planning as to how things will be done. Architects through their practice and theory generate new ideas
and forms and invite the participation of their clients and users. Michelle Fine (2000) was quoted in
Gergen and Gergen (2000) questioning the future of qualitative research with references to relational
inquiry which fits the process of making architecture: “What elements of qualitative research are
productively engaging toward democratic/revolutionary practices; toward community organizing; toward
progressive social policy; toward democratizing public engagement with social critique?” (1998, p. 1038)

The most important message that came out of understanding a/r/tography is that the human spirit is an
amazing, regenerating force. Like water in a river, our brain will seek an outlet and find ways to
communicate, to express. We need to provide opportunities and means for everyone, especially people
with dementia, to continue to communicate in many forms. We need to listen to the unsaid and to what
may be missing. While others may accept the appearance of dementia and take its impediments for
granted, we must question that acceptance, look below the surface and tap into the human spirit — of the
seniors and ourselves.

Just like alr/tography, we need to allow the images, the text, the story, the real and the imagined to
coalesce into meanings so we can understand better how visual and performing arts can be used in
communicating when other ways of communicating fail.

AJr/tography allows researchers to bring their own storyline into the situation under study, a storyline
that may influence, intersect, observe and interact with whatever the researcher/artist is engaged with and
brings to the study. A/r/tography gives freedom for the researcher/artist to process theory into the

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production of the art. In one singular expression, theory and practice are fused. Artists understand this
fusion; they do it all the time whether they are aware of it or not.

I employed alr/tography as a mean to collect data throughout the study. This approach provided an
opportunity to examine the role of the researcher in making a difference in the seniors’ abilities, as they
were demonstrated through creative self-expression, and by changes that were made to manipulate the
architectural environment. The multiple roles of researcher/educator/artist/facilitator in the
implementation of the creative expression activities program were also explored in an effort to elicit
crucial information that could be used by behavioural scientists with a focus on dementia care.

During this study I had the opportunity to propose a design for stained glass doors for the L’Chaim
Adult Day Care Centre. The design, which is discussed elsewhere in this dissertation, is based on my
experience as a stained glass designer and my familiarity with the Jewish culture and faith. I also
experimented with architectural drawings in an effort to shed my position as an authority, the one who
knows better, by condensing key issues that could be understood at a glance, and appeal to various
cognitive abilities in seniors with mild cognitive impairment to moderate dementia. The idea was to bring
across information without having to read the whole document, which would have been a monumental or
impossible task for the participants. The drawings include photographs that were taken of participants
during the various activities, significant quotes and textural summaries regarding the spaces that were
used during the various sessions. I was also aware that an aJr/tographer did not necessarily have to
produce an artistic product as long as the rigor of the study and its philosophy were maintained. As stated
by Irwin and Springgay (2005): “Artists engaged in alr/tography need not be earning a living through
their arts, but they need to be committed to artistic engagement through ongoing living inquiry” (p.11).

As I was exploring ways to go about my academic inquiry, I realized that I had included intuitively in
my practice many of the ingredients that describe alr/tograpic research. I was interested in experimenting
with ways that would better the quality of life of seniors with dementia with a focus on the links between
creative expression abilities, space and programs. Experimenting comes naturally to professionals trained
in architecture and design. We are trained to look at the world around us, assess it functionally and
aesthetically, to almost automatically and spontaneously look for ways to see things differently. We
assess existing situations of spaces interlinked with human behaviour, and then we revise or design spaces
to suit the clients’ physical and emotional needs. And we assess the results of our work, and its impact on
the client’s well being, to judge whether or not the project was successful and whether it answered the
objectives of the project.

I was also aware of the balance of power between myself and the participants. I fully understood the
conflection between being an architect, researcher, facilitator, educator, when I invited the participants to
express their opinion as to how I should position myself in the room when I talked to them. I like to stand
in front of the group, like a teacher in a classroom. No one complained. It was taken for granted that this
is how it should be. But when I opened the floor for discussion as to whether I should sit or stand, it
quickly became an issue of exhibiting superiority, the person who knows best, the expert. The moment I
sat down, the balance of power changed. As one of the seniors at L’Chaim Centre put it: “You are now
one of us”. Such a small gesture became very significant in the interaction with seniors with dementia.

In addition to the new understanding about standing or sitting and the roles attached to it, I learned
that reflexivity, which is sharing personal and subjective life experiences with participants, caffies a
danger of silencing participants if the researcher goes overboard telling these stories. I learned that there
was a fine line between getting the participants’ attention with personal stories and the danger of
overburdening them.

Initially, when I planned how the data would be collected, I was aware that some limitations would
affect the procedures and the overall approach to this study. First, the opportunity for experiments with
major architectural changes was slim and, therefore, participation in changing a real situation would not
exist or be affected by the feedback from participants. Although I was drawn to participatory action

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research, at that point I opted not to use it. There was also deep scepticism about whether people with
dementia could participate in research inquiry in a meaningful way. As the study progressed
unpredictable new developments made me aware that seniors with dementia could participate in research
when given an appropriate opportunity. Since the decisions to make some interior changes were going to
be made very fast, just when I was about to go on a trip, I was asked to provide ideas for floor covering
and wall and door paints. I used data collected in a previous session that included the seniors’ ideas on
how they would like to design their dream art studio in the Centre. After the renovation was completed, I
interviewed the seniors about the changes again, made notes of their opinions and made some efforts to
address their concerns. This process is still going on.

At L’Chaim, I was able to respond quickly to the changing situation. To support the need to be
flexible and open to unpredictable events, one can listen to the views of some researchers who are artists.
Lenore Wadsworth Hervey’s (2000) book Artistic inquiry in dance/movement therapy, creative
alternative for research, Shaun MeNiffs work (1986) Freedom ofresearch and artistic inquiry and Roger
Grainger’s book (1999), Researching the Arts Therapies, A Dramatherapist’s Perspective support my own
way of thinking. Lenore Wadsworth Hervey quotes McNiff (1986) as he explains the characteristics of
creative researchers and their traits:

The need to explore the widest range ofpossibilities and chance events; imagination;
openness; persistence; the ability to change strategies in response to the material under
review; the mixing ofdisciplines; a willingness to err; intuition; an interest in the
unknown; an inability to simply follow the tradition of logical analysis; personal powers
of observation and interpretation. (p. 282)

Any artist/researcher who is engaged in artistic inquiry can identify with this description. Artists
inherently resist urgings to follow step-by-step prescribed regulations. A certain rebellious streak leads
artists to veer off the main course and look for ways to capture the process of inquiry from several
unconventional angles.

At the beginning I envisioned a democratic style of inquiry, where all concerned participants would
be equally important — mainly to protect the least heard people: the seniors with dementia. From a purely
academic standpoint, conducting participatory action research would be controversial since seniors with
dementia need to be declared competent and capable of giving consent. Nevertheless, working within the
limitations of this population, I still managed to accommodate input from the seniors utilizing their
remaining cognitive and physical abilities. As Roger Grainger (1999) put it:

Ifwe are lucky, ofcourse, we may find exactly the right kind of research technique that
we need. Ifnot, we must use the most appropriate one for our purposes. This may mean
adjusting the situation in order to find a suitable way

...
(p. 33)

Grainger (1999) states that involvement is a key issue in research using “as many sources of
information as possible. Instead of concentrating on observations” (p. 99) made by unbiased observers, all
parties have direct input into the research process. In his research he uses “interviews, questionnaires
diaries and journals, narrated accounts of personal experiences, reports of interactions observed either
overtly or covertly or both, plus the use of video” (p. 100). He also explains that “leaders of the group go
to considerable lengths to develop a shared atmosphere of trust and co-operation” (p. 100).

A model for researching creative expression abilities, social interaction as they are linked to creative
expression programs and the physical therapeutic environment is Roger Grainger’s book, Researching the
Arts Therapies; A Dramatherapist’s Perspective (1999). Grainger joins Shaun McNiff in his approach to
the arts in healthcare. They both embrace a wide angle approach that marries the arts with the sciences.
Their approach is to research the arts in a natural way, offering the least resistance to what begs to be
explored. Their philosophical approach to research shows flexibility, openness to changes that flow with

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whatever arises from the exploration; it celebrates ambiguity, thriving on tension, as the researcher and
researched are engaged in a dance-like relationship.

Grainger’s approach literally embraces life. He mixes methods of research as needed. It may be a mix
of any of the following: qualitative and quantitative research methods, action research and art-based
research. Like Shaun McNiff and others, he draws examples from art, music, dance and movement
therapies. In this way, we see ourselves as practitioners and researchers as the same time. Our research is
grounded in our experience. As in alr/tography, Grainger concurs that “The impetus to explore it
[psychological therapies] came from my own personal involvement in it” (p. 9).

Grainger tries to explain why research in the arts cannot be forced into compliance with rigid
scientific rules. The following quote illustrates a fundamental thought that supports the reasoning as to
why the arts in the service of healthcare need to be approached differently:

Thus although the creative therapies may be said to ‘use’the various art forms, they do
not do this in the sense that we often mean by the word use. They do not subsume them in
any way. In the human attempt to be ‘scientflc’ they may try to reduce them to something
that can be reproduced in terms of one own existing mental schemata, but they are
bound to fail because art cannot be used in this sense. It has an innate tendency to keep
cropping up when and where you were not actually looking. Because ofthe effect it
sometimes has on you, your reaction to it, it sometimes feels that it is it that is actually
using you ... Phenomenologically, arts stands apartfrom what it is deeply concerned
with: because it is a living symbol ofrelationship and ‘betweenness’, it can help us in our
search for human wholeness. (p. 12)

Grainger warns that limiting ourselves to research that allows us to study “what we are able to
measure” (p.1 8) will reduce what we really want to know or change altogether the direction of the
inquiry.

Summary of Research Methods

This study employed a!r/tographic research within the qualitative paradigm. A/r/tography seeks
knowledge through living inquiry and a commitment from the researcher as an artist and educator to a
process of questioning. AIr/tography recognizes the ambiguities, uncertainties and the difficulties that can
arise from situations and seeks understandings of them. A/r/tography allows the researcher to be self
reflective. A/r/tography gathers information from relational conditions that support democratic
relationships with other participants in the inquiry. It also invites participants to be part of the study
process and experience the resolutions if they happen. A/r/tography and its understanding of the multiple
roles of the researcher and his/her involvement through relational inquiry fits perfectly with the making of
architecture as practice and theory. The three forms of knowing (theoria), doing (praxis), and making
(poesis), which are fundamental concepts in alr/tography, are also the structural pillars of architecture.

Ethics in Research

Ethics is an area of major concern when conducting research with vulnerable populations such as
seniors with dementia. The literature on the topic of ethical issues in healthcare in general is enormous. In
a course on ethical and philosophical issues in community-based research presented by Drs. Michael
McDonald and Jim Frankish, I had the great opportunity not only to discuss ethical issues that were
relevant to the participants we work with, but also to reflect on my own values and woridview, to be
aware of the levels of objectivity or subjectivity reflected in my research. This course covered
fundamental challenges regarding the ethical conduct of research and related issues of power,
participation and ownership of knowledge. Articles by authors such as MackIm (1999), Minkler, Faden,
Perry, Blum, Moore & Rogers, (2002), Williamson and Prosser (2002, 2002a) all touch on dilemmas and

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problems in conducting research. Issues such as personal rights versus the good of the community at large
were discussed.

In studying seniors with dementia we need to be aware of: a). The limited memory capacity and
frailty in seniors with dementia, b). Their ability to give written consent, c). The role of the legal guardian
and their relationship with the senior with dementia, d). The role of the administration in the care facility,
e). The trust that needs to be established between the researcher and participants and all other concerned
parties.

I am mostly concerned with: f). How much can we tell the seniors about their diagnosis of dementia,
and what purpose would it serve? g). In the pursuit of academic honesty, should we cause sadness and
anxiety in our participants by reminding them of their diagnosis, knowing they may forget about it in few
moments or in a day or two? h). By not telling them, do we then sacrifice their right to be informed and
knowledgeable about the study they are about to enter? i). What happens when a senior with dementia
gives consent, but the legal guardian disapproves of their participation? j). What happens if a facility
manager is reluctant to let research work be done in the facility, even though the resident and the family
approve?

An attempt to answer these difficulties in executing ethical research lies in a fundamental
philosophical approach to life that can transcend borders of culture and geography: It is the profound
conviction to maintain and respect human life and the right to live in dignity. This respect for human life
transcends the duty between child and parents and encompasses the duty between an individual and the
society at large:

The home is infinitely more important to a people than schools, the professions or
political life; andfilial respect is the ground ofnational permanence and prosperity. Ifa
nation thinks of its past with contempt, it may well contemplate its future with despair; it
perishes through moral suicide. (In Pentateuch and Haftorahs, p. 299)

To satisfy academic requirements, I realize it is important to back up personal convictions with
literary sources. In Denzin and Lincoln (2000), chapter 13, Valerie 3. Janesick (2000) states that:

The myth that research is objective in some way can no longer be taken seriously ... As
we try to make sense of our social world and give meaning to what we do as researchers,
we continually raise awareness ofour own beliefs. There is no attempt to pretend that
research is value-free. Likewise, qualitative researchers, because they deal with
individuals face-to-face on a daily basis, are attuned to making decisions regarding
ethical concerns, because this is part offlfe in the field. From the beginning moments of
informed consent decisions, to other ethical decisions in the field, to the completion ofthe
study, qualitative researchers need to allow for the possibilities ofrecurring ethical
dilemmas and problems in the field. (p. 385)

Janesick also discusses the need to construct an “authentic and compelling narrative of what accrued
in the study and various stories of the participants” (p. 386).

In the following areas I attempt to answer ethical considerations:

Frailty, memory capacity and giving an in formed consent. The health condition of seniors with
dementia was the single most important factor in designing this study. Based on my experience I set these
conditions:

• Limit the time allocated to each session
• Be prepared in case of emergency and have resources in place for support

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• Be careful not to expose the seniors intentionally to stressful activities or stressful environments
in order to prove a point. While some experimental situations can be considered, I would not
worsen existing conditions

• Limit situations that knowingly keep away interventions that may benefit them
• Allow participants to move around and leave at any time

Memory capacity. Based on my experience, seniors with dementia may remember giving consent for
time periods ranging from a few minutes to several hours or several days. It depends on each individual
and their capacity to remember. I made sure the seniors were reminded every once in a while of the
reasons I interacted with them and the objectives of this interaction.

Written consent and dementia. Most seniors with early to moderate dementia can still read and
write. They may not understand complicated concepts, any more or less than people outside the research
field, or their peers of normal aging. Therefore, written and verbal information needs to be clear and
simple to understand, without compromising the integrity of the study.

All the participants at L’Chaim Centre provided their consent. At the Margaret Fulton Centre, the
consent of the selected participants was accompanied with their family’s consent.

The role of legal guardians and the relationship between them and seniors with dementia. In
an ideal situation both parties would be in agreement and happy to take part in the study. However,
legally, seniors with dementia can be declared incompetent by the legal system and consequently
relinquish their rights to act independently and be solely responsible for their actions. Problems arise if
the parties do not see eye to eye and one would like to participate in the study while the other refuses.
This is a delicate situation. If a senior with dementia refuses to participate, that decision should override
any other. If the legal guardian refuses, if possible, further negotiation can take place in very tactful ways
and with full respect for the outcomes. As it turned out, one participant at Margaret Fulton Centre refused
to participate in a couple of sessions. Although her husband was fully supportive of her participation, I
felt it was more important to respect her wishes and let her leave the room and join another activity.
Preserving her rights to control her wishes was more important than my need to conduct this study.

The role of the administration in the care facility. The administration is there to protect the seniors
with dementia and make sure their needs are met according to the policies of the facility. However, some
situations may become sensitive in cases where the research work may be rejected or manipulated for fear
it may interrupt the daily routine in the facility or threaten the administration by being critical. At
Margaret Fulton Centre, there were issues with scheduling and the difficulties in assigning staff to help
during the session. However, at the L’Chaim Centre, there were underlying issues of power and control
that concerned the director.

The trust that needs to be established between the researcher and participants and all other
concerned parties. This took time, and careful consideration was given to be sure consents were given
of free choice. In both Centres the process for acquiring the consents followed the prescribed regulations
provided by the University of British Columbia and the Vancouver Health Authority.

How much to tell the participants about their diagnosis of dementia. This is one issue I struggle
with when working with seniors with dementia. On the one hand, I am expected to announce my
intentions clearly and without ambiguity, yet there is a concern about discussing dementia with the
seniors for fear of causing them unnecessary stress. I rely on the administration to provide me with
medical information and to let me know if the seniors are informed of their medical condition. Many of
the seniors did acknowledge their memory problems. Some knew about their diagnosis but forgot it, and
did not mind being reminded. No one got upset to learn about their condition. I announced my intentions
only when I felt that it was appropriate to discuss them and when we all felt safe. Generally, I avoided the
issue if! could. I believe the participant has the right to know about his or her health condition. However,

67



I also believe in protecting participants’ wellbeing and this is the point where it becomes an ethical
dilemma with no easy answers.

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Sites Selected

The Margaret Fulton Adult Day Care Centre in North Vancouver and the L’Chaim Adult Day Centre
at the Jewish Community Centre in Vancouver were the sites chosen for conducting the intervention of
creative expression activities and documenting the physical facility for data collection. The two facilities
provided different qualities of space, participants, and operational procedures for the program of creative
expression activities.

Figure 4: Locations of Margaret Fulton and L’Chaim Centres

The Margaret Fulton Adult Day Care Centre

This relatively new facility is located at Mahon Park in North Vancouver. It provides a broad
range of health services and support as well as socialization opportunities for seniors. The Centre, built in
2000, was designed by Sean McEwen, Architect with significant input from the Centre’s staff. It can
accommodate up to 30 seniors a day, but is funded for only 25.5 seniors. There are four full-time

employees, 6 part-time employees and 28 volunteers. The Centre includes: Entrance! reception area,
nursing station, director’s office, staff area, quiet area, dining room, washrooms, outdoor area/garden,
kitchen, janitor’s room, laundry room, bathing facility, beauty salon, arts and crafts area, exercise area,
sitting area/fireplace, emergeney!treatment room, storage room. The Centre covers about 6,000 sq. feet.

(Source: GVRD cert/Ied Municipal Map)

Figure 5: Exteriors of Margaret Fulton Centre in North Vancouver, BC

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The program in this Centre includes nursing supervision, health monitoring, assistance with personal
care, and recreation for groups and individuals. A hot lunch with special diet options is provided. The
program also provides valuable respite care for families by taking in frail elderly individuals cared for in
the home; it is one of only two programs that provide this care in the Region.

This Centre was the focus of a study conducted by Stacey Diane Grant for her master’s degree in
gerontology at Simon Fraser University in 2001. The objective of the study was “to determine how adult
day care (ADC) clients with dementia are affected by relocation when staff, programming and daily
routine remain constant” (p. 1) Grant sheds light on the interplay between the physical environment, the
use of the space and the physical and cognitive abilities of the seniors with dementia. She also refers to
the environmental press, a term invented by Lawton and Simon in 1968, who describe it in these words:
as “the competency of an individual decreases, the greater the impact of environmental factors on that
individual” (Grant, 2001, p. 5). Personal competence is described by Lawton (1998, p. 2) as “[Ijntrinsic
performance potential, the maximal expectable performance in biological, sensorimotor, perceptual and
cognitive domains.”

Figure 6: Interior Shots of Margaret Fulton Centre in North Vancouver, BC

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The L Vhaim Adult Day Care Centre

L’Chaim Adult Day Care Centre is located at the Jewish Community Centre in Vancouver. The
Centre offers therapeutic, social, and recreational activities for homebound people who are elderly and/or
have disabilities. It provides a Jewish atmosphere and hot kosher lunches. The Centre, established in
1985, moved to its present location in 1996 after the entire building was renovated. It can accommodate
15 seniors at a time and has 10 part-time employees, no full-time employees. The Centre has 16
volunteers, 12 of whom sit on the board of directors. It covers about 1,400 sq. ft. The Centre includes: one
large lounge with furniture that defines areas for various activities, some lounge chairs for relaxation, a
fish tank, kitchen area, washrooms, outdoor deck, two offices, storage room and treatment room, which
was used for storage until recent changes to the centre. It is now a treatment room again.

A SIN

Figure 7: L’Chaim Centre Exterior Shots

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Participants Selected

This study focused on men and women with dementia over the age of 60 at the two adult daycare
Centres. The initial ann of this study was to explore how the physical setting supports, stimulates or
hinders the learning environment for seniors with early to moderate dementia to express their creative
abilities. As the selection of participants began, it became apparent that selecting a homogeneous group of
people in both Centres would be too difficult to achieve. Of the two Centres it was easier to select a group
of participants of similar cognitive abilities at the Margaret Fulton Centre, since it was geared to serve
difficult cases with more advanced dementia, while participants at the L’Chaim Centre were of mixed
abilities, ranging from normal cognition with physical frailty to mild cognitive impairment to moderate
dementia.

72

Figure 8: LChaim Centre Interior Shots



Over the course of this study, emerging new information became available on mild cognitive
impairment (MCI) and the significant implications of detecting this condition as early as possible. MCI is
a stage in memory decline between normal aging and the diagnosis of Alzheimer’s disease (AD). It is
sometimes referred to as amnestic mild cognitive impairment (aMCI) and is characterized by a mild
memory decline in the context of normal daily functioning (Feldman & Jacova, 2005; Petersen, 2004).
The majority of individuals with MCI develop Alzheimer’s Disease (AD) within 6 years (Petersen,
Grundman, Thomas, Thal (2004, p.1 83-194). Literature on MCI indicates that learning interventions may
help people with MCI to halt the deterioration. Several studies underway are exploring memory
intervention in aMCI. One of them is funded by a 2003-2005 Alzheimer’s Society of Canada grant, where
Drs. Troyer, Murphy, Anderson, Craik, Moscovitch & Marziali examined the effectiveness of a
multidisciplinary intervention program for improving memory functioning in individuals with aMCI.
Preliminary findings indicate that the intervention resulted in increased use of memory strategies,
increased appreciation for the effects of lifestyle factors on memory, and improved ability to learn new
names. Given the recent information on MCI, participants who were diagnosed with MCI, were included
in the interviews and the intervention in this study.

The selection of the participants was controlled by the directors of both Centres. At the L’Chaim
Centre, permission to conduct the study was dependent on my consent to include all the seniors,
regardless of their range of abilities. At the Margaret Fulton Centre, the director selected eight potential
participants —later was reduced to seven people — with group of five women who stayed together through
most of the four sessions.

Figure 9: Participants at the MFC and LC Centres

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Data Collection

The data was collected in several ways. It included field notes, filming, photography, and drafting. No
field notes were taken during interviews. All field notes were written immediately after each interview
and each session. The field notes were based on my perceptions and were entered on a computer. The film
activity was recorded and coded; the recordings were transcribed verbatim. The digital photographs were
transferred to the computer, and the drawings were entered on the computer in AutoCad.

Recording the Intervention

1. Field notes. Notes were written immediately after the activities were completed, usually within 4
hours. They included my personal observations, feelings, thoughts, comments, understanding of
what transpired during each session and ideas for the future. The notes, including the date,
location, and who was present, were entered on my computer.

2. Filming and sound recording. Filming gave me the opportunity to see things that transpired
during the sessions I could not catch in the moment, whether it happened out of my range of
sight, or I was too busy to see or hear the importance of the event when it occurred. It also gave
me a more comprehensive view of individuals and of the group, and the ability to review it
several times.

Two cameras were used: a stationery camera and a mobile camera. One Sony PD 100 DVcam
continuously filmed from a fixed wide-angle position showing the entire group seated around my
working area. It used 3 hour tapes. The sound was recorded from one wireless microphone I wore. A
second backup mini DV camera was used for close up and roving shots. This camera required tape
changes at 90 minute intervals. Normal room lighting was used except for one test session
experiment using added focused light. The video tapes were then transferred to VHS viewing tapes
with Time Code information made visible on screen.

The VHS tapes then were played on a rented professional video cassette player with a shuttle control.
The films were labelled and divided into four groups: DV tapes for Margaret Fulton and L’Chaim
Centres and the same for the VHS tapes. The timeline that was inserted on the VHS tapes for editing
purposes helped to locate specific clips with ease. Here is a description of the process:
• DV acquisition xfer to reference viewing media with time code (tc) picture burn :hr:mn:sc:fr
• Edit process to digitizes DV camera footage using bum reference as directed
• Edit First to Final Cut through three approval stages before outputting to Master
• Output Master including thesis menu index for footage references, as directed by the author

3. Transcribing. A UBC student was hired to do the bulk of the transcribing. I checked the text for
accuracy as I reviewed the video tapes. After the films were transcribed I selected the most
significant moments to be included on a DVD that is attached to this document. Although some
information was lost in the process viewing the videos for accuracy helped tremendously, since I
could then concentrate on smaller details. It actually forced me to pay attention to the smallest
sounds and to translate Hebrew and Yiddish into English. Transcribing verbal sounds into text
was the relatively easy part, what was more complicated was describing the body language.
Transcribing forced me to pay attention to the written word while blocking out other stimulus
such as hearing and seeing. Transcribing was an essential part of the study that complemented
other ways of collecting data.

4. Photography. I kept a digital camera with me at all times. I have used photography for many
years as a way to freeze interesting moments wherever I go. This study was no exception. With
the consent of participants, families and the administration of the Centres, I took photos of
participants interacting, laughing, holding a violin, doing artwork and dancing during the
sessions. I did not use the camera when situations were sensitive, since early on. I decided that the
needs of participants would come first before the needs of my research.

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5. Drawings. I used sketches and photographs to document the location of furniture, cupboards, TV
screen, music instruments and plants. Floor plans were supplied by the architect of Margaret
Fulton Centre and the building manager at L’Chaim Centre. The drawings of Margaret Fulton
Centre were up to date. The floor plan at L’Chaim had to be redrawn since the measurements
were not to scale. The information was given to a BCIT student who used AutoCad for transfer to
the computer. I worked closely with the student and provided additional information in free hand
drawings. Once the information was entered into the program, we could move things around and
experiment with sizes and distances in a fairly short order.

The room arrangement for each session at the two centres was documented. It included the
furniture placement, room dividers, all the fixed features such as doors, windows, lights, kitchen
counter and sink, where the participants were sitting, where I positioned myself, measurements of
distances between participants and objects, the location of the camera and the camera man, the
musicians and the musical instruments, and the TV. Each drawing was accompanied with still
photos that were taken at the same session and included photos of inside and outside spaces. All
of this information was used in the final drawing for each Centre and contained recommendations
for future architectural changes.

6. Interviewing. The participants were asked if I could visit them at home for an interview. I
described the style of the interview as a relaxed conversation. I made a point of not taking notes
during the interview, nor did I use the camera. I felt privileged to enter their private life and
wanted to keep it that way. For ethical and safety reasons, in my later notes I did not give too
much information about the participants’ homes for reasons of privacy. In the case of participants
with more advanced dementia, I called the families to arrange an interview once the participants
themselves expressed an interest in doing so. Wherever possible, I preferred that a family member
was present. The interview lasted from one to two hours. The visit was designed to give me some
clues about the interests the participants may have had in the past and in the present. It was an
opportunity to see hanging photos or photo albums of family, friends, pets and traveling. It was a
time for reminiscing and sharing life experience. The information collected was then used in
ways to attract the participants’ interest in the creative expression activities program, such as
asking questions that were relevant to them. The interviews gave a better understanding of the
person inside the disease. As a researcher I found the life experiences of the participants
fascinating; they enriched my own life experiences and helped me connect and bond with the
people I was studying.

Analyzing Data

I was looking for new understandings and emerging categories from recurring situations that could
eventually congregate into patterns. I also was looking for unique moments that stood out and contained
significant information. I identified these patterns by using color coding, available through -Microsoft
Word. As I read the written data, I assigned a color to each situation, such as being anxious, sharing life
experiences or expressing an opinion. The color coding turned into a legend that grew more refmed as the
study progressed. The legend was re-adjusted, upgraded and re-inserted on each document as I searched
for details that had escaped my attention. If necessary, I added highlights to the missing analysis. Towards
the end, the legend grew quite comprehensive and patterns took visually and contextual form. This
technique appealed to my artistic taste and called on my curiosity as to what color code meaning what
situation, activity or behaviour were most prominent.

Legend (example)

Needs Hebrew translations from the video and inserted into the

_____________

transcriptions.

Dalia sharing personal information

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I
I

Participants sharing life stories. Reminiscing.

Participants’ acknowledgement of memory problems

Memory and behavioral issues

Space Issues (lights, circulation, finishes etc)

Socializing

Participants evaluating/commenting on to day’s session

Participants enjoying music and the session. Showing interest.

Non-English Words (N-EW’s)

Staff interfering with activity

Safety issues

Ideas for future sessions

Show this in a clip where relevant
Part cpints be art supplies
Dali g insti

Tools for Collecting Data: Interviews

Interviews with Participants at Margaret Fulton Centre

Originally, eight women were selected at Margaret Fulton Centre to
participate in this study. Seven of them participated in some or all of the
sessions. All were previously diagnosed with dementia. Their ages were
66, 72, 76, 81, 83, 87, 92 years old. The oldest person participated in only
one session out of four sessions; she stopped coming to the centre for
medical reasons and therefore was not interviewed. Another was admitted
to a long term care facility and stopped coming to the Centre altogether.
The remaining five women formed a core group that participated in most
sessions. Three participants were interviewed in the presence of their
husbands. One participant was interviewed in the presence of her daughter.
The following is an example of the field notes that were taken immediately
after the interview was completed.

Figure 10: Margaret Fulton
Centre Art Facilitator and a
Participant

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Example Interview with a Margaret Fulton Centre Participant: July 27, 2005 Interview with
Margaret Dyks and her husband at their home

I made a mistake. I arrived one day early for the appointment. I wrote it a little messy in my calendar
and read it wrong. Nevertheless, Bill and Margaret were home and had time for an interview.

Margaret was sitting in the living room on their couch. They had just arrived from the dentist where
Margaret had a tooth fixed. Margaret was dressed in a sweat shirt and was pulling on her sleeves to cover
her hands. Bill was in shorts, a T-shirt and sandals. It was a hot day but I
noticed that she is also cold at the day care and is always dressed warmly. At times too warmly.

It seemed as if it was taken out of the 60s. Something like my mother
would have.

Bill sat down with us since Most of my conversation was with Bill.
Although Margaret would smile or watch me talk she would look away whenever I wanted to make eye
contact with her. She kept on
looking at Bill as if asking for approval before she answered my questions or even responded to any of
my comments.

was telling me about their 3 grown children, 2 daughters and one son He also told me about their
j!utine and skating. Bill gave me an envelop with copies of a letter to the editor of the North Shore
erand an article that was published as a result.

Bill took me to the kitchen to show me 2 albums full of newspapers articles and memoirs he was writing.

Bill agreed it was a good idea. I don’t know if he will follow up
on the advice.

Margaret seems to show interest when the topic of discussion is about skating and singing. At one point I
asked Margaret about her singing in her church choir and if she enjoyed it. Her answer was short” I am a
singer” and she looked at Bill at the same time. I was there for about 2 hours. During that time Margaret
sat in the living room and did not get up once, even to join us as Bill was showing me around.

While I was there I had to call my own doctor for an appointment. As I was dialling the number, I noticed
that the phone was covered with phone numbers not in an organized fashion. Bill saw me looking at that
and he was quick to explain that it was to help Margaret remember phone numbers

Towards the end I asked Margaret if she would like me to come back. She responded by shrugging her
shoulders and twisting her lip to one side, as if saying she was not so sure about it. I have to admit, I was
surprised at her response, and yet I needed to be reminded that having dementia might bring out responses
that usually would be more controlled.

When I left, Bill was very apologetic and waved good bye.

‘It
was apparent that Margaret trusts her husband Bill and is dependent very much on his care They still go
out to music events, skating and occasionally see friends for dinners orir:h.

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I visited 9 out of the 14 participants at home in an effort to
learn more about their background, families and interests. I did
not visit two of the participants that were identified as having
normal cognitive abilities; I was mainly looking for clues in
the participants’ own home environment that might provide
information on their interests in art work, home decoration,
taste in colors, hobbies, and to listen to their life experiences as
we leafed through their photo albums and photos hanging on
the walls. By doing so, I gained a better understanding about
how to engage them during the intervention of the creative
expression program. The following is an example field notes
that were taken immediately after the interview:

Example Interview with a L’Chaim Centre
Participant: July 14, 2005 Interview with Jack Beckow

I arrived on time at 2:OOm as we had agreed. It is a hot summer day. Jack buzzed me in through the
intercom. I went up to the 12 floor where Jack greeted me very warmly. He was dressed in a blue
jogging suit. The air was flowing in from the open doors to his balcony. There was a beautiful view
looking over the flats of Richmond and the approaching airplanes.

rlooked but very focused. He wanted to know the purpose of the interview and I told him about
the topic of the study He sounded very mterested He told me that he was just mterviewed by a person
from the Jewish Bulletin newspaper, that lots of information is gj to in the article and that I should
look into it. I did not want to tire him, so my questions followed whatever direction the conversation was
leading us.

There are a few art pieces on the walls. There is no clutter. I found out
that his first wife died tragically in a fire that started from a cigarette she smoked in bed He was left with
young children. I don’t know too many details about them. He remarried a musician and divorced several
years ago. He stayed friendly with his ex-wife.

As we were talking about L’Chaim, I told him that Michel and June would love to have friends come
over. 1-Ic was not sure he could tolerate Michel’s talk and attiti . I told him that, in private, he is
really delightful.

lack was talking about opera Be invited me to the next room to see his collection Behmd the opr
there werat leasC5shelves,5 feet long, full of videos of operas, all labeled and organized meticulously
On the wall was a poster of the 3 Tenors Next to it was a poster of Pierre Trudeau, one of the prime
ministers of Canada I asked Jack about it he answered that Trudeau was the best politician in Canada
and that he admired him.

We continued to talk for a little longer. Jack was telling me how important L’Chaim was for him, that he
lost all zest for life and stayed motionless in his apartment until he came to L’Chaim, where,with the

help of the staff, he started tp enjoy life again His most important observation was that being treated likea person was crucial in hisW

Interviews with Parncits at the L’haim Centre

Figure 11: L.’Chaim Participants
Engaged in Art Activity

I a consultation session. I

__________

His financial advisor and a family member had just
not meet them. Jack planned it so I could be with him alone.

78



I told him that I am finding it interesting that at least three men in our group are design-oriented and I
wouldn’t have known that if I had not talked to them individually and seen their work. Michel was a
fashion designer and builder, Jack was an aircraft designer and builder, Avraham was a needlepoint artist,
even though, according to him, he was a professional soldier in the Israeli army.

This led me to think about the next project far L ‘Chaim. Based on my deeper understanding of the
participants in the study, I have decided to ask the participants to design their dream art studio/or
creative expression activities. Jack thought it was a great idea. He had a wonderful smile on his/bce and
I could see his eyes sparkling. I think I have found a link to his passion — building.

I parted from Jack with a big hug and a kiss and a promise to see him again next Monday.

Significance of interviewing Participants at Their Home

Getting to know the person inside the condition

Finding clues that would attract the attention of the participant and make the activity program
relevant for him

Allow the researcher to develop a better understanding and bonding with the participant

Encourage the sense of familiarity between the participant and the researcher

Meet relatives and friends that form the support group and gain more infornntion through them
when the participant can no longer provide it

See the participant in a home environment and look for differences in behaviour that may impact
his or her participation at the Centre

Tools for Collecting Data: A/r/tography Field Notes

As the program developer, facilitator and researcher, I was the person responsible for the design and
implementation of the program and assumed the role of participant/observer. I visited the two sites
numerous times before the study began in an effort to get to know the staff, the directors and the physical
environment. At the L’Chaim Centre I conducted a workshop for staff and volunteers. My intimate
knowledge of the Jewish faith and culture proved to be an asset that worked well for me and the
participants. At Margaret Fulton Centre the situation was different. I felt 1 needed more time to become
familiarized with the facility, its staff and operational procedures. For that reason, I volunteered at
Margaret Fulton Centre for several months before the study began and came to understand the multi
cultural nature of this Centre, with clients who came from different countries, faiths and races.

My own recent brush with serious medical problems opened an emotional connection with the people
I worked with and led me to a different level of understanding of the meaning of sickness; diminishing
energy, of being dependent and needing help from family, caregivers and strangers; the desire to be
counted and noticed as a person, to be helped but not pitied. I have developed a deeper understanding of
the meaning of constant pain and its impact on our cognitive and emotional abilities and expression.

The field notes provide insight into the various roles I assumed through intentional planning or
through events as they arose. These field notes, written immediately after each session, deliberately
separate the many roles that I assumed in this study. This exercise proved to be difficult at times, since the
various roles happened concurrently. Trying to establish when one role starts and another finishes was an
artificial, analytical exercise. However, there was no other way to write simultaneously about all the roles
at once. For example, if I could describe my roles through music, I could have assigned instruments to
each role and played them all at once in an orchestra. However, since I am not a composer, writing must
remain my tool for expression, with additional help from the visual arts as the study progresses.

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The colourful legend attached to each report was developed as the study progressed and as issues
came up and evolved later into concepts and patterns. This coding continued to expand into other areas of
the data collection and its analysis, through the field notes to transcribing the films.

Example at Margaret Fulton Centre

July 19,, 2005: Hand Massage Session and the Big Walkout

Legend

Space issues, furniture, lights

E-Mails correspondence with staff

Any problem to pay attention to, such as behaviour, safety

I I Ask David about camera work and room layout
Researcher using knowledge from architecture

I I A point to check again. Ideas for future consideration

Present: Dalia, David. Seniors: Lucia, Margaret, Elena, Carol and Betty.
Weather:
Transportation: My own vehicle. David came separately in his car.

Researcher

State of my own mind: I was not worried about the session at all. I knew what I was going to do and I
was ready for whatever would transpire. I am still sad that Carmel left and I did feel her absence. In the
last month she became a very important part of my work with the seniors with dementia.

My physical and emotional state: I was ready and felt good. I have to admit that I feel more connected
when I work with Jewish elderly. There are so many things in common that need not be explained. The
commonality of tradition, faith, the Hebrew and Yiddish languages, the familiarity and the nuances of
similar mannerisms and sense of humour. I think that this kind of familiarity provides a sense of
confidence, safety, warmth, soothing and embracing. Perhaps it is a sense of knowing you belong
somewhere. Being an immigrant to Canada myself, I am very much aware of the need to belong
somewhere. That is why I try my best to integrate the two Spanish-speaking women, Elena and Lucia, as
much as possible, but not nearly as much as I would have liked to do if I knew how to speak Spanish, or
could have the support needed for them.

Preparation for the session: I decided to divide the group into two. The English-speaking women,
Carol, Betty and Margaret in one group and the Spanish-speaking women, Elena and Lucia in the second
group. I prepared one of my sessions on cosmetics, beauty treatment, hand massage, creams, lotions and
smells. I brought with me lotions I bought in Israel, products of the Dead Sea, small towels and manicure
materials. I also selected background music from the tapes at the Centre.

Educator/Learner Facilitator

I and asked if I would consider having Elena and Lucia join the session. I told her
I would need to think a little and that I would give her an answer in a few minutes.

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Instead, I used a card table 3x3 feet, which presented a
different kind of dynamic in the physical proximity between myself and each participant.

I told Maureen I will stay with the 3 women. Joan Skeet arrived and asked if she could bring the women
in. David and I agreed. Joan arrived with the women and I could see right away that

-n saying she had spent all morning in this room and would like to be outside.

_________

but could help bring in the participants. Carol was tlying to convince Betty
to join her. l a walk. Margaret was in
agreement that she Joan was looking at me and
waiting for a sign about what to do. I told h... women are free to do whatever they want and that it was
more important to protect their right to control their own lives.

Joan took them out and I was talking to the camera and to David about what happened. As a reminder, at
the last session all the women agreed

When Joan came back with the women, . I was glad that Joan finally took her out.
That was the right thing to do. However, Betty was sitting down and Joan urged her to stay. At this
moment I let Joan control who stays and who goes. The participants trusted her and liked her. And so,
Carol left, Betty stayed and Lucia and Elena joined us as well.

The situation called on my skills as a facilitator, my knowledge of ethics issues of people with cognitive
impairment and their right to live in dignity. I felt I was equipped to handle the situation in an appropriate
way and the courses I took on ethics issues in health care were very important.

David stayed in his usual corner and filmed towards the windows.

When I came into the room David had set up for the session
today of massaging hands, where I needed to reach every participant. I thought the round table would
have been the best choice

I think I need to design a new table that would answer many needS and uses

ArchitectlArtistlResearcher/Facilitator

— We settled for a card
added a fifth chair for me.

of the room with 4 chairs around

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Example at the L’Chaim Centre

July 18, 2005; Designing a studio for creative expression activities

Legend

Space issues, furniture, lights

I I E-Mails correspondence with staff
Any problem to pay attention to, such as behaviour, safety

I I Ask David about camera work and room layout
Researcher using knowledge from architecture

LJ A point to check again. Ideas for future consideration

Present: Debbie, Dalia, David, June, 3 volunteers. Seniors: Jack, Ruth, Tobi, Irena, Sonia, Avram,
Harriet, Sara, Anita.
Weather: •
Transportation: My own vehicle. David came separately in his car. June came along to help. David and I
went for lunch afterwards at Enigma and out to UBC to take photos of UBC sites for our Society’s web
site. June went back home separately with my car.

Researcher

State of my own mind: Carmel left for NY and Israel two days ago. It was a very emotional departure
and painful. I was wondering how I would handle the situation if I was going to be asked if she had
already left. The seniors showed a great deal of interest in Carmel and her travel plans, especially her
going to Israel.

My physical and emotional state: I was very relaxed and looking forward to the session today. I wanted
to see what the seniors would come up with.

Preparation for the session: I called Debbie at home and discussed my plans for today’s session. I told
her I am going . I explained that I would conduct a
discussion first of what a creative expression studio needs in general, and what it needs when it is
designed for seniors. for various reasons. First, not all the
participants have dementia. Second, I felt there was no reason to make this point and embarrass or cause
emotional stress to those who have dementia. I was interested in having their input in the planning and at
the same time observe their abilities to express themselves.

Supplies for the session: B lead pencils, already sharpened with erasers on the pencil ends. It turned out
that separate erasers that were heavier and bigger were better for the task. I also brought 14x1 7-inch
sketch paper, suitable for pencil and pen. The paper was acid-free and 100% recycled. I was not sure if
the size of the sheets would be sufficient for the task; however, they turned out to be a good size.

Educator/Learner Facilitator

This session was especially interesting for me as an educator, learner, facilitator and architect. I knew I
was going to stretch to the limit the creative abilities of the participants. I knew this was going to be
intense and would demand a great deal of focusing on the topic while utilizing planning abilities and then

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expressing them on paper. I knew that very few people have drafting skills. And yet, I wanted to give
them the opportunity to be part of my work in a meaningful way. Until today, I was the one in the leading
role. Today, I wanted to hear and learn from them.

I knew I had to approach the session very carefully while creating an understanding about what I am
looking for. I began by telling them that their input is important and may contribute to a better space for
creative expression.

I knew there would be a stage of self-doubt, of in something so new in a centre
like this. I also tried to change my position in the room from standing to sitting. The seniors really liked it.
Jack said: You are now one of us and not like a leader. This was exactly what I wanted to portray. I
finally managed to find a situation where I could tip the balance a bit and be on more ‘with
them. This is a stri in all ii work with senior

This awareness is actually at the forefront of
my work with seniors, but it is not always possible to achieve:

• Any group of people waiting for a project to take place waits for instructions
• Some seniors with dementia are not any different from well seniors but they may need more

encouragement, more appropriate information to work with, some guidance to make
connections, and some patience on the facilitator’s part while the brain makes the connections
that lead to expression.

As the project progressed it was fascinating for me and the staff to see the level of involvement and
expression that was demonstrated today It definitely validated my long-held observation that with
appropriate approaches and challenges, seniors with dementia may rise to the occasion and reveal
more óf:théfr blltiesthanpnviously deiflittrated.

Architect/Artist

This time I decided to turn the U-shaped orientation towards the windows. My
intention was to create a visual buffer between the main entry and the participants sitting in the room. I
located the wicker partition to block the main entry from the visual field. The notice board was wheeled
in between the kitchen and the activity space. It was later wheeled out in front of the participants to
display sheets from the extra flip chart.

We knew that the seniors would be looking into the windows and into the light. We also knew that I
would be seen only as a dark figure because of the light behind me. We were prepared to experiment with
the existing lights, adding lights and changing the position of the window blinds.

Findings:

1. With the exception of one person, most seniors did not like the existing fluorescent lights. The
complaint was that they were too bright and harsh. Except one, most preferred the less harsh
lights.

2. Most liked a spotlight on me since it helped them see my face better. However, the participants
wanted a spotlight with softer light. David inserted a filter that dropped the light by 50%.

3. Most seniors, except one, liked the softer light from the ceiling even during their project. I think
the white sheets on the table reflected enough light back.

4. We closed the window blinds that were close to the participants. They liked it better.

5. The notice board was in the dark and needed to be highlighted. We moved the spotlight that was
on me to highlight the board. Everybody agreed it was much better.

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6. I noticed that no one paid attention to the main entry and that people who did come in left the
room very quietly, once they realized that there was a session in progress. It was much easier for
me to engage the participants in the activity and we were less exposed to interference.

The session

The session today was to program, plan and design a creative expression studio.
This time the participants were the clients and the designers. We

started with laying out the program, which focused on the activities and the needs of the users.

Debbie was writing down key thoughts that the seniors expressed. I was helping to direct and clarify what
I was looking for. Within the first hour we had a program. We also went into interior finishes, such as
floor finishes, wood flooring, carpets, mirrors, colors, curtains and so on. All of the items can be reviewed
on the video and on the sheets from the flip chart Debbie worked on.

We then proceeded to draw the spaces. I told the participants to ignore sizes and concentrate on how the
spaces relate to each other and not to be afraid to write and explain the drawing. Some people took to it
and started to draw right away. Tobi seemed to be very involved in the project and wanted blue, red and
white to be the dominant colors in the studio. She also drew a swing in her studio. Others wanted to
participate in the project but asked for help in drafting the spaces, and so, together with the helpers, they
came up with the space they wanted to see.

Jack and Avram joined forces and collaborated on the project. Anita was reluctant at the beginning but
ended up with an elaborate drawing. Michael was reluctant but with encouragement did manage to put
down his thoughts. Ruth worked with Heather (a helper) and seemed to be enjoying it. Harriet was right
into it. Sara enjoyed it and told me at the end that she was going straight from here to apply to an
architectural school. I loved her sense of humour. Sara had a helper too but was very instrumental in
giving directions. Debbie was working with Tobi and went along with whatever Tobi wanted. Later,
Debbie said to me, “It was amazing to watch what was going on.” I told her, I was amazed too and results
like these make all the effort worthwhile.

Figure 12: A Senior with Moderate Dementia at the L’Chaim Centre Designs her Creative
Expression Studio

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The analysis of self when interacting with seniors with dementia for the purpose of improving their
architectural environments that would accommodate their cognitive and physical needs is an important
part of understanding the world the seniors with dementia live in. The multiple roles of the researcher as
an educator, facilitator, artist, architect and gerontologist are all intertwined. Understanding the physical
environment and its appropriateness calls on expertise from several disciplines. Although it was difficult
to separate the roles at times, it was a worthwhile exercise since it translated deep buried intuition into an
awareness that later became a tool in designing spaces for seniors with dementia. For example, in
interacting with the participants I realized, based on literature review and my own experience that the best
distance for interacting with a person with dementia is within a radius of 4 feet around them and at eye
level. This observation has implications about what we can fit within this space. Since it is so small, we
need to think about where we position ourselves in relation to the participants: who or what should we
bring into the circle with us? What activity would revive interest and how should we present it to be most
effective? Is one specific artistic style of presentation better than another? How far do we go as
researchers in the sometimes elusive quest for meaningful change?

Figure 13: Participants at L’Chaim and Margaret Fulton Centres

Significance of Air/tography Field Notes and Analysis

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AIr/tography helped bring issues to a new awareness. I did not always have answers to my questions
but at least I was aware of them. A/r/tography is not so much about finding answers as being aware of
questions in an ever evolving stage. In the process of interacting with seniors with dementia, I found out
more about myself. It actually had therapeutic effects on me. It allowed me to discharge emotions and
express myself in many ways. No boundaries were enforced on me, but the principles of ethics. David
Maclagan (2001), an artist, art therapist and a lecturer at the Centre for Psychotherapeutic Studies,
University of Sheffield argues that “...where communication of various kinds between conscious and
unconscious takes place, can in itself be therapeutic in this sense” (p. 90-91). So the wheels turned, I was
there to help the seniors with dementia and found myself going along for the same ride. At times, the
multiple roles got me into troubled relationships and misunderstandings as a demanding society called on
me to define what was I exactly. Was I an architect, was I an expert on dementia, was I a gerontologist?
A/r/tography allowed me to be a person who was sensitive to issues those experts were concerned with.
The biggest question is how to translate this theoretical approach to life to the practical world outside of
academia?

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Figure 14: Participants at the L’Chaim Centre Engaged in Music Activity



Tools for Collecting Data: Filming

I chose to film the creative activity sessions with the participants in order to free my attention so I
could concentrate on interacting with them, while at the same time making a complete record of their
behaviour and mine in the spaces selected for the activities. Filming allowed repeatable analysis of the
physical environment and documented the use of space and circulation. Filming also helped focus my
attention to details that escaped my mind. When events are seen from another angle, we have additional
ways of understanding. Filming produced a rich source of information in a relatively short time without
having to subject the participants to prolonged experimental situations. According to Ranneskog,
Asplund, Kihlgren, & Norberg, (2000), video recording of music activities with seniors with dementia
allowed the researchers to focus on facial expression without having to interfere or get too close to the
participants. It also allowed repeated examinations of the raw material until reasonable interpretation of
the event was achieved without having to go back and bother the participants again.

David L Brown, who has collaborated in
producing videos on my work with seniors, is the
videographer. Over the last two years, David and I
have learned much about filming seniors with
dementia in their environment. David is familiar with
my interest in specific behaviours or reactions
expressed by the seniors. Together, we try to catch on-
camera behaviours we would like to revisit and try to
understand. David has given me a rare opportunity to
stay engaged with the seniors as a facilitator, and still
have a say in the.

We used two cameras: One camera was stationary
with a wide angle lens, while the other moved and
focused on details as they occurred. The videos were
analyzed for behavioural patterns, verbal and non

verbal responses to the sessions as they were conducted in different spaces. I opted not to use a software
program for video analysis since the number of participants was relatively small and manageable. I also
enjoyed aesthetically the method I selected to color code similar ideas, events and behaviours into
patterns that carried not only textual information but also fed my artistic curiosity about using the arts in
the service of science.

We considered several sites before selecting the two for this study. Being able to film the sessions
was a factor in selecting a potential site. We spent several hours analyzing the sunlight as it traveled
through the spaces where the activities would take place. We decided that the comfort and wellbeing of
the seniors would take precedence over the needs of the camera; the camera work would need to adjust to
furniture positioning, direction of natural and artificial light needed for the seniors’ art activity and where
I positioned myself as a facilitator with access to each participant. We decided that we would not stage
the site nor the participants to accommodate the camera.

At Margaret Fulton Centre, I drew on my experience as an architect as we imagined the movement of
participants around the room, the location of the media equipment, the sunlight, whether to bring or not to
bring the outside view into the room, how to manipulate the blinds, the proximity of my position in
relation to each area, and my access to each potential participant. We considered the furniture
arrangement as the participants entered the space, as they would relate to each other as a group and their
ability to concentrate on the task in front of them. All this was done in preparation for site selection and
for camera positioning. These preparations could not take place when participants were around. No clients
of the centres were present at these preliminary investigations.

Figure 15: David L Brown, the Videographer,
Sets up the Cameras at the L’Chaim Centre

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As the study progressed, we analyzed the videos in preparation for the next session and made some
changes, for instance, to the furniture arrangements in both Centres. We obtained floor plans from the
director at the L’Chaim Centre, and directly from the architect of Margaret Fulton Centre. The locations
of the cameras in relation to windows, doors, media centre, music equipment, kitchenette, chairs, tables,
side tables, sofas, plants, lights, fmishes such as wall paints, fabric, floor covering, ceiling covering, were
all documented and are included in the attached architectural drawings of the two Centres. Other crucial
aspects such as visual access or lack of it to the outdoors and whether environmental features have an
institutional or residential character were noted in the filming.

The example at the end of this chapter shows the method
used to analyze each of the 20 videos. All videos were
transcribed and color coded for emerging patterns that
revealed creative expression abilities and social behavioral
in the various manipulations of space, furniture and to a
certain degree changes in the quality of light too. In addition
to the textual analysis, we observed each video several
times, looking for information that was not apparent in the
transcript, but could be observed visually, such as body
language. With no sound, it was easier to pick up behavior
that occurred outside of my sight during the activities and
pinpoint details that did not seem important at the time but
later took on a significant meaning. One particular behavior
that stood out and would have been lost if the camera had
not picked it up was this. As one participant got up and

headed to the washroom, I moved in to the empty space to help her neighbor. What I did not realize when
the participant returned was that she did not want to bother me and, therefore, wondered away. It all
happened when my back was turned, while I was totally absorbed in helping another participant. Later I
decided the awkward furniture arrangement interfered with my ability to control the entire room.

In this example, the letters LC stand for L’Chaim Adult Day Care Centre. Color coding was layered
on the top of the transcription for analysis. The analysis allowed an intentional search for significant clips
that were condensed to a short DVD presentation. The DVD is attached to this study.

Tools for Collecting Data: The Inteiventlon — The Creative Expression Activities
Program

In my program the ability for creative expression is demonstrated in artwork, writing poems, dancing,
music, singing, story telling, reminiscence, cooking, flower arrangements, designing spaces, visiting
galleries and commenting on artwork, and holding varied discussions. This program is based on a multi
faceted approach with input from several disciplines: nursing, psychology, social work, education,
architecture and various forms of the arts; dance, music, painting and writing. This approach to creative
expression activities is based on understanding dementia as a disease, using the seniors’ remaining
cognitive and physical abilities to integrate their past into the present social context.

This program uses a personal approach as the main key to unlock barriers, build trust and use our
automatic reaction to what is familiar even when our ability to remember diminishes. Its goal is to
encourage caring communication with all seniors. Only when we learn about our seniors’ past life, respect
that world and treat the person with dignity, can we start to have an impact on their cognitive ability and
provide access to creative and social abilities.

Timeframe for the Sessions

Although I preferred conducting the sessions between 10 and 12 in the morning when the participants
arrive right after breakfast and are ready for activities, I realized that we needed to fit into the Centres’

Figure 16: Turning the U Table Around
with the Opening Towards the Windows

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existing schedule in order to cause the least disruption. At the L’Chaim Centre we were able to maintain a
morning schedule, right after the arrival of the participants at the Centre. However, at Margaret Fulton we
had to fit in with the Centre’s schedule and our sessions were planned immediately after lunch around
1:30 pm. Both times raised some problems. At L’Chaim Centre, we had to wait for the seniors to arrive
by special bus, which was sometimes very late and could affect the Centre’s entire schedule for the rest of
the day. In turn, this put pressure on us to finish our sessions at the scheduled time or even before that, so
the seniors could get ready for lunch and staff could clear the tables and prepare to serve lunch. The
afternoon sessions at Margaret Fulton Centre presented other problems. Right after lunch, the seniors
wanted to go for a walk, especially if the weather was nice outside. Some seniors already displayed
anxiety in anticipation for the 3:30 pm departure. Overall, the sessions went smoothly and as we learned
more about the Centres, the participants and staff, we managed to overcome most problems.

Selected Sessions from the Creative Expression Activities Program

Two sessions were initially selected for this study (appendix c). The first, on friendship, presented a
topic that has been well received by seniors with dementia and demonstrated in numerous workshops in
Canada and the U.S. It involves a discussion, poetry writing and artwork. The second session, on music,
presented segments from well known and loved composers, played by musicians. The sessions ended
with dancing and painting to the music. Each session lasted anywhere from 75 to 90 minutes. The seniors
participated once a week. Initially it was planned that the same group of seniors would experience two
sessions on friendship and two of live music, in two different spaces in two repeated rounds. However, as
the study progressed, changes were made along the way to reflect participants’ needs, wants and the
Centres scheduling. I made changes to parts of the selected activities to adjust to the spaces and to the
span of attention of the seniors on that day. Since the focus of this study was on the architectural
environment, I felt ethically obliged to provide the best I could to keep the seniors engaged and benefiting
from the intervention. In addition, at the 1’Chaim Centre, we held seven sessions instead of the original
four and so topics were added that included participants’ requests and activities I was looking to explore
to strengthen this inquiry.

Observed Everyday Creativity

A number of creative expression activities were observed based on the definition of everyday
creativity in the literature. Everyday creativity manifests itself in being curious, in an ongoing process of
self-evaluation and personal growth. Creative expression was observed in the following behaviours: (1)
sensory expression, including (a) visual and (b) verbal expression, and (2) social interaction. These
behaviours were observed and identified on the various forms of data collection: field notes, filming and
direct observation. The level of response and the need for assistance: (1) independent response, (2) partial
assistance and (3) total assistance, was also observed. However, a systematic observation that would
employ quantitative measurements was not included in this study.

Sensoiy expression. There were occurrences of sensory expression or lack of it that included: (a)
use of colour combinations; interesting interplay between the intensity and the hues (did not materialize in
this study due to lack of time, equipment and personnel), (b) appropriate use of image and colour to fit
expected norms (i.e. a piano is drawn in black with appropriate shape), (c) correlation between verbal
expression and the targeted task (designing an art studio that included an easel), (d) awareness of the
visual interpretation of an image and colour that do not follow expected norms, (i.e. the senior is aware of
the departure from imitating real life objects), (e) the kind of explanation accompanying the visual
activity, with emphasis on verbal expression; using humour, life lessons, unusual twists to the story, and
(f) listening to music and making connections to life stories (i.e. this music reminds me of the good old
times when we did not have television, and radio and live bands were the main source of entertainment).

Social interaction. Social interaction was observed in the occurrence or non-occurrence of certain
behaviours, such as: (a) sharing and expressing feelings (i.e. He sure went through hell, or I know what
you are talking about), (b) giving compliments or criticizing (i.e. you look really good today, or why is

89



she talking so much), (c) smiling or laughing, (d) making eye contact with the speaker, (e) asking a
question or leaning over to conduct a private talk, (f) touching or patting, (g) being upset, angry, agitated
(i.e. insulting others, not being able to stay seated, getting up to leave in the middle of a session without
explanation, shuffling objects for no reason, bad mood).

At the end of each session, participants were asked briefly for their thoughts regarding their
experience in the session. Staff and families evaluated the social validity of intervention goals, procedures
and outcomes by electronic mail through casual correspondence. No systematic follow up was conducted
after each session to see whether staff and families observed any changes in the behaviour of the seniors
with dementia outside the designated space. However, information was gathered through casual
conversation with caregivers, families and the participants themselves wherever relevant and appropriate.
Future idea to be explored would be whether or not there are long-lasting changes in behaviour beyond
the walls of the designated spaces for arts activity.

The creative expression activities were planned to take place once a week with each group, in each
daycare facility. Each session was planned to last for 90 minutes, depending on the energy level of the

Engaging in Creative expression Activities

Figure 17: Participants at L’Chaim Centre

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participants, their interest level and their health at the time. It began with 20 minutes of socializing,
serving coffee, tea and baked goods while discussion on any subject was encouraged. Next was a
prepared activity lasting about 20 minutes. It included a display of relevant materials. Discussion was
encouraged to draw on the seniors’ own experiences. Following the discussion an activity of about 30-40
minutes was introduced. Free discussion usually continues and takes on the flavour of the moment. Ten
minutes before the session was over, I started to indicate that the session was coming to a close and
pointed out that lunch was about to be served in the dining room.

The two topics selected for the
intervention were used in several long-
term care facilities and successfully drew
out various reactions from seniors with
dementia. However, since several more
sessions were added at the LChaim
Centre, more topics were added to avoid
repetition. The first topic on friendship
included a discussion on various types of
friendship, drawing on the seniors’ past
and present experiences. The last five
minutes of the movie “Casablanca” was
played, demonstrating how a new level of
friendship was struck between the French
policeman and the nightclub owner. An
activity of poem writing followed the
discussion and the movie clip. Key words
on the topic of friendship were called out
by the seniors and were written on a flip
chart of 24” x 34” paper. As the sheets of

paper filled up, they were displayed side by side at the eye level of the seniors. A new sheet of paper was
then displayed on the easel to further develop the poem into sentences. I read the words aloud as
sentences were called out. The group needed to agree and approve of the fmal product. All suggestions
were considered and an effort was made to incorporate even awkward key words. A sense of humour was
significantly employed.

The movie “Casablanca” was replaced by the “King and I” for the L’Chaim Adult Day Care Centre to
protect seniors who were Holocaust survivors. The change was made to reduce stress or avoid bringing
back unpleasant memories. A second topic consisted of listening to music, dancing to music, playing to
music, painting to music and reminiscing about the time the music was composed. There were no
restrictions but the seniors’ own creative expression.

Tools for Collecting Data: Space Diagrams

In addition to field notes, interviews, and filming, I documented the existing conditions of furniture
layout, location of partitions, participants, staff and various equipment, such as TV screens, aquariums,
cameras and musical instruments. Each drawing is representative of a specific situation. It also indicates
areas of problems such as inadequate space or glare from a window. These drawings are an important part
of the analysis of space. They present the existing space, suggested changes and design resolutions. They
appear in Chapter 5 for the purpose of clarity and flow in that discussion.

Figure 18: Presentation Board Separating the Main
Activity Room from the Kitchen Area at L’Chaim Centre

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Example of Video Transcript and Analysis

Documents an intervention session where the ideal studio was discussed.

LC-Session #5- Tape 1. Designing a creative
expression studio and experimenting with light in
the space.

Legend

I. I

I
I I

Needs Hebrew translations from the video and inserted into the
transcriptions.

Dalia sharing personal information

Participants sharing life stories. Reminiscing.

Participants’ acknowledging memory problems

Memory issues and repeated questions

Space Issues

Socializing

Participants evaluating/commenting on today’s session

Participants enjoying music and the session

Non-English Words (N-EW’s)

Staff interfering with activity

Stty

Show this in a clip

Ideas for future sessions

Participants showing interest in the art supplies

00:00:09:00 (number indicates time code inserted in the video) Setting up the session
00:02:29:00 Sonia is arriving
Sonia: if you are smiling everything is good
Memory issues. Dalia: I came to see you but you were not home.
Sonia: someone died in my building and all the people went to the funeral in a big bus.
Dalia: I had to call the manager because I was worried. The manager opened your apartment...l was
glad you were not there...
Sonla: Thanks God.
Dalia: Thanks God (in Yiddish)
Dalia: do you want to take off your coat? What do you think? Maybe you want to find a place to sit? So
many choices. Difficult to decide.

Sofia: nobody is sitting there.

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Dalia: then you don’t have to
00:04:16:00 Dalia: you are the first so you can pick the best seat.
Sonia: if I need two, I can take two
Dalia: yeah.
Sonia: laughing

Dalia helping Sofia to take her coat off.

Dalia: Sofia you are dressed so hot
Sonia: as if it was minus outside
Dalia: this is cute a little pin

In the background Heather, a volunteer is preparing the name tags for the participants.
Sonia wants her scarf back after she took her coat off. Dalia is arranging it for her.

Dalia: you can go and sit wherever you want my darling (talking to Sofia)

Dalia is talking to staff member about her weight loss and her diet.
Carmel left to NY and Israel.

00:09:28:06 Dalia: hello Irena
Ira: in Hebrew, I don’t have any energy
Dalia: trying to translate from Hebrew to Yiddish for Sonia
Dalia: it is hot but not like in Israel.
Ira: almost
Dalia: Ira do you speak Yiddish
Ira: I understand all, but all my languages are mixed now
Daha: Sonia said she can hear everything but does not understand
Sofia: where is your daughter?
Dalia: she left (in Yiddish) on Saturday. She is in NY for few days and then to Tel Aviv. It is difficult saying
good bye.
Ira: what is she going to do there? Learn music?
Dalia: no, international relations
00:13:04:20 Jack is arriving. Dalia: hello Jack, come on in, where would you like to sit?
Dalla: hello Harriet.
Harriet: I am doing fine (goes to her seat and walking with her walker)
Dalia: Jack, do you need any help?
Jack: my box is right over there
Dalia: Harriet, where do you want to sit? Here or there?

Space Issues. 00:14:05:17 Harriet; let me sit over there, then I can see everything that is happening.
(facing the room and the kitchen)

Dalia: just be careful there. (Dalia is moving a chair and pointing to something on the floor)
DaNa: sit here and I will push the chair under your tush.

00:14:40:20 Space issue. (light from Windows) Dalia to David: I can tell you right now that the light
from the windows is really bright. We will see how the reaction will be.

Dalia: Jack, are you going to sit beside Harriet?
Dalia: this is a good couple. (laughing)
Jack: how is your beautiful daughter doing? I guess she is doing her own thing.

Space issue. Harriet is waving to Debbie who walked in.

Debbie: good morning

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Use this clip. 00:16:31:05 Dalia’s thoughts. Debbie is checking the radio for background music. I
remember very vividly how this insignificant act hurt me, realizing I will not have Carmel there to work with
me. Today, or never perhaps. An era came to an end.

Dalia: I like your sandals

00:17:54:22 Space issues. David is adjusting the lights that will focus on me.

Dalia: Sofia we have to go to the table (in Yiddish).
Dalia: hello, good morning

Jack and Harriet are having fun and pointing at something.

Avrahm arrives.
Dalla: good morning
Avrahm: Good morning in Hebrew. I thought you would call me and visit me.
Dalia: my daughter left and all weekend it was very busy.
Avrahm: I can imagine
Dalia: I have already been to some people
Avrahm: I know
Dalla: how do you know?
Avrahm: I come here, no?
Dalia: if you want I can plan it with you right now
Avraham: best time is Thursday, whenever you want

Dalia is going over to get her daytimer.

Sonia is coming to the table and selecting a seat. Avrham brings some magazines to Harriet
and Jack. And goes over to Dalia to set a time.

Dalia: I will give you a note to remind you of my visit
Avrahm: I don’t need a note. I will remember.

Sonia is still looking for a seat. Av. Is sitting next to Jack.

Av: for how long will you need me?

Dalia: for an hour
Av: let’s decide on Thursday at 11:00am

Sonia goes over to Jack to get her name tag.

00:21:31:00 Ira arrives and sits down at the table

Sonia is talking to Jack and Jack in the corner. Sonia, sees Ira and brings her her name tag

Sonia is not sitting down yet.

Socia’ Sonia is going around and decides to sit next to Harriet not next to Ira.

Samantha is serving coffee to the participants.

Dalia would like to have some coffee too.

Av: where is Carmel living in Israel?
Dalia: Carmel right now in NY. In Tel-Aviv in the dormitories. Dalia is telling about the bad conditions of
the dormitories...

The old nurse Pauline is back. Sheila the other nurse is gone.

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Av and Dalia are talking about Carmel in Israel.

Dalia: Today we have a special project.
Ày: today I came on purpose early
Dalia: did you come because of me?
Av: yes
Dalia: I am honored

Dalia introduces herself to Pauline.

00:31:00:00 AnIta is arriving

Samantha and Dalia are discussing her going to NY in about a week.

Dalia: Ira do you want more coffee?
Ira: no

Anita telling Dalia about an amazing wedding she went to during the weekend. Describes many
details down to flower arrangements.

Debbie is joining the group and sits down next to Sonia.

00:38:17:00 Toby is arriving

Dalia: Toby where do you want to sit?
Dalia: where is Michel and June? Are they coming? Shall I start?

00:40:17:30 Session begins late

Dalia: this is our group today

Dalia sharing personal stories. Dalia: this is my sister-in-law. She helps me and I am married to her
brother. And now that my daughter is gone to Israel, I need all the support I can get.

Anita: my grandchild is coming from Israel I can send hin to you

Dalia: no thanks
Dalia: Toby and Irena, I will bring you here (points at two seats next to Sonia)
Dalia: so you are closer

Socializing Av: Toby did you come alone in the car

Toby: I came with Jerry
Dalla: we are going to be a smaller group today, but that is OK. That means you will get more attention
from me.
Dalia: can I take those books? Sorry, I feel like I am in a classroom.
Debbie: Jack you are wearing a very smart shirt today
Dalia: Jack you are getting lots of complements today. I like the color too.

00:43:10:00 Ruth arrives

Space Issues. 00:43:34:00 Dalia: since we are a smaller group I will bring the table closer.

Jack is busy finding Harriet’s name tag. Debbie is coming to take the box.

Dalia: today is a special day. Too bad we don’t have more people.
Anita: today is national ice cream day.

95



Dalia: Anita did you think I would serve ice cream this morning?
Anita: why not?

Space issues. Dalia is sitting on the table.

00:46:29: 10 Space Issues. Dalia: what we did today we rearranged the furniture again. This time you
are looking towards the windows. Does it bother you?

Anita: through the windows
Debbie: to the window
Dalia: you are facing the windows
Anita: there are windows there too (pointing to the far end windows)

Space issues. Light issue. Dalia: does the light of the windows bother you?
Anita: not right now but eventually it will, since the sun goes around.

Dalia: so what can we do to prevent the glare?
Toby: you put the blinds down
Toby: you don’t have to do right now, but when it comes around...
Dalia: right, right

00:47:46:10 Dalia sharing personal stories. Dalia: What I am finding, since I have problems with my
eyes... This for instance is too bright for me (pointing to the light mounted on a pole) as if I need a hat or
sunglasses.

Debbie gets up and changes the lights. She uses a dimmer and reduces the intensity of the lights.

Dalia: David, can you still see us?
Debbie: this is how the lights used to be in L’Chaim. Dma read an interesting article on lighting and
apparently you can see better with brighter light
Dalia: lets vote which light is better. I am just thinking. I need your honest opinion. Don’t worry about
criticism, you are helping me design the right environment.

Debbie is turning the lights brighter and dimmer.

Harriet: I like it dimmed. Absolutely.

Dalia: who likes it dimmer? Av, Jack, Harriet and Toby like it dimmed. Anita likes it brighter. Ruth and
Sonia are not responding.
Dalia: What we are going to do today came out from a conversation with Jack in his apartment. It
occurred to me that we can design tighter a perfect art studio. The perfect place we can do whatever we
want. Don’t worry about money. Let’s say we have a sponsor that will give us all the money in the world.
Debbie: Jimmy Paterson Who will give us the money to design creative expression studio.

00:51:22:00 Dalia sharing experiences. Dalia: telling her story how she saw Patterson the other day
buying ice cream at Baskin & Robin’s.

Debbie: money is no object

Dalia: This is a wonderful exercise. Debbie I am going to need you to write. I am an architect. I
design spaces, I talk to people I learn what they need and what they want and then I put it in a
drawing. We are going to become architects today. Each one of us will get a paper, pencils, a
ruler, crayons, and if you want to do it in free hand, I don’t care.

If you have a problem, we will work with you. I want you to write down your thoughts, and so on. And now
we are going to start. I will tell you what I want and what I need. You are my clients. I am interviewing
each one of you. So now let’s pretend.

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Jim Paterson is asking us to design the most incredible art studio and we will call it Creative Expression
studio.

Dalia: when we say art studio we all think about what?

Space issue. Daha: but when we say creative expression studio, what do you think we mean?

Anita: I am already designing a bedroom that I would like to see.
Dalia: I will stop you right there.
Anita: why
Dalia: we were commissioned by Jim Paterson to design an art studio, creative expression studio.
Anita: an art studio
Dalia: so you think about it
Dalia asking Av: what do you think is happening in a creative expression studio?
Dalla: What would you like happening for you in a creative expression studio?
Av: I cannot think

Creativity Dalia: let’s start with art. What is art.

Av: pictures
Daha: do you want to display them, or make them or both?
Av: make them

Dalia: and what action?
Toby: if I tell you you will know what it is
Dalia: OK
Debbie asking Av: do you want to draw a space. Does the space need to be suitable to learn how to
draw the pictures?
Av: not to learn, I design the pictures, like the exhibition here, but not abstract.

Anita is touching Jack liking his answer.

Dalia: I want to ask you. Think about it.

The breakthrough in the discussion

Dalla asking Av: think as a painter. What will you need as a painter. What will make you happy as a
painter?
Av: I need the paints.
Dalia: OK. What else?

Anita: he needs an easel and he needs brushes.
Av: and a very good light
Ruth: north light, the right light
Anita: cleanser for the brushes
Jack: paints
Anita: canvas
Dalia: are you going to be standing or sitting?
Anita: sitting
Av: standing
Dalia: you are about 80. How long can you stand?
Av: no, sitting. Even now I am sitting

00:59:00:00 Michael is arriving

Dalia: we need chairs to sit. You can stand too.

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Dalla: We are designing the most perfect creative expression studio. Think about yourself as an artist and
what you need around you.
Dalla: Now, this is for painting. What if we do if we work with clay?
Jack: we need clay.
Dalia: we need sculpturing tools. Did any of you sculpture in clay? What do we need?
Michael: Pottery
Dalia: a turning wheel
Michael: sometimes you need a turning wheel and sometime not
Dalia: what do we put on the clay when we turn it around?
Anita: water
Dalia: how will we get the water?
Anita: from a sink
Dalia: we need a sink, right
Av: if we talk about a sink, we will need a washroom
Dalia: fantastic. We will need a washroom

Dalia: why do we need a washroom close by?
Av: wash the hands and go pipi

Dalia: do we need a washroom far away or close by?

Space issue. Agreement around the table it needs to be close by.

Anita: to take care of our bodies
Dalia: when we have a problem walking we need it close by, right?
Anita: absolutely
Dalia: what else do we need in a studio?
Anita: you need someone to model for you

Dalia: Debbie write it down.
Dalia: like?
Av: needle work
Dalia; what do we need for needle work?
Av: a frame
Anita: needles
Anita: and threads
Av: magnifying glass

Dalia: what about light?
Av: there is light in the magnifying glasses
Daha: I need to see what you are doing (pointing at Av) do you have it at home?
Av: yes.

Dalia is giving her a five.

Harriet: Acting and dancing. Those are creative expression.

Dalia: What do we need for dancing?
Harriet: a body that can dance
Av: and younger legs
Dalia: let’s say God came from heaven and said, I will make you younger and you have all the money in
the world, what will you need in a dance studio?
Av: good hearts
Anita: toe shoes

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Michael: music
Anita: we need bars
Debbie: she means ballet
Dalia: that is OK
Av: I look at dance competition. Very nice.
Av: are you coming next Monday (asking Dalia)

Jack is leaning over and talks to Sonia

Dalia: what do you need to see in a dancing studio?
Av: girls
Anita: men
Dalia: Men who are beautiful dancers.

Space issue. Dalia: think about the environment itself. I am an architect and you are helping me.

Anita: a park, a large area for dancing and a teacher

Debbie: mirrors
Michael: a bar
Av: no no
Dalia: he is talking about a drinking bar
Dalia: I am doing it for elderly people.
Anita: this is hysterical

Anita: they get no satisfaction from that.
Dalia: is that true?
Debbie: People I have danced with in their chairs had big huge smiles on their face

Anita: Iget out of breath. lam a good dancer.

Dalia: if you happened to be in a chair, I can dance with you. Trust me, you will enjoy it.

01 :06:44: 15 Anita is shaking her head in disagreement.

Dalia: asking the group. Why do you think people in their chairs can still enjoy dancing?
Harriet: movement
Dalia: what else can they do?
Harriet: they can sing.
Jack: they can participate and be part of it
Anita: you cannot do it in a chair
Debbie: you are thinking about ballet.
Dalia: sits down on the table and demonstrates a plie (a ballet position)
Av: if I do a plie, I will get a cramp in my legs

Socializing. Everybody is laughing

Dalia: I did not finish yet with the dancing. What kind of air we need?
Av: we need air condition
Dalia: to stay alive

Socializing. Toby is laughing hard in the background

Dalia: what colors would you like to see on the walls?
Av: when you are talking I see in my imagination them dancing. It is very nice

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Jack: Pastel colors

Debbie: we will have to design two studios
Dalia: yes. Or we will do one month like this and one month like that

Debbie: there must be studies done which colors are best for studios. Is it quiet colors like Av or colorslike Toby is saying?

Dalia: if it is a night club we don’t see anything. What we see is sweat.
Av: we need good deodorant
Space issue. Anita: we need a shower

Dalia: this is good thinking, even though it is outrageous. Wouldn’t it be nice if we could go and take aquick shower and refresh ourselves? I like that.
Anita: absolutely
Dalia: how practical do we have to be? In a room like that where we do all the creative expression. Thinkabout the cleaning. If we do any sculptures with water and clay, we have to worry about how to keep theplace clean, right? What floor shall we use?
Av: Use ABC
Dalia: ABC?
Dalia: Can you dance on carpet?
Anita: you can not dance on carpet.

Dalia getting up and saying hello to Sara

Dalia: we cannot work on carpet. Why?
Anita: it sticks
Toby: you might trip on it
Dalia: What else?

Dalia briefing Sara as to the topic of the session. Designing the most beautiful creative expression studiowhich is like an art studio. Money is not an issue. I am the architect and you are all my clients and you aretelling me (Dalia is helping Sara with the chair as she sits down to join the group) what I need to thinkabout. So lets vote here. What floor will accommodate most of our activities:

Space issue. Anita: Wood floor
Dalia: wood floor with a good varnish.
Anita: Varitan, so you can wipe it with a damp mop

Sara is nodding her head in agreement Dalia is going back to sit on the table

Dalla: Ruth what do you think? A wood floor or a carpet?
Ruth: I just put down a wood floor.
Dalia: so let’s vote. Who wants carpet and who wants wood.

Anita, Av, Jack, Harriet, Toby, Michael and Sara are voting for wood.
Ruth: you said wood. You need to raise your hand.
Dalia: what about you Sofia?
Sonia: wood
Dalia: the people have spoken.

Socializing. Laughs around the table.

100



Anita: laughing hard. You are adorable.
Sara: this is what they said when they hang Marie Antoinette
Dalia: no. they used the guillotine. This is a horrible death. At least it is fast.

Dalia: what do you think? Think about this beautiful room we just came up with?

Dalia: what do we need for acting?
Av: a stage
Jack: a podium
Anita: you need a place for books
Dalia: a library?
Anita: yes
Dalia: a collection of plays to get ideas from
Anita: yes, yes
Dalia: what else do we need?
Av: we need a play writer
Dalia: walking over to Sonia. Sonia, what do we need when all the actors come together?
Sara: a studio
Dalia: we need to know what we need inside the studio
Dalia goes over to Michael and takes the magazine away.
Anita: you need a microphone.
Dalia: Michael, you are here to use your brain and you are going to work really hard and use it.
Dalia: Michael, what do we need in a place people act?
Anita: costumes
Michael: stage director
Dalia: approaching Irena for her opinion.

Irena answers: I don’t understand a thing (in Hebrew) Dalia translates it for her.

Dalia turns to the group asking for time to explain Irena what was going on. Everybody is listening. There
is some joking going around with Harriet and Jack, Anita and Debbie.

lrena:l was an actor

Av: we need something more important. He demonstrated a fire extinguisher.
Sonia: we need mirrors
Av: big sign smoking forbidden

Socializing. Many are laughing around the table. Sonia and Ruth do not laugh

Sara: we need a director
Anita: we need the man who puts up the money.
Dalia: we need sponsors for the shows. Right.
Dalia: what about the environment?
Michael: make-up artists

Socializing. Sonia: Debbie has something to say

Debbie: stage lighting
Dalia: if we want to change the stage all the time, who do we need?
Michael: Stage hands
Jack: manager
Dalia: what else
Space issue. Anita: a moving stage

101



Dalia: that is good
Dalla: does every play or show has the same decoration? So what do we need?
Anita: no
Michael: scenery
Anita: different sets
Dalia: who does those set?
Jack: set designer
Dalia: oy yo yo. Finally

Dalia is going around to give five to the participants. When she approaches Sonia, Sonia says: zi gizent
(in Yiddish) for health.

Toby raises her hand to sake with Dalia.
Debbie comes over to Dalia: Debbie: give me ten.
Dalia: give me a hug. I have to be nice since she is my future in-law
Sonia: ten plus ten.. .the rest of the sentence is not understood
Debbie: when Carmel comes from Israel we....
Dalia: when Carmel comes back she probably will be 200 pounds eating too many Shuharmas and too
many Falafels.

Dalia: I think we are missing several more things in this wonderful studio of ours

Dalla: what do we need for signing?

Sonia: singing in the rain

Sara: microphone
Anita: piano
Jack: curtains

Socializing. Lots of talking around the table

Daha: that was good, we need curtains
Anita: someone who can sing
Dalia is laughing
Anita: we need Debbie (ref to Debbie’s singing)
Dalia: when they sing are they accompanied by someone?

Anita: sometimes there is a whole orchestra

01:22:27:00 Dalia: what we did so far are very active activities, let’s think now about passive activities
when we do nothing but...

Dalia pointing at her eyes and says: what are we doing?
Av: we are observing
Jack: we are watching
Jack: we are projecting
Dalia: that is good too
Dalia: and when we do observe what will be a situation when we watch quietly
Anita: when you are rehearsing
Dalia: that means we need a place for audience

Dalia: you are getting better as time passes

102



Memory issue. Dalia losses her train of thoughts. Debbie reminds her the discussion was on observing.

01:23:43:20 -01: Dalia: a passive way being very creative. We don’t always have to sing or
dance. I know many ways how I could be very creative without saying even one word.

Dalia: one of the creative expression activities is writing.
Dalia goes over to Anita and asks for five.
Dalia walks over to Ira to explain her in Hebrew what is going on.

Dalia: this is what I am trying to do with the people here. I can be very creative in my mind.
Anita: If you are reading a script and you watch how they perform...
Debbie: we are talking about reading as creative expression, not performing
Av: you are saying in your mind, you know, if I am sifting in the park and I am dreaming that I
won a million dollars so I am very creative

01 :26:15:00 Dalla: right. So creativity can also happen in our brain without singing, dancing. I need to be
clearer here a little more, we went from very creative expression showing our feelings and interacting with
others but there are times we can be very creative and we don’t have to do all of that.

01:26:17:20. Dalia: when is it happening to you?

Av: When I go to Israel I make a list of what) need to take. I am in making lists
Dalia: creative in making lists and planning
Ruth: when you are

Dalia misunderstands. Ruth points to her head. Others are helping out.

DaNa: playing is very creative
Dalia: do you mean playing cards, scrabbles?

01:27:08:00 To be used in clip.

Sara: nods her head in agreement
Dalia walks over to Anita to give her five and says: I love that
Anita: I love you
Dalia: Thank you I love you too
Debbie: when you read a book you imagine the characters how they look like

Anita says something.

Space issue. 01:27:39:00 use for a clip Dalia is trying to go back and sit on the table. The table is on
wheels and keeps moving. She apologizes to Sara who sits close to the table. Dalia moves the table
away and goes to get a chair. Debbie moves the table away. Dalia sits down.

Av: you are creative
Dalia: I am now one of you guys. This is nice
Anita: isn’t lovely
Dalia: So I have a question for you.
Anita leans forward and says: what?

Space issue. DaNa: Don’t think about me think about you. Would you rather see me sit or stand?
Anita: I rather would like to see you happy. It does matter if you sit or stand, it is still you.
Dalia: this is a very good and diplomatic answer. What I need...

103



Dalia: am I too low for you or you would rather see me standing
Sara: I am more comfortable if you are sitting down
Michael: yes

O1;28:27:O0 Dalia: standing up again and demonstrates: you don’t feel like I am presiding over you,
right?

Anita: it does not matter
Dalia: what do you think Jack?
Jack: directors sit down, don’t they and they direct everything. They don’t stand up on the stage
Dalia: so I feel very comfortable. Are you comfortable with me?

Harriet, Sonia, Toby are shaking their heads in agreement.

01:29:00:00 clip use. Jack: if you are standing you are considered the leader, when you are sitting you
are one of us

Dalia: thank you very much

Dalia getting up to shake Jack’s hand

Av: most of the times the director sits higher than the people and he is talking from up (and he points
down)
Dalia: you know what, I am very much aware of it. I would rather sit when I talk and then I feel like one of
you.
Dalia: Debbie you may want to write down that the leader should sit down, because I feel like I am riding
you all the time.

The participants disagree with the last statement of Dalia.

Dalia: Debbie you are now our leader. Write down it is a psychological aspect. Finally I feel like I am more
relaxed.

Anita and Debbie are talking in the background.

Use for clip. 01:30:48:00 Dalia: so what do I need in this studio? We did not talk about fresh air. Think
about the walls of this perfect room of ours. Do you want it to have contact with the outside?
Anita: I want windows
Av: When Saturday and Sundays come along all the walls fall on old people.
Dalia: what do you mean by that?
v You are lonely You are sitting at home and the walls surround you
Dalia: are we talking about creative expression studio at your house or a studio for all of us right here?
Av: for all of us.
Dalia: Anita says she wants windows

Space issue. Anita: you know what, windows can be anywhere depending on how the building is
constructed.

Dalia: right
Anita: there are windows around the ceiling, there are around the room, whichever
Dalia; are you talking about eye contact?
Anita: no, I am talking about breathing

Dalia: OK. What if I bring air from the ceiling, do we still need windows?

01:32:27:00 Clip. Space issue. Av: it is important to have a window with a nice view.

DaNa: Anita says the windows are not that important as long as we have fresh air. This is one opinion.
For Av a window with a view is very important.

104



Av: when I lived in West Vancouver I had a window with a one million dollar view. The sea... the trees.

Clip. Space issue. Jack: The sound of the acoustics are very important in a studio

Dalia walking over to Jack for another hand shake.

Dalia: sound and acoustics very important.
Anita: absolutely
Dalia: what about windows?
Jack: if you are talking about audience you need darkness.
Jack: for the studio we need windows

Daha: he is talking about two scenarios. For the audience we need darkness since they need to
concentrate on the activity, for a studio we do need windows.
Harriet: obviously we need two separate places. A studio with windows and a auditorium with a stage.
Dalia: I can drop shutters on the windows and in a few seconds it becomes an auditorium. With a press
of a button we can do it. Money is not an object, we can be flexible.
Anita: shades can transform...

Michael’s cell phone is ringing. Debbie is asking him to take it in the corridor so as not to disturb the
session.

Dalia: we need decorations that will transform our thoughts and allow us to get lost in it. Right? It is very
important.

Space issue. Clip use. 01:35:18:00 Dalia: we came to the conclusion that we do need a very flexible
creative expression studio.

Sara nodes her head in agreement.

Dalia; because we have different needs to answer all kinds of activities.
Dalia: but I am still waiting to hear what else can we watch, not a play.
Av: a concert, a ballet
Sara: a movie

Dalia is getting up to give her a hug and a kiss

Jack: how could we forget it
Av: A movie you can see in on the TV.
Dalia: we need a television too. What else?
Debbie: a popcorn machine

There is laugh around the table

Debbie: otherwise I am not coming to your movie.
Harriet: How many of us can chew popcorn?

Lots of laugh around the table. Toby thinks it is very funny.

Dalia: what do we need when we watch a movie?
Av: we need a screen
Michael: to sleep (perhaps he meant a seat)
Debbie: comfortable chairs
Space issue. Sara: acoustic system
Dalia: a sound system

Dalia: what else do we need when we watch a movie?
Anita: patience

105



Heather the caregiver is walking in.

Dalia: if the film is too boring, what do we fell like doing?
Anita and Av: walking out
Dalla: so if we walk out what do we need to be safe when we walk out?
Anita: a flashlight or light along the wall

Daha: so picture it, the movie is terribly boring. We are walking out. Where are we walking out to?

01:38:19:00 Memory issues. Anita: the hall which is a part of our studio

Dalia is getting up to shake Anita’s hand.

Dalia: did we forget anything?
Sara: somehow we have a building and assuming we have the walls. We need seating
Dalia: we are all old people. We are walking with our walkers and our chairs, we are not that steady on
our feet. What do we need in terms of space wise?

Someone said space.
Dalia: so we need space for circulation

Dalia: Lets see if two people walk side by side, do you think there is enough space to walk behind (and
she points out the space between the table and the wall) is there room to walk safely without tripping
over?

Dalia: so what do we need?

Av, Anita: room
Dalia: so we need room for circulation, right? how many times you walk with your cane and if you are not
watching you may trip over?
Anita: lots of times

01:40:15:00 Clip use. Debbie: not at L’Chaim. We are always aware of properly placed furniture.

Dalia: for that we need lots of room, right? Lots of room.
Dalia: lets continue before Sara falls asleep
Sara: I am not falling asleep
Dalia: you were thinking about what we were talking

Debbie: are we not going to eat ever in this place?
Anita: we are not going to eat there while all this is going on

Socializing. Toby is talking to Sonia in the background and pointing to Sara or to Dalia. Sonia responds
but the camera could not pick up the conversation.

Debbie: maybe we will not eat in the creative expression studio. When the activities are finished we will
go out for lunch.
Dalia: or
Av: we will go to Macdonalds
Toby: I would say beer
Debbie: let’s say apple juice
Dalia: to be freilach (happy in Yiddish)
Sara: I understand what freilach means, but I cannot see what beer has to do with what we are doing
Dalia: we have to honor the input of everyone and go along with it
Sara: I understand that. I guess we will
Anita: you don’t have to drink if you don’t want it

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01:42:29:00 Sara: there is a good point
Dalia is laughing.
Dalia: so we already have this wonderful place. We have everything. Only one thing is missing which can
be very creative. Cooking.
Av: Ha, cooking?

Giggling around the table. Av is reacting and says something which is misunderstood.

Dalia: we have to think how the colors look on the plate, well balanced, you want a beautiful presentation.
The Japanese are great artists when it comes to that.

01:43:17:00 ReminIscing. Clip use. Anita: I will grant you all of that, but after 55 years of cooking I don’t
feel like doing it anymore. I’ll go to a Japanese restaurant instead. I am serious.

Dalia: OK. What if you were sitting and watching others cooking?
Anita: that is OK as long as I am not cooking.
Toby: pointing at Anita and laughing. I am with her. I am not cooking anymore I go out to eat.
Dalia: good. Does anyone is watching Martha Stewart or a cooking demonstration?
Jack: the food channel

Debbie: my son is addicted to the Iron Chef

Dalia: Yes. I love watching others cooking and how they display the food. This is very creative. I have a
feeling that in our beautiful facility we will bring in a chef
Anita: this is wonderful.

Anita, Sonia, Sara Toby would like a chef to come in instead of them cooking.

Debbie: we will hire an Iron Chef.
Dalia: OK. This is what we are going to do now. We talked so much. I am going to give each one of you a
piece of paper

01:45:01:00 clip use. Space issue. Dalia: I am wondering how we could put on display all the writing?

Anita: between the panels on the window

Pauline the nurse helps with the arts supplies. Dalia is walking over to the blackboard on wheels and
brings it over to where the fhpchart is. Space issue. Dalla is carrying a cane of a participant who left
the cane hanging from the board.

Dalia: I think it is Sara’s cane

June my sister-in-law is bringing it over to Sara who is busy saying:

01:45:47:00 - Sara: I will not be writing
Pauline: I think she wants you to draw
Debbie: Dalia will explain it again
Toby is talking to Sonia in the background.
Dalia: I will explain

Socializing. Clip to use. Toby: they are worried since they don’t have anything to write with or draw with

Dalia: it is coming

David reminds Dalia about the light issue. Dalia turns to the group.

Space issue. Lighting issue. For a clip. 01:46:20 00 —01:48:26:00 Dalia: When you look at me and I
need your honest opinion, can you see me well?

107



Sara: you are in the shadow. The sun is coming behind you

Dalia moving backwards a little.

Dalia: how about that
Sara: now it is better. Now it is not, someone turned off the light. (David turned on the lights) now it is
better.

David went to the light pole and tries to adjust the light.

Debbie: any Hollywood actor likes when the light in on them.
Ruth: I don’t need... .just listen to you

F Toby to Pauline: I want a red pencil and a...

Clip. Space issue. Sharing personal stories. Debbie: I have a question. Sometimes I don’t see very
well and unfortunately sometimes don’t hear very well, can you hear better when you see the person
better?

Space issue. Av and others agree that seeing helps the hearing.

Debbie: l hear much better when I can see them
Anita: when you can watch them

Staff interferring. Pauline is going ahead and providing participants with art supplies. Dalia stops her
since it is not the right time to do it yet.

Dalia: OK guys. I want you to concentrate and look at me since you are helping me. Look at me. (David is
turning off and on the lights) and tell me which way is better.

Space issue. Clip use. Participants agree it is better with the spotlight on Dalia.

Av: the window behind you (points at the far end of the centre next to the kitchen, because it is very shiny
in the background.

Dalia: can you go and close the blinds there? (June is going to do it)

01:48:26:00 Av: says in Hebrew that it blinds him

Dalia: this is great because it helps me

June closes the blinds of the far window.

Av: this is much better

Dalia tells David to turn the spotlight on Dalia.

Av: what a difference. Like night and day.
Dalia; what if we closed the blinds behind me, would that be better? Let’s try
Av:Ithinkso

Debbie goes to close the blinds of the windows along the wall in front of the group.

Clip. Space issue. 01 :49:09:00 Anita: bright light hits me right here (she points at her forehead)

Dalia: does it hurt you?
Anita: I don’t know, I can see but when he puts it on I can right away pain (points at her forehead again).
Anita: I see perfectly without
Sara: It is too sharp and you get a headache from it

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David is going to dim the spotlight

Dalia: we are going to try and make you all happy
Anita: comfortable
Debbie: and that is not easy at L’Chaim making everybody happy.

Anita is imitating Debbie “making everybody happy”

David is working on his lights.

Anita: I see you very fine. I hear you very well.
Dalia: OK.
Sara: It bothers me very much
Dalia: what if I put you, sit next to Ruth
David: the focus is on you
Dalia to Sara: don’t look at the light

Debbie is moving next to David.

Sara is still complaining that the light is too sharp.

David moves the lights more away from Sara

Sara: this way is better

01 :50:53:00 Socializing. Ruth: let’s switch seats

Dalia: that is a good idea. Let’s see

Dalia is helping Sara with the move

Dalia; we are talking about testing here. We are not going to leave it if it bothers you.
Sara: I can always close my eyes.

Dalia is trying to sit where Sara was sitting.

Dalia to David: it does shine in my eyes.
Dalia to Ruth: have a sit and let me know

Debbie is taking dishes away to the kitchen

Sara: Dalia could you please bring me my bag
Dalia: yes, it is right here

Clip. Space issue. 01:51:54;00 David: Dalia if the lightwas shining off the ceiling the lightwould not
bother you

Dalia to Sara: are you bothered now?
Sara: no
Dalia: you will be working on the paper. Is it too bright for you now?

01:52:30:00 Clip. Space issue. Debbie turned down the lights. Most people agree around the table
that it is much better dimmed.

DaNa: OK. I gathered that because the light reflects back from the white paper.
Dalia to David: I think we can turn it off.
David: but now it is very difficult to see the board (refers to the blackboard with the flipchart sheets)
Dalia: what if you shine it to the board?

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Dalia: can you see the board?
Harriet: yes

Others are nodding with their heads in approval

Sonia is putting on her sunglasses (perhaps with distance lenses) and looking at the board.

Dalia: Sara are you OK
Sara: I am fine
Dalia: good
David: shall I leave the light on?
Dalia: yes, until someone starts screaming
Debbie: I told you it is hard to make everybody happy.

Dalia starting to give instruction on the project.

Dalia: write your name on the top. Start designing the studio. You don’t need to measure. It is not the
measuring of one inch or two. This is not the issue. Put your ideal creative expression studio which we
talked about today. We were talking about. We talked about art, dancing, acting, singing, people who
want to observe. It does not have to be perfect. You are architects right now. Artists. The more sketches I
see, the more chaos I see, the better it is. I don’t need to see very straight fantastic lines, that does not
matter to me. Just start putting your thoughts on.

Debbie: just put your name on the paper

01:55:00:00 Dalia: start designing your ideal art studio.

Participants are taking pencils and starting to work.

Av: does not want to write. Neither Ruth.

Irena is looking for help. Debbie is pointing to her. Dalia is walking over to her. Heather from staff
is going to help Sara. Pauline is working with Ruth. Debbie will be working with Toby and Sonia.

Socializing. Av and Jack would like to work together.

Dalia: Avrahm you can read Jack what we have wrote on the flipchart.

Dalia explains in Hebrew to Ira the instructions for the project.

Ira does not want to do it.

Dalia: what it is Toby? A swing in your studio? That is great.

Memory issue. 01:56:36:00 Debbie leans over Toby and says: remember? We are talking about
creative expression studio.

Dalia walking over to Anita.

Anita: I don’t know what I am doing
Dalia: Think what would you like to see in an art studio
Anita: I would like to make my bedroom
Dalia: OK. Do your bedroom

Anita is not that sure

Dalia walks over to Michael: What is that?

01 :57:23:00 Michael: a pottery studio

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Dalia: I like that
Dalia: are you sitting nearby? Is that a wheel?
Michael: yes, this is a wheel.
Dalia: great. Write here pottery studio
Sonia is working on her drawing.

01 :57:55:00 Dalia to Pauline: write down what she says.

Dalia to Michael: what else do you need?
Michael: stools to sit on
Dalia: make an arrow and write stools.

Dalia walks over to Irena: in Hebrew. What would you like to see in your studio? Do you know how to
write your name?

01:58:51:00 Irena is writing her name down. Debbie is looking over the shoulder of Sonia and Toby. Anita
is working on her own. Av and Jack are working together. Harriet works alone and looks over to see what
Jack and Av are doing. Sara and Heather are very busy with their design, Pauline with Ruth and Dalia
with Ira.

Dalia to Ira: what studio what have made you happy?

Ira is trying to speak in English to Dalia.

DaNa: would you like a big room? So, make a big room

Ira is starting to draw.

Dalia is pointing to Jack and Av about their collaboration.

Debbie: best architects work in teams.
Dalia: absolutely
Debbie: what are you doing there Tobs.

2:00:10:17 Dalia is going around taking photos.

Dalia to Michael: What is that again? Where do you dance in your studio? Oh, is this a long table? I like
that. So, in this studio we don’t do dancing. Do you want to see if we could include other activities?

Memory issues. Michael: what kind of activities?

Dalia is going over the activities that were discussed earlier with Michael.

DaNa to Michael: Would you like to think in a broader sense

Michael answers (could not understand)

Dalia: try. Would you like another piece of paper. I will give you another one.
Debbie to Toby: a record player?
Dalia: how is Anita doing? For someone who said... look at that.
Anita: Here is the entry to the room...

Dalia puts her glasses on.

02:04:23:00 Dalia: you are doing exactly what I wanted. This is excellent.

Dalia: if you need more paper just let me know.

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Dalia brings over an eraser to Harriet.

June (Dalia’s sister-in-law looks over the shoulders of participants to see if they need her help)

Debbie is sitting between Sonia and Harriet. Toby is working on her project.

Dalia: I have some pastel colors for anyone who would like to highlight some things

Clip use. Socializing. 02:05:19:00 lots of activity around the table

Dalia: so Michael, is this is a piano?

Michael answers.

Dalia: so write it down
Michael: I am waiting for another paper.
Dalia: I am sorry. I forgot. I will bring you another paper.

Dalia: If you need more paper just ask. I will be more than happy to give you

End of Wide Shot (WS) tape I of 2

Figure 19: Participants at L’Chaim Centre Bending Wires to 3D Shapes

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Analysis of Videotaped Session

LC. WS. Session 5, July 18, 2005. Tape I of 2

Designing a creative expression studio. Design, space, lights issues.
Discussions on creativity, and what is art.

Social Situation
• Several of the participants seem to enjoy watching who is coming into the centre. They wave to

incoming visitors and monitor who is coming in and going out when they have full view of the
entrance.

• Participants with dementia: Toby, Ruth, Sonia hardly say a word, yet they are focused, listening
to everything that is going on. Toby called me over to let me know that they need pencils to draw
with. No one even got up to go to the washroom. No one fell asleep.

• Anita, who is diagnosed with dementia, is very active and very responsive.
• Harriet, Jack, Avraham were quieter than usual.
• There is interaction between Toby and Sonia, Jack and Av, Harriet and Jack.
• Ruth, who said very little during the session, did volunteer to switch seats with Sara. I was

surprised to hear her offer. I was worried about whether she was aware of what was going on.
Later, after the session was over, Ruth came over to me and said quietly, I heard every word, I
was right into it. I just did not feel like talking. You are wonderful and I enjoy every minute of it.

a Toby does participate every once in awhile. Although the contents of her sentences are at times
off the topic, she shows an interest in speaking and staying connected.

a noticed a reluctance to be the first person to sit at the table. This could be a space design issue as
well.

• Harriet chooses a seat based on her visual contact with the rest of the centre.
• Participants who don’t speak the language arc left out, in spite of the effort to include them. This

happened at the Margaret Fulton centre as well.
• Avraham showed an interest in how Toby managed to arrive at the centre.
• It was interesting to hear Jack suggesting that I should sit down, since it would make me one of

them (the participants), and not take the leading role.

Participants’ Abilities
• The participants’ abilities are being demonstrated through the activities and the discussions on the

arts, creativity and space design.
• Having a diagnosis of dementia needs to be more clearly identified since not all the dementias

exhibit the same symptoms. For instance, Anita is losing her ability to control her responses. Her
outbursts are embarrassing and family and friends are avoiding her. Yet, she is clear about her
wants and desires, although socially they are not accepted. At a visit to her house, Anita
expressed her affection for another man in the community. It was done with no hesitation, in front
of her husband. She even brought out a photo of the man. I believe that if Anita was well, she
probably would have concealed those thoughts. Toby too expressed her opinions on sensitive
topics such as sex, which she might have kept more private before she got sick with dementia.
Ruth will not share her thoughts too much in public but will do it later in private. Her memory is
suffering. Although at first glance, Michael seems to be OK, it becomes clear as the conversation
develops that he has problems concentrating — his logic is somewhat unclear. There is a general
feeling that he may not get all the content of the conversation right.

• Among participants who are not diagnosed with dementia, a few may have mild memory
impairment (MCI) or just slowing down of responses.

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Space Issues
• Although the tables were arranged for a bigger group, I felt we needed to reduce the number of

tables to fit the smaller group. Closing the distance between myself and the participants plays an
important role in establishing better interaction.

• There was very little interruption from visitors and very little waving, I think because the group
was tucked away and did not have eye contact with the main entrance. This needs to be
examined. If the priority is on the participants’ being engaged in the creative expression program,
then we need to reduce interruptions to their concentration. If the emphasis is on socialization
between the participants and visitors, then we need to improve opportunities for this desired
behaviour. If both are important, the limitations and the desired outcomes need to be taken into
consideration when designing a studio for such activities.

• I cannot find a good place to sit and conduct the session at the same time. I tried the empty table
until Sara came along but she was left out of the circle of discussion. Participants prefer to see me
sit and not stand.

• The intensity and direction of the lights occupied a great deal of discussion around the table. Here
are some of the comments:
— an object against the light looks dark with no details
— sharp lights cause pain and glare
— seeing improves hearing
— windows are important but where to place them depends on the use of the space
— when working on white surfaces such as white paper, lights need to be dimmed

• Wood floor is preferable to carpet
• Washrooms need to be close by

Dalia as participant/obseiver, researcher, architect, educator

I was really curious about how this session would turn out. I was interested in the drawings the
participants produced. I was surprised that all of them took up the pencils and produced something. There
was a genuine effort to develop an art studio. Even those who protested that they didn’t feel like writing
ended up drafting. Toby was my biggest surprise. She was so alert during the whole session. She did not
say much but she was listening, laughing, watching intently. The way she got involved with the drawing
made me feel so good. It made me feel that all the efforts made in engaging the seniors with dementia are
of value. Watching her face, her sincerity was so heart-warming. Although she wanted a swing in her art
studio, it really did not matter. I was reminded that friends of mine, who were artists, installed all kinds of
objects and spaces in their studios they would not dare put in their homes. So what was the difference
between them and Toby’s desire to have a swing? I would like to have a hammock in my dream studio. I
guess that would not qualify as relevant in the eyes of some people, but then who cares. If Toby was
following her hidden desires, logical or illogical, she was engaged in the project, which made her feel
proud of her work. Looking at her and watching her proved to me why it is so important to continue
working with these seniors as long as possible. After visiting Toby at home, I realized that being engaged
in creative expression activities provided her at least with one place she could express herself and be
outside the shadow of her husband.

I tremendously enjoyed the process of bringing the group together to think about elements of design,
space, light and quality of finishes. Participants with and without dementia were engaged in the process.
Each participant engaged according to their own abilities.

Staff Issues

By now, the staff understands that the participants need time to concentrate. As a result, interruptions
were limited and done discreetly. No one was pulled away from the table. Serving of coffee and tea was
limited to the beginning of the session.

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CHAPTER IV: UNDERSTANDINGS DERIVED THROUGH
INQUIRY

By using aJr/tography this study arrived at understandings in three main areas:
• Understandings derived from the literature review,
• Understandings revealed in the implementation of the creative expression activities program,

and
• Understandings based on the physical changes to the environment and the users’ response to

them.

In this study we linked the role of the physical environment with the creative expression abilities of
seniors with dementia. We experimented with various changes to the environment, observed the reactions
of participants, and interviewed a range of stakeholders including the seniors themselves. We also
considered the physiological and cognitive changes associated with aging and dementia with references
that linked them to creative expression abilities. Those references assisted us later in formulating a
theoretical approach to space design for these seniors as they engage in creative expression activities.

Themes That Emerged from the Literature Review
1. The person-centred approach to care, defined as personhood, is crucial in achieving positive

changes in problem behaviour, improving communication and independence.

2. The environment in which seniors with dementia reside can be considered therapeutic only if it
embraces a comprehensive approach to care, based on preserving the person’s dignity, and
protecting the person’s rights.

3. Caregivers need to understand the condition from a neuro-psychological perspective, be aware of
the social construct developing around the person, be sensitive to changing needs and be flexible
in treating the person as the condition progresses.

4. There is a lack of empirical research on appropriate creative expression activities specifically
designed for seniors with dementia. With no appropriate studies available on assessing their
creative abilities, there is no clear understanding of what meaningful creative expression activities
for these seniors could be. With more studies on such activities, the more effective the therapeutic
environment will become.

5. There is lack of input from people with dementia who are capable of contributing their views
about how their space can be used. The scientific community has failed to involve their subjects
as equal partners wherever possible.

Design Principles for a Therapeutic Environment

I adopted the following five design principles from Cohen and Weisman (1991) in their discussion of
institutional environments, specifically in a special care unit. Cohen and Weisman recommend:

Principle 1: clusters of small activity spaces
Principle 2: opportunities for meaningful wandering
Principle 3: positive outdoor spaces
Principle 4 other living things
Principle 5 spaces from public to private realms

I applied these principles to the two selected adult day care centres, where frail seniors with and
without dementia spend most of the day two to three times a week. These seniors still live in their
community, at home or with their family. In addition, to minimize the negative impact of the institutional

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setting on seniors with dementia, I took into account the recommendations of Cohen and Weisman (1991,
p. 65- 89) to consider these elements that can enhance the therapeutic environment:

• regulated stimulation and challenges
• autonomy and control
• ties to the healthy and familiar
• functional ability through meaningful activity
• safety and security
• orientation to space and time
• wandering treated as an opportunity
• social contact
• opportunities for privacy

These elements are dealt with in discussing the physical arrangements of the two sites in connection
with the detailed drawings in a following section. After addressing the five principles, I add two new
principles to take into account the level of participation the seniors engage in and the preferences the
seniors appear to exhibit for ethnic groupings.

Applying the Five Design Principles at the L’Chaim and Margaret Fulton
Centres

Principle 1. Clusters of Small Activity Spaces

At Margaret Fulton a great deal of attention was given to the design of small activity spaces.
Designing smaller spaces came as a reaction to the large open spaces typical of church basements that
housed adult day care centres mainly because of financial constraints. Most of the time, these small
spaces work well depending on the kind of activity, the noise level, the activity generated and the number
of participants. At the Margaret Fulton Centre, the intention was to provide a cosier, home-like
atmosphere. However, in this study we discovered that size alone was not enough to attract participants to
stay in a space; other considerations played an important role in the decision, such as windows and access
to the outdoors. It was the small size of the back room at Margaret Fulton Centre that resulted in a walk
out of three women participating in the study. One refused to come back. She opted for an activity in a
larger room and a walk in the “fresh air”. Although there were windows in the room, only a small fraction
of them opened up enough to allow the outdoor air to flow in a significant way. In addition, the weather
outside played an important role in attracting the participants for an outdoor activity after several days of
continuous rain.

While Margaret Fulton Centre provided smaller spaces for a variety of activities, the L’Chaim Centre
provided one large open area where all the seniors worked on the same activity at the same time and in
the same space. This type of design generated problems of noise and did not provide variety, from private
to public spaces. To add to the problem, L’Chaim Centre provides services to a great mix of seniors with
various abilities. One large space does not allow for several activities to occur at the same time. The lack
of transition zones from public use to private use of space in the Centre encouraged interference from
visitors coming in and out of the Centre at will. Although this interference was very apparent in most of
the sessions, it was welcomed by the participants who were curious about who enters the Centre. I noticed
that those who came late during the day to join at the end of a program raised some criticism from those
who were there earlier and on time. To resolve this issue, I would recommend sectioning off a small space
for those who arrive late; they can join the rest of the group at lunch time. As well, when people do not
get along, a physical separation could help ease the tension.

Drawings LC 1-5 at the L’Chaim Centre and drawings MF 1-4 at the Margaret Fulton Centre
illustrate the problems of small spaces and the need to take into account the number of participants in any
given activity, their range of body movement, walking aids, wheel chairs, the number of staff or

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facilitators managing the activity to ensure safe circulation, and access to the seating area and washrooms.
Architectural designers of dementia care facilities face challenges that may contradict each other, such as
the need to create spaces that are small yet big enough to accommodate all physical and mental needs of
an elderly person with dementia. This is not an easy task and the solution may lie in designing flexible
spaces that can be divided easily to suit a variety of activities and different group sizes.

Principle 2. Opportunities for Meaningful Wandering

The desire for wandering is one of the behavioural symptoms of dementia. An understanding of this
kind of behaviour is relatively new in the field of dementia care and, until recently, was perceived as a
very disturbing behaviour that needed to be stopped, whether through the use of physical restraints or
medication. Today, with better understanding and a more perspn-oriented approach to dementia care,
wandering can potentially turn into a positive experience if appropriately incorporated in the design of
therapeutic environments for people with dementia. Not only that, care providers now recognize that
wandering has the potential to become an interesting and meaningful experience, when familiar symbols
and focal points are provided along the wandering path.

At the L’Chaim Centre there is no designated space for indoor or outdoor wandering. Of course, the
seniors can leave the Centre and wander around the building of the Jewish Community Centre, but then
they will find themselves in a non-protective environment, with stairs leading to other floors and to the
outside, that pose a real danger of getting confused, falling or getting lost. The present space at the
L’Chaim Centre is too small to consider such an activity. The majority of the clients seemed able to focus
on the tasks in front of them and the need to wander was not that urgent or apparent.

At Margaret Fulton Centre, the option for wandering inside the facility and outside was incorporated
within the design of the facility. The wandering path outside the facility goes around and through a
gazebo with flowering plants, hanging pots and benches. The path is within an enclosed garden, which is
nestled next to a park on the edge of a wooded area of very tall trees and thick vegetation that include ivy,
moss and fallen tree trunks. There is plenty of activity in the adjacent park where children and adults visit.
The wooded area is rich in birds, squirrels and noises that are heard from a variety of sources. The seniors
can sit at a bench and follow the children chase a ball or watch the birds flying over. They can stop to
examine the various plants along the path while supporting themselves with a guard rail. At one of the
sessions outside the Centre, as we were sitting at a garden table next to the wandering path, one of the
participants in the study was attracted to the birds flying over and to the noise of the children coming
from the park. As a facilitator who encourages creative expression, I seized that opportunity and
developed a discussion on birds, trees, nature and the attributes of being able to sit outside and witness a
flight of a bird, hear children play and be reminded of grandchildren and our own childhood memories.
Although she usually has difficulties concentrating on the task in front of her, she managed to be fully
coherent and engaged in her interest of that moment.

The interior wandering path at the Margaret Fulton Centre was less successful in providing an activity
that did not conflict with other activities happening at the same time. The interior path is partly a corridor
and partly a space within another designated area. During bad weather, walking activity stays within the
facility and the path intrudes on other activities. This conflict of activities was demonstrated at one of our
sessions in the arts room. As we were setting up the space for the study participants, I noticed an increase
in the amount of walking activity through the space we were using. My first reaction was to ask the staff
to stop the wandering through our space. All I could think about was the potential difficulties that lay
ahead of me in trying to keep the attention of the participants. In fact, there was not enough room for
wandering seniors, their care aids and myself, as I needed room to bend over the desks, the piano, piano
bench and the pianist, and to make room for a music stand, a flipchart, desks and chairs for staff and
clients, and room for the cameras and the camera man. The space was so tight that the camera man could
not check both cameras. At the end of the session, he told me that the wide angle camera was not
recording. I was so disappointed because we would have caught on camera the commotion and the
interference of the wandering activity that day. To add to the stress, seniors were using the space to get to

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the washrooms; those doors opened to the arts activity room. There was too much happening in one small
space.

As I contemplated how to salvage the session planned for that day, I almost lost a great opportunity to
gain a better understanding about what was happening. The director reminded me that earlier I requested
that the Centre’s activities continue, no matter what, so I could learn from difficult situations. As the
wanderers and their helpers continued to pass through our space, I became agitated and could not
concentrate on the task in front of me. I felt that my effort to build up a rapport with the study participants
was undermined. The musician was upset at not having enough room to manipulate her bow or to
maintain eye contact with the participants; the wanderers were walking right in front of her. The
facilitator from the staff who was assigned to help me apologized several times. I explained that it was my
own request that everything should continue as usual. Of course this was an extreme situation.
Nevertheless, it illustrated the damage caused to efforts to communicate with people with dementia when
unrelated activities interfere. A couple of participants got up and left and never returned until one of them
was accompanied back by a staff member. The level of agitation was apparent and, with no possible
control over the situation, I lost my ability to hold the interest of the group. When the wandering ceased
so did the interruptions. Then it was possible to revive interest in the planned session for that day.

Incidentally, it needs to be noted that the wanderers and their care aides were amused at the situation
and could hardly wait to return for their next rounds to comment or joke with us and the study
participants. As they passed by, one wanderer asked a participant if anyone would be waiting for her at
home. Another asked what we were doing. Others commented on the piano and violin playing. Our
presence and the activity of arts and live music provided a meaningful and entertaining focal point on
their wandering path. The question that arose from this experiment was about how we could continue to
solicit reactions to interesting activities along the pathway without disrupting another activity, which was
responsible for soliciting these amused reactions of the wanderers? How could we carry out two activities
without disturbing each other and yet provide an opportunity for one of them to be observed, heard and
provide opportunities for meaningful interaction even for a short time? And how could we resolve the
conflict of two activities with an architectural solution?

Drawing MF-5 of Margaret Fulton Centre demonstrates one solution that could be achieved with
minimal cost and without the need to change the existing programs. I suggested diverting the interior
wandering path away from the Arts area by expanding the north wall outward a few feet and partially
enclosing the Arts area with pony walls; this would allow visual observation from both sides of the wall
and provide access to sound. By doing so, the wandering activity could go on while the others
concentrated on their artwork. For more privacy, the facilitator could hang visual barriers above the pony
walls.

Since Margaret Fulton Centre is a relatively new facility (it was opened in 2000), it is less likely that
such recommendations would be implemented in the near future. In contrast, the L’Chaim Centre
happened to be ready for some renovation and that opportunity coincided with this study. And so, we
were fortunate to recommend changes at the L’Chaim Centre and receiye feedback about them.

Principle 3. Positive Outdoor Space

At Margaret Fulton Centre a great deal of effort went into providing an outdoor area that not only is
pleasant visually, but also is very useful as a wandering path, out door picnics, a place to sit quietly in a
gazebo, a place to watch nature, a place to watch others at a distance and close by. The outdoor area is
beautifully nestled within the larger natural setting and in good weather it acts as an extension of the
facility itself. The French doors are fully open in good weather and since the garden is surrounded by a
fence, clients can move around and in and out at will. There is a sense of freedom. However, some clients
don’t feel this sense of freedom. One person in particular who wanted to leave the premises asked why he
was treated like a criminal. I stood there lost for words because this is how I felt myself. Here is an adult

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whose oniy problem is that he cannot remember his way back once he leaves, but not remembering did
not affect his understandings of being locked away.

At L’Chaim Centre, the outdoor area is secondary to the main space indoors. Outdoors is a balcony
that is shared space. The balcony can only be reached through the lounge area, which makes it less
accessible. Outside there are wooden benches and a trellis that is bare during winter time. The plants and
pots are neglected and do not provide special interest. L’Chaim Centre could make use of the outdoors
more productively.

In both centres, there is very little protection from rain or wind. Margaret Fulton Centre has a deep
overhang extending from the roof. However, the space is used to store garden furniture, tools and
miscellaneous objects.

Principle 4. Other Living Things

Both centres had children day care centres a floor below them. Clients could watch the children
during their play outside. At L’Chaim Centre, one client pointed out to me his great-grandchild as he was
playing on a swing. This client would check his watch and leave the room so he could wave to the child
from the balcony. Both centres interact with the children in various programs designed especially for
intergenerational activities. In both places there are no live-in animals. While this is a desired element
according to Cohen and Wiesman’s (1991) design principles, it was not practical in this setting since
everybody goes home around 4:00 pm each day. In addition, L’Chaim Centre operates only 4 days a week
and other organizations also use the centre. At Margaret Fulton Centre, the outdoors provides exposure to
living things from a distance, while at L’Chaim Centre there is a relatively large fish tank, but I did not
see anyone expressing interest in it during the times I was there.

Principle 5. Range of Public to Private Spaces

In architectural terms public space refers to spaces that are accessible by anyone who wants to use
them and follows the behaviour for that space set by the architect, the developer and the regulating
authorities responsible for the safety of the users. Semi-private spaces are more restrictive as to who may
use the space, while the use is more defined. For example, a public space can be a street, a sidewalk or a
plaza. A semi-private space may be a waiting area at a doctors’ office or a walkway leading to a private
house. Private space is somewhat more complicated. It can be as simple as our home, our bedroom or our
car. However, private space can also be a matter of individual perception and may change from culture to
culture. Private spaces can be designed to be included in public spaces, such as a hidden corner behind a
statue in the middle of a plaza. So, how does all of this relate to the data collection and analysis at the two
facilities in the study?

At the L’Chaim Centre I see mostly a semi-private space that begins at the entry to the Centre and
continues through the corridor and the main activity room. There are no visual barriers, nor human
behaviours to indicate that the space entered is limited to specific users. There are no indicators and clues
that stop people from entering the space if they have no reason to be there. There is no control point to
monitor who enters and who leaves. As a result, people wander in and out of the Centre, not realizing they
have just disturbed an activity or someone’s concentration. Even the offices of the program coordinator,
nurse and director are open to anyone who wanders in. The two washrooms do provide private spaces
once inside. However, one washroom door opens directly into the main activity room and compromises a
very private activity. Drawing LC-6, demonstrates a solution as to how a semi-public space can be turned
into a private space: the treatment room depicted there now has a door for privacy. The existing space was
loosely defined by a desk and two chairs and was used by the nurse. It was exposed to passing visitors
and did not protect the identity of the client nor the reasons for seeing the nurse. To resolve the problem,
the nurse used a divider that provided some visual separation from visitors. As a result of my
recommendations staff reclaimed a small room in the back of the facility that originally was planned for
private treatment and later became a storage room. New room dividers and new furniture arrangements

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helped define smaller spaces for various activities. The activities coordinator reported that it took some
time for the clients to get used to the new arrangements, but slowly they are responding to the changes
and using the smaller spaces more often.

At Margaret Fulton Centre, I found a very clear transition from public to private spaces. The facility
was designed by an architect with input from the director and staff. A roof overhang at the front entry
protects all corners from the weather, especially the clients. The overhang also separates the facility from
the rest of the public area and sends a message that this is a building that protects its inhabitants. The front
doors are locked and only those with an approved code can enter and exit the facility. Inside the facility,
there is a clear range of semi-private to private space. Small groups may gather in front of the fireplace;
there is the option to close off treatment rooms from the rest of the facility. At earlier times the Centre
used small spaces for small group activity, such as playing cards. To play cards, a group of four to eight
seniors would congregate at the far end of the dining room using collapsible cards tables. There was an
unspoken understanding that the noise level of the activity had to be controlled and any expression of
enjoyment had to be moderated. Keeping this activity quiet took away from the spontaneity and the
organic flow of communication, discussion, laughing, teasing, singing, or yelling out when losing or
winning.

The five design principles were applied to the Margaret Fulton and L’Chaim Adult Day Care Centres,
even though these design principles are most applicable to the design of a new facility or a major
renovation. In existing centres, applying design principles is somewhat more complicated, possibly for
lack of space, funding, type of clientele and the kind of services to be provided. Therefore, the following
recommendations should be seen from a general point of view and called on when they become relevant.
Since Margaret Fulton Centre is a relative new facility, its design already includes many aspects of these
principles. The L’Chaim Centre and other centres like it need in depth review for changes.

General Recommendations

The following suggestions for design consideration apply to each design principle within the context
of the two centres:

Design principle 1. To provide clusters of small activity spaces to promote homelike atmosphere.
• Long corridors can be broken up by adding dining rooms, kitchen areas and activity rooms
• Divide large multipurpose activity room into smaller and specialized spaces
• Group together residents of similar ethnic background in each cluster
• Provide ethnic food
• Use interior finishes to reflect taste, values and beliefs typical to the culture

Design principle 2. To provide opportunities for meaningful wandering
• Open dead-end corridors and join them together to allow a continuing wandering path
• Provide spaces of interest and landmarks along the path such as a seating area and art
• Make sure floor finishes provide safe and smooth surfaces for walking

Design principle 3. To provide positive outdoor spaces
• Emphasize the doors to the outside, make them easy to be recognized and to be handled
• Provide secured outdoor space by building a fence covered with vegetation
• Provide a garden for the residents to work in
• Look into having a pet that will use the garden as well
• Provide interesting pathways with opportunities for resting and socializing
• Provide protection from the elements
• Provide transition zones such as greenhouses and sun rooms
• Continue to provide outdoor ethnic symbols typical to the culture
• Locate a washroom nearby

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Design principle 4. Provide other living things
• Add plants and animals, wherever applicable, to be taken care of by the residents to increase

feelings of autonomy and control, sensory stimulation, reminiscence and social interaction. Plants
provide colors, flowers, and fragrances, while animals can provide visual and auditory
stimulation.

Design principle 5. Provide a variety of opportunities for movement from public to private spaces
• Satisfy the need for semi-private, or in-between spaces before entering a public space. Consider

adding spaces that allow observation from a distance
• Introduce spaces for solitude, perhaps a small place with seating for one
• Provide protected spaces to prevent over-stimulation and allow for physical distance. Use a

furniture layout conducive to social interaction or solitude

Design Principle 6: Provide Spaces for Different Levels of Participation in
Creative Expression Activities

Although the five design principles recommended by Cohen and Weisman (1991) were sufficient to
capture most of the architectural concepts in designing spaces for seniors with dementia, they lacked in
depth identification and integration of the subtle differences in the levels of participation that the seniors
displayed during the inquiry. Although Cohen and Weisman touch briefly on the idea of “in-between
spaces” (p. 87), it was mostly applied to transitional realms between the in door and the out door spaces.
I identified four different behaviours that were exhibited: active participation, silent participation, distant
participation and passive participation. Each type carries behavioural information that needs to be
considered when designing spaces for seniors, regardless of the setting. Once we acknowledge the
importance of the arts in dementia care, the next step would be recognizing the importance of appropriate
space for creative activities that meets these levels of participation. Taking all of these elements into
account would have a significant impact on the field of architecture and the design for seniors with
dementia. The following are the four types of participation and examples that were observed:

a) Active participation is defined as full engagement, including physical and verbal interaction with
others, making efforts to communicate in any way possible. Examples: In L’Chaim Centre, participants
responded to music, jokes, stories, teasing in a very normal way. They asked questions, they were happy
to dance with me and express opinions on all kinds of topics. They were engaged in making art,
manipulating telephone wires and designing their dream studio. They responded with humour and critical
comments throughout the study. At Margaret Fulton the level of active participation took on a different
flavor, yet there were moments of equally active engagement as I witnessed at the L’Chaim Centre. The
fact that the seniors at Margaret Fulton were a homogenous group with moderate dementia framed my
whole experience with them. Perhaps my expectations of their remaining abilities were lower as a result.
The language barrier with the Spanish women made it difficult to assess of their ability to be engaged in
active participation. But when music was the highlight of the session, the Spanish speaking women were
equally as involved as the English speaking women.

b) Silent participation happens when seniors are present at the activity, but choose or are not able to
express themselves verbally. Still, they may show interest through non-verbal indicators such as facial
expression. For example: at L’Chaim Centre, several participants who sat at the table did not say a word
or volunteered very few words. However, from their eyes and body language I understood they were
following what was happening around the table. One instance in particular remains fresh in my memory,
when one woman with moderate dementia approached me after the session was over and said: “I want
you to know that I have heard everything you said and that I come especially to hear you. I love your
sessions.” Her comment only reinforced my belief that silent participation is no indication of lack of
interest, and every effort should be made to include these silent participants. Every once in a while I was
surprised at the responses and comments I received from seniors who had a more advanced form of
dementia than the rest. A woman who was usually very quiet during all our sessions at L’Chaim Centre
commented to another participant that she didn’t understand what creativity meant. I was not expecting to

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hear anything from her, but here it came Loud and clear. Situations like this only proved to me that I need
to be vigilant and expect the unexpected when dealing with seniors with dementia. At Margaret Fulton
Centre, I experienced the same surprise. One of the English speaking women, who hardly said a word
unless she was asked first, commented that singing in her church was creative. On numerous occasions I
could see a foot moving to the music, a smile, and eyes that followed me as I moved around the room. As
far as I was concerned, the silent participants were as strong in their present as the active participants.
They were just quieter.

c) Distance participation describes a person who may watch the activity from a distance. While this
person may or may not contribute to the ongoing activity, their interest is sufficient to keep them close by.
This group proved to be the most challenging one. For example, they would not sit around the activity
table, yet their actions left all of us in limbo and added a low level of stress to all of us while hovering in
the background. I felt the need to bring them in. Other participants were restless when I made these
efforts, and so was I. To ignore them would mean leaving them out, to include them would take my
attention away from those who were already seated and ready to participate. What could be done to lure
these seniors in? It occurred to me that perhaps this was a space issue. By nature, some of us need to pass
through a transition zone before we commit ourselves to anything. So, I became aware that some of the
seniors needed time and space before committing themselves to any activity and perhaps they would stay
in that gray zone for an unspecified time — what alr/tography calls the in-between areas in the seams of
two fabrics. This kind of behavior carries significant information for designing therapeutic environments
for seniors with dementia and deserves our attention.

d) Passive participation occurs when individuals view a video, television or movie. This is still a
form of participation and there is always the chance that it may progress later into any of the other types
of participation.

Design Principle 7: Provide Spaces to Open up Opportunities to Celebrate
One’s Ethnicity

Although the issue of ethnicity was not the focus of this study, I became aware of it as I delved deeper
into the process of collecting data. The two Centres were fundamentally different from each other in the
clientele they served, which had a significant impact on the social make up and alliances or friendships
that were formed. The L’Chaim Centre serves Jewish elderly men and women. Although they may come
from various parts of the world, they are bound by faith, tradition, customs, the common languages of
Hebrew and Yiddish and similar life experiences. All the participants with the exception of one person
liked to be with each other and craved being with other Jews. At Margaret Fulton the situation was
different. It is a multi-cultural Centre that resembles the make up of the Canadian society at large. The
Spanish-speaking women liked being with each other, while the others hardly paid attention to them.
There was a definite preference for companionship based on cultural affinity. I have to admit that a
different kind of energy was established between me and the seniors at the L’Chaim Centre that set it
apart from what happened at Margaret Fulton Centre. At L’Chaim Centre, I felt I did not have to prove
worthy of the seniors’ affection. I was accepted as one of them. This easy acceptance also framed my
interaction with them. Discussions flowed without me having to think about every move or having to be
politically correct in every word. There was an underlying understanding that did not need to be stated up
front. There was that comfort zone we all shared regardless of the dementia, the frailty and a whole host
of issues each one of us brought in as participants. This feeling of familiarity freed the seniors and me to
enjoy each other’s company on a much deeper level. On the other hand, at Margaret Fulton, I actually
identified with the Spanish speaking women. Like them, I had an accent and like them, I still feel like an
outsider. The reason I bring up this issue of ethnicity is because it appears to have a made significant
contribution to the quality of interaction with the seniors in both places. As easy as it was in L’Chaim
Centre to establish warm relationships immediately, it was much harder at Margaret Fulton Centre to gain
the trust and closeness I enjoyed at the L’Chaim Centre. I would like to explore this topic more deeply in
the future. It would be interesting to see how facilitators from different backgrounds interact with seniors
with dementia who belong to one ethnic group.

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Active, silent, distance & passive
Participations:

‘ Viewing and making art
‘ Viewing, listening and making

music
‘ Viewing dance and dancing
• Viewing & listening to reminiscing
• Viewing and participating in

cooking and eating

37

For what purpose

• Expectations of parties involved
in correlation with users and
function

Space requirements

Accessible & secured storage
• Horizontal & vertical work surface
• Washroom
• Kitchen
• Display area
• Distance & passive viewing
• Media viewing

The following flow chart (see Figure 20) summarizes the various aspects that need to be taken into
consideration when designing space for creative expression activities. Architects and designers may find
this chart useful. It is based on the type of participation, and the type of activities in creative expression
programs.

Who are the users

Seniors with dementia:
• Background information
• Medical information
• Mental & physical abilities
• Social skills
Facilitator, staff, volunteers, family
and friends

What type of participation

What materials & equipments

E

• Art supplies
• Playing instruments
• Furniture
• Lighting
. Media equipment

JL
Accessibility and circulation
requirements

. Entry and exit to and from the area
of activity

• Resident mobility by foot,
wheelchairs, walkers

• T .ncaticrn of wishrooms

Interior finishes

• Color, texture, patterns and
lighting to suit design criteria for
users, function & type of
participation

Space design

• Size, shape and the
interrelationship between the
various functions and types of
participations

Figure 20: Environmental Analysis of User, Function and Space Requirements for Creative
Expression Activities

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Physical Changes to the Environment and the Users’ Response to Them

Although the four types of active, silent, distant and passive participation were identified as an
important element in designing spaces for creative expression activities, the opportunities to
accommodate these important behaviors were limited at the two Centres. At L’Chaim space was at a
premium and therefore I was reluctant to use space that was needed very badly for group activity. Silent,
passive and distant participation could then occur from anywhere in the room. At Margaret Fulton Centre,
the four types of participation could be accommodated in some spaces while not in others. The smaller
spaces were too enclosed and changing them dramatically would not have served the Centre in a practical
way. To accommodate the various types of participation we needed to consider them in the early design
phases of the facilities’ programming. As a result of the difficulties in implementing specific spaces for
the four identified types of participation, we followed the approach I have taken in varying the furniture
layout and in my interactions with the seniors. I encouraged silent participants by looking at them and
creating eye contact, including them in the conversations, distributing the art supplies to them just as I
would to everybody else. In participation from a distance, I made sure I projected my voice to reach them
made, eye contact, smiled, made comments to engage them and bring them slowly to the activity table.
Those who were passive and not interested at all were invited to sit on more comfortable chairs near the
activity if they wanted. No pressure was exercised to join the group.

Responses of Stakeholders to Changes in the Environment

A surprise series of events emerged when two board members of the L’Chaim Centre informed me
that there were some plans to refresh the interior finishes of the centre. This move originated with the
administration of the Jewish Community Centre (3CC) rather than L’Chaim Centre, which rents space
from the JCC., Nevertheless, the administration of the L’Chaim Centre welcomed the initiative. Based on
my experience as an architectural designer and on feedback I got from the seniors and staff, I offered
some ideas about interior changes they would like to see and about my understanding of the physical and
cognitive abilities of seniors with dementia. Since I was embarking on a long journey abroad, I asked the
two board members to collect some linoleum samples and a range of paint samples, so I could put
together a color scheme to take back for approval by the board and the director of the Centre. The
proposed color scheme was accepted and so was the new floor covering and its design. The changes took
place while I was away. I must admit I had been sceptical that any changes would take place. I knew at
the outset of this study that any architectural changes to spaces at the two sites were unlikely to happen.
However, now I would have a real opportunity to suggest changes and receive feedback from the
participants; seniors and staff.

While I was thousands of miles away from Vancouver, I received the following e-mail from Debbie,
the Program Director at L’Chaim:

I wanted to drop a quick note before my ‘shabbos chicken’to let you know that L ‘Chaim
has been painted, your requested color, and the marmoleum floor has been going in for
the last two days. They are not quite finished, but it looks INCREDIBLE. Iwas thinking
ofretiring, but now I will have to work there anotherfew years, to enjoy it. It is so bright
and clean, amazing. You ‘re a genius. Can ‘t wait for you to see it. I will be away when
you get back, but feel free to drop by.

Upon my return I asked Debbie to schedule another session with the seniors to document their
responses to the recent changes. David, the film producer and I arrived for an additional session. The
group of seniors was a mix of old and new corners. The session started with sharing my travelling
experiences in Israel, which is a favourite subject at the L’Chaim Centre, where Jewish sentiments about
the state of Israel run very deeply. The other half of the session was devoted to feedback from the seniors
regarding their perception of the newly decorated space. Debbie wrote down the comments from the
group on a flipchart. One week later, she sent me an e-mail with all the responses that were collected that
day:

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Feedback from the seniors of The L ‘Chaim Adult Day Centre, recorded on
Friday November 25, 2005

Question: How do you like the changes made to the Day Centre?

Answers:
Floor is safe. Looks cleaner, bigger. Colors are cold. We need artwork
on the walls. Better than carpets. Contrast in color between furniture
and floor is good. A little too sanitary looking. We need to make it
warmer. Too nude. Need to dress it up. The carpet was ‘homier’. Pleased
with changes. Larger, brighter, fresher. Black out blinds need color.
Curtain? Valance? Floor must be coated. Looks pretty. (Anita, not
present, wants me to add this to list... Doesn’t like two tones in the floor.
It’s cold. Wants a home-like feel)

Question: What would make it more home-like?

Answers:

More pictures. Valance, curtains, drapes. Fake fireplace. Floor lamps,
table coverings, good smells, painted border, flowers in uniform pots.
Corkboards with our work. Dividers making defined seating areas.
Pillows.

Later that day, the director of the Centre invited me into her office to discuss the recent changes and
budget issues regarding requests to warm up the place and make it cosier. Some concerns were raised
about the process of how the changes were achieved. The director felt that she should have been advised
of the proposed changes earlier. Since I was not present to continue any consultations with any of the
parties involved, the matter took on a life of its own.

I must say that I was worried about the results of the renovation. Not being there to supervise the
implementation of the interior changes potentially could have been a source of problems. However, when
I walked into the centre to collect the seniors’ reactions after an absence of two months, I was pleasantly
surprised. The place looked airy, clean, brighter, easier to maintain and looked much larger. The lighter
colors on the walls, doors and floor opened up the space and gave an impression that some walls had been
extended outward. However, with the physical changes there was a change in the atmosphere and
ambience the Centre projected when the darker colors and the dark carpet were there.

The need to feel at home and the importance of it was demonstrated clearly in the response of the
participants to the changes. Although the changes were welcomed and appreciated, the sorrow for the loss
of the home-like feeling was evident. I knew as a designer that a home-like atmosphere could be regained
easily by adding some accessories that are typical to residential homes, such as a fireplace, curtains, warm
lights and pillows and so I was not that concerned. In a subsequent telephone conversation with to discuss
recent developments in an effort to improve the home-like atmosphere, she reported that some of the
ideas suggested by the seniors during the feedback session were implemented and that an electric fire
place was seriously being considered. She reported that several room dividers were purchased in an effort
to divide the large room into smaller spaces for privacy, feeling of intimacy and the enhanced home-like
feeling. A couple of cork boards were purchased as well for artwork displays. At the entry Debbie
provided a couple of chairs, a small coffee table with a display of flowers to receive the seniors as they
come into the Centre and break the long corridor into segments with interesting focal points along the
way and a place to sit down when waiting for a car ride.

What transpired at the L’Chaim Centre since the study began was beyond all my expectations. I was
fortunate to witness changes over a short period of time. I had the opportunity to observe meaningful

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changes, assess them, get feedback from all parties involved and be able to respond again to some of it.
Even more fulfilling, I am still involved with an ongoing process of facilitating changes. I felt that my
research work served as a catalyst for changes that had been needed in the Centre for a long time. I truly
expected to conduct my study and be out of there the moment sessions were over. However, a bond
developed between myself, the seniors and the staff, Debbie the program director, in particular. She made
me feel at home and was very gracious and very accommodating.

In addition to the architectural changes that took place in the Centre, there were also other changes to
the programs and the approach to programs implementation. Earlier, on September 8, 2005, Debbie sent
me this e-mail:

The experience of having Dalia Gottlieb Tanaka do her research at the L ‘Chaim Adult
Day Centre has been a positive one for staffand clients.

The staff has relearned the importance of empowering seniors to make their own
choices, in programs, and changes to the environment. This writer was making all the
decisions and has now implemented a shfl in her approach. This writer also now realizes
that the setting as is, is very distracting to the participants. That had become, ‘the way it
is’ at L ‘Chaim, but changes will now be made to make leading a group easierfor the
programmer. Room dividers, boards, arrangement of tables, asking other stafffor no
disruptions, etc... will now be used. We will also start using mini mentals as part of our
initial admission of the client, fit has not already been done by the case manager.

The seniors always lookedforward to Dalia ‘s visits. Theyfelt honored that someone was
doing this type ofwork that would impact their lives. That Dalia cared and wanted to
make a difference endeared her to them. They loved her ‘give me five’ request. They felt
they were being rewardedfor a special contribution.

Surprisingly, they were willing to try the furniture in different combinations. This writer
thought that fragile seniors do better with no changes to routine. But the seniors of
L ‘Chaim regarded Dalia ‘s changes; eg. to furniture, lighting, music, routine, or
breakfast choice, as adventures. This made Dalia ‘s visits exciting. No one reacted
negatively.

We wish her luck in her continued endeavors.

Debbie Cossever, Special Care Counsellor
L ‘Chaim Adult Day Centre
Activities Coordinator

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Summary of Understandings Based on the Inquiry

The results of the inquiry on creativity, dementia and the therapeutic environment have led to a
consensus that creativity is a purely human quality. Although some researchers would argue about the
level and quality of creativity in each person, the ability to express oneself continues at least through early
to moderate dementia. Areas destroyed in the brain show reduced cognitive ability but other areas may
continue to perform intact for a while longer. Through appropriate programs conducted in responsive
environments designed to accommodate their needs, these seniors may continue to enjoy life to the best of
their remaining abilities.

Understandings that emerged from this inquiry encourage space designers for seniors with dementia
and their various activities to be responsive to the specific function, the users and expectations about their
abilities as they progressed during this condition. A large, multi-purpose space is no longer adequate for
all creative expression activities unless it can be divided into smaller spaces with temporary room
dividers. A mix of spaces to suit a mix of activities would benefit seniors with dementia. Based on this
analysis and previous experience working with seniors with dementia, it became clear that the areas in
great demand (fig. 34) were: 1) The multimedia centre, 2) The outdoor area, and 3) The washrooms. This
observation became important when designing a space for creative expression activities. By providing
direct access to highly used spaces, we can streamline routes to space and equipment, reduce walking
distance and the need to move people around, reduce stress to participants and caregivers. As a facilitator
for creative expression activities, I would enjoy being able to manipulate space and furniture according to
number of participants, type of participation, type of activity and types of abilities while having easy
access to supplies and media equipment. While being cognisant of space arrangements and creative
expression activities, it is also important to acquire more knowledge from a multidisciplinary perspective
based on the psychosocial model of dementia care, which is based on the person within the disease,
including the history of each participant and their medical condition.

The following presents a summary of the key issues addressed and the changes recommended for
both the Margaret Fulton and L’Chaim Adult Day Care Centres based on an in-depth review of the
variations in space arrangements and the creative expression activities sessions held. It includes design
resolutions to the sites and applies general standards recommended by Cohen and Weisman (1991).

Furniture Arrangements at the Margaret Fulton and L’Chaim Centres

L’Chaim Adult Day Care Centre

Identifying space problems. The L’Chaim Adult Day Care Centre represents what is known in
architectural jargon as the “Church Basement” model. Moore, Geboy, Weisman and Mleziva (2001)
describe it as: “... a large space as one that can accommodate the wide range of activities they expect to
conduct in the course of providing adult care services” (p. 4). Many long-term care facilities and adult day
care centres make use of a large, open multi-purpose space — and not all open spaces are inappropriate.
The appropriateness depends on the activity provided and the support that makes it a success or failure.
Moore et al. make a direct correlation between space and its use in dementia day care and state that:
“Activity, experience and physical setting are fundamentally intertwined” (p. 15).

Although this study set out to examine the requirements and design solutions for a creative expression
studio for people with dementia in day care centres, we soon discovered that designing such a space could
not be limited solely to the space within its walls, nor could it be designed for an isolated event.
Therefore, it appears that the design of a studio for creative expression activities needs to be expanded
into the rest of the day care centre that takes into consideration situations that occur before, after and
during the times that creative expression activities take place.

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Certain general problems are usually associated with the “Church Basement” model. We observed
these problems at the L’Chaim Centre and made efforts to resolve them within the limited means
available:

a. There were not enough environmental cues to increase a sense of orientation, to suggest a
specific activity or to set up expectations for certain behaviour.

b. There were difficulties in visual, olfactory and auditory control.
c. There was no privacy in one-on-one interactions, nor opportunities for small group activities.
d. The large space encourages “overpopulated activities” (Moore, Geboy, Weisman and

Mleziva 2001, p. 13) that contribute to increased physical distances between service
providers and participants.

Resolving space problems. To resolve the four overarching problems, Moore et al. (2001) suggest
eight attributes that are crucial when designing therapeutic environments for people with dementia:
“provide a sense of: orientation, safety and security, privacy, quality stimulation, supporting functional
abilities, personal control, familiarity and continuity of self and social interaction.” (p. 23). Most of the
eight attributes were used, with the exception that privacy or the lack of it was omitted. The lack of
privacy was found to be a constant area of concern throughout the data collection. Categories were used
when they were relevant and were otherwise omitted. In addition to the attributes cited by Moore, Geboy,
Weisman and Mleziva (2001)1 added a category that took into account my own perspective as a
researcher/facilitator or as a staff member on a contract basis. For purposes of this study I refer to that
category under Staff Issues.

What follows is a systematic analysis of each of five sessions out of seven that were conducted at the
L’Chaim Centre. The following analysis must be viewed together with the complete 1 lxi 7-inch drawings
at the end of each session described. Those drawings represent a visual summary of what transpired at
each session. Partial drawings with a focus on the furniture arrangements are included in each situation.

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Furniture Arrangements: Sessions One to Five

Session One — Music

£L.J.

__

I KEYBOARD CU NS

I C FOOD TROLLEY
S

LINOLEUM
GARBAGE

CARPET p SIDE TABLE

/ 3’ - KITCHEN
2 3 6f / 211 F

FISH TANK 15 M R -
‘- .

250

14 L

RESTING 13 12: 11 10 94 8 LOUNGE AREA
I AREA

‘ 37 / CARPET

-

C.rj STORAGE

b •. — — -—
/ 32-0

DECK

Figure 21: Session One — Music
See Drawing LC - I
All tables are arranged into one large rectangular shape (5 feet wide by 12 feet long)

1. Environmental cues
• Participants needed to turn around to face the violinist. Some remained where they were, with

their backs to the violinist.

2. Safety and security
• No room to dance and turn safely
• Floor finishes inappropriate for dancing
• The researcher was unaware that one senior could not go back to her seat since I took the seat to

help another senior
• Space for circulation is sufficient with this furniture arrangement, which may be the reason why

the staff prefers it

3. Familiarity and continuity of self and social interaction
• Participants prefer it when the facilitator/researcher sits down during discussions. This raises

interesting issues of power balance between participants and the researcher, who is perceived to
be in a position of control, power and leadership. This point may have an impact on the
relationship the researcher is trying to build, to develop equality and trust that will facilitate
openness and, hopefully, will lead to creative expression.

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4. Quality stimulation
• Visitors walking in and out at will are in direct contact with participants while they are engaged

in various activities. There is a need to allow maximum opportunities for participants to be
exposed to quality stimulation without being interrupted by visitors or staff during an activity.

5. Difficulties in visual, olfactory and auditory control
• No sound or visual separation from the kitchen
• No sound or visual separation from main entry
• No sound or visual separation at the nurses’ station for privacy and treatment
• No discreet access to the washroom

6. Overpopulated activities
• No separation for additional concurrent activities
• Difficulties in reaching participants over the massive size of the tables
• Difficulties in maintaining direct eye contact within the 2 to 4 foot comfort zone
• Some participants were too far away from the researcher or hidden behind others
• Visual and hearing issues for participants and for the facilitator
• No sufficient solutions to display objects close by
• No sufficient solutions to display extra sheets of the flipchart close by

7. Staff issues
• Staff could strain their backs when reaching out to participants across the tables, behind them or

next to them
• Difficulties in maintaining visual and auditory control with all the participants on an ongoing and

equal basis

130



N
o
te

s
F

ro
m

V
id

eo
A

n
a
ly

si
s

W
S

(w
id

e
sh

o
t)

S
e
ss

io
n

O
n
e

-
M

u
si

c
Ju

n
e

20
,

20
05

O
v

er
ar

ch
in

g
p
ro

b
le

m
s:

N
ot

en
o

u
g

h
en

vi
ro

nm
en

ta
l

cu
es

2.
N

o
vi

su
al

,
ol

fa
ct

or
y

an
d

au
di

to
ry

co
nt

ro
l

3.
N

o
p

ri
v

ac
y

4.
O

v
er

p
o

p
u

la
te

d
ac

ti
vi

ti
es

(M
oo

re
et
.

20
01

)

S
p
a
c
e

Is
su

es
:

1.
E

n
v
ir

o
n
m

en
ta

l
c
u
e
s

•
P

ar
ti

ci
p

an
ts

n
ee

d
to

tu
rn

ar
o

u
n

d
to

fa
ce

th
e

vi
ol

in
is

t.
2.

S
af

et
y

an
d

se
cu

ri
ty

•
N

o
ro

om
to

d
an

ce
an

d
tu

rn
sa

fe
ly

.
•

F
lo

or
fi

n
is

h
es

in
ap

p
ro

p
ri

at
e

fo
r

da
nc

in
g.

•
D

if
fi

cu
lt

ie
s

in
co

nt
ro

ll
in

g
al

l
ac

ti
vi

ti
es

.
•

In
su

fi
lc

ie
nt

sp
ac

e
fo

r
ci

rm
il

at
io

n.
3.

F
am

Il
ia

ri
ty

an
d

co
n

tI
n

u
it

y
o

f
se

lf
an

d
so

ci
al

in
te

ra
ct

io
n

•
P

ar
ti

ci
p

an
ts

p
re

fe
r

re
se

ar
o
b
er

to
si

t
do

w
n,

w
hi

ch
re

v
ea

ls
is

su
es

ab
ou

t
po

w
er

an
d

eq
ua

li
ty

.
4.

Q
u

al
It

y
st

im
u
la

ti
o
n

•
V

is
it

or
s

w
al

ki
ng

in
an

d
q,

A
t

w
ill

in
te

rf
er

e
w

it
h

on
go

in
g

ac
ti

vi
ti

es
.

5.
D

if
fi

cu
lt

ie
s

in
v

is
u

al
,

o
lf

ac
to

ry
an

d
au

d
it

o
ry

co
n

tr
o

l
•

N
o

so
u

n
d

or
vi

su
al

se
p
ar

at
io

n
fr

om
ki

tc
he

n
an

d
m

ai
n

en
tr

an
ce

.
•

N
o

pr
iv

ac
y

at
th

e
nu

rs
es

’
st

at
io

n.
•

N
o

vi
su

al
or

d
is

cr
ee

t
se

p
ar

at
io

n
fo

r
w

as
h

ro
o

m
.

6.
O

v
er

p
o

p
u

la
te

d
ac

tI
v
it

ie
s

•
N

o
se

p
ar

at
io

n
fo

r
co

n
cu

rr
en

t
ac

ti
vi

ti
es

.
•

D
if

fi
cu

lt
ie

s
in

re
ac

h
in

g
pa

rt
ic

ip
an

ts
ac

ro
ss

ta
b

le
s.

•
D

if
fi

cu
lt

ie
s

in
m

ai
nt

ai
ni

ng
di

re
ct

ey
e

co
nt

ac
t.

•
P

ar
ti

ci
p

an
ts

to
o

fa
r

aw
ay

o
r

hi
dd

en
be

hi
nd

o
th

er
s.

•
V

is
ua

l
an

d
h

ea
ri

n
g

di
ff

ic
ul

tie
s.

•
N

o
ea

sy
w

ay
to

di
sp

la
y

ob
je

ct
s.

7.
F

a
c
ll

lt
a
to

rs
is

su
e
s

•
R

ea
ch

in
g

p
ar

ti
ci

p
an

ts
ab

ro
ss

th
e

ta
b

le
st

ra
in

s
th

e
ba

ck
.

•
D

if
fi

cu
lt

ie
s

in
m

ai
nt

ai
ni

ng
vi

su
al

an
d

au
di

to
ry

co
nt

ro
l.

C
re

at
iv

it
y
,

D
em

en
ti

a
an

d
th

e
T

h
er

ap
eu

ti
c

E
n
v
ir

o
n
m

en
t

D
al

ia
G

o
tt

li
eb

-T
an

ak
a,

M
A

rc
h

In
te

rd
is

ci
pl

in
ar

y
P

ro
gr

am
U

ni
ve

rs
it

y
of

B
ri

tis
h

C
ol

um
bi

a
V

an
co

uv
er

,
B

C
.

L
E

G
E

N
D

C
lo

se
-U

p
()

P
ro

bl
em

C
am

er
a
,

V
is

ua
l

N
i
d
e

S
ho

t
D

is
tr

ac
ti

on

C
am

er
a

L
L

on
g

T
ab

le

C
am

er
am

an
(2

9
.5

x
7
1
”)

M
M

ed
.T

ab
le

(
)

M
us

ic
ia

n
(2

9
.5

x
4
r)

R
es

ea
rc

h
er

c
C

ar
d

T
ab

le
(3

6
x
3
6
)

P
A

R
T

IC
IP

A
N

T
S

Q
U

O
T

E
S

B
ar

n
ey

:
It

b
ro

u
g

h
t

b
ac

k
p
le

a
sa

n
t

m
em

o
ri

es
of

m
y

yo
ut

h
an

d
m

y
y
o
u
n
g
er

d
ay

s
w

he
n

I
u
se

d
to

go
to

th
e

ni
gh

t
cl

u
b

s
an

d
d

an
ci

n
g

ho
ld

in
g

la
dy

re
al

ly
cl

o
se

an
d

da
nc

in
g

w
ith

h
er

so
it

b
ro

u
g

h
t

b
ac

k
lo

ve
ly

m
em

o
n

es
.

Ir
a:

T
he

G
er

m
an

s
to

ok
th

e
pi

an
o.

I
di

d
no

t
p

la
y

th
e

p
ia

n
o

si
n

ce
th

en
.

R
u

th
:

W
el

l
I

th
in

k
I’

d
li

ke
to

co
m

e
ag

ai
n.

L
’C

ha
im

A
d
u
lt

D
ay

C
ar

e
C

en
tr

e
V

an
co

u
v

er
Je

w
is

h
C

o
m

m
u
n
it

y
C

en
tr

e
S

E
S

S
IO

N
I

-
M

U
S

IC
Ju

n
e

20
,

20
05

A
L

L
T

A
B

L
E

S
G

R
O

U
P

E
D

T
O

G
E

T
H

E
R

L
C

-1
(i

n
d

is
se

rt
at

io
n

p.
13

1)
A

rt
w

or
k

se
ss

io
n

U
:)



Session Two - Repeated Music Activity

Figure 22: Session Two - Repeated Music Activity
See Drawing LC —2
Tables arranged in a U-shape with opening facing main entrance

1. Environmental cues
• Floor finishes need to be selected to accommodate the type of activity
• Not all participants have a good view of the musician and need to be reminded to turn around

2. Safety and security
• Moving the notice board as a visual barrier between the kitchen and the main gathering area was

a positive move. However, it reduced the space for circulation around the tables and there was a
concern that the participants might trip over the legs protruding from underneath the notice board.

3. Familiarity and continuity of self and social interaction
• The participants exhibited remarkable patience as the furniture was moved around, and failed to

comment on their own. Most of the comments about the furniture arrangement were solicited,
which raises several questions:
— Are the participants not aware of the changes?
— Do they see the changes but prefer not to comment?
— Are they worried about creating a fuss over it?
— Do they care? Does it matter?

• Participants seem to have less stress about seat selection
• Adding two screens, one that screened the kitchen and another that screened the rest area near the

fish tank, immediately provided a cosier feeling that defined the area of activity better.

4. Quality stimulation combined with the next item

ADMINISTRATION
OFFICE

FOOD TROLLEY

WASHROOM

,, c

KEYBOARD •ij WS

i .

CARPET NEW LOCATION
OF NOTICE

RESEARCHER’S
. BOARD

__•

TABLE

FSHTANK 13

‘. ‘ ‘12-
L

RATTAN ::
SCREEN -11 -3

S RESTING ),io2 L M -
AREA < ,- .-,-

98-765

DECK .
STORAGE

b — -

S.

LINOLEUM —
GARBACE

SIDE TABLE

KITCHEN
F

LOUNGE AREA

CARPET

DECK

25-O

I

132



5. Difficulties in visual, olfactory and auditory control
• To reduce interference from the kitchen and increase concentration abilities, the researcher used

the notice board as a partition and hung large images of pianos and stringed musical instruments
on wide strips of white Tyvek, a building material, which were draped over the notice board. By
doing so, she presented a rich visual display of musical instruments in close proximity to some of
the participants, providing clues and reminders of the topic throughout the session.

• Banners hung from the ceiling did not seem to be noticed

6. Overpopulated activities
• Most of the problems resulting from the furniture layout in the first session were resolved:

— It is easier to address participants from the front, rather than from the back or the sides. This
makes it easier for them to watch the facilitator speak and follow facial expressions or any
other demonstration, such as giving instructions. According to one participant: “seeing makes
hearing better”

— It is easier to maintain direct eye contact within the 2 to 4-foot comfort zone
— The distance to each participant is equal
— There is better visual and hearing contact with each other
— Solutions were improvised for displaying objects, such as placing extra sheets from the

flipehart closer to participants; need a better, more permanent architectural solution

Three issues remain unresolved:
• The group of participants is still too large
• No ability to create concurrent activities due to lack of appropriate space
• No space to divide the group into higher and lower functioning individuals as needed

6. Staff issues
• Difficulties in moving chairs around, especially with participants already sitting in them
• U-shape arrangement seems to work well for me as a facilitator leading the program on creative

expression activities. Staff reported later that they have begun to use this layout on other
occasions. Other solutions could be tried but, due to obvious limitations of this study and cost,
they were not pursued. Perhaps a circle with individual curved desks could work as well or even
better.

133



N
o
te

s
F

ro
m

V
id

eo
A

n
al

y
si

s
W

S
(w

id
e

sh
o
t)

S
e
ss

io
n

2
-

R
e
p

e
a
te

d
M

u
si

c
Ju

n
e

27
,

20
05

S
p
a
c
e

Is
su

es
:

1.
E

n
v
ir

o
n
m

en
ta

l
c
u
e
s

•
In

ap
p

ro
p

ri
at

e
fl

oo
r

fi
ni

sh
.

•
D

if
fi

cu
lt

ie
s

se
e
in

g
th

e
m

us
ic

ia
n.

2.
S

af
et

y
an

d
se

cu
ri

ty
•

N
ot

en
o

u
g

h
sp

ac
e

fo
r

ci
rc

ul
at

io
n

ar
ou

nd
th

e
ta

b
le

s.
3.

F
am

il
ia

ri
ty

an
d

co
n

ti
n

u
it

y
o

f
se

lf
an

d
so

ci
al

in
te

ra
ct

io
n

•
S

en
io

rs
di

d
no

t
co

m
m

en
t

ab
ou

t
ch

an
g

es
in

fu
rn

it
ur

e
ar

ra
n
g
em

en
t

w
hy

?
•

A
re

th
e

p
ar

ti
ci

p
an

ts
no

t
aw

ar
e

of
th

e
ch

an
g
es

?
•

D
o

th
ey

se
e

th
e

ch
an

g
es

bu
t

pr
ef

er
no

t
to

co
m

m
en

t?
•

A
re

th
ey

w
or

ri
ed

ab
o

u
t

cr
ea

ti
ng

a
fu

ss
ov

er
it

?
D

o
th

ey
ca

re
?

D
oe

s
it

m
at

te
r?

•
L

es
s

st
re

ss
ab

o
u

t
se

at
se

le
ct

io
n.

•
S

cr
ee

n
s

pr
ov

id
ed

a
co

si
er

fe
el

in
g

an
d

vi
su

al
ba

rr
ie

r.
4

&
5.

Q
u
al

it
y

st
im

u
la

ti
o

n
co

m
b
In

ed
w

it
h

d
if

fi
cu

lt
ie

s
in

v
is

u
al

,
o

lf
ac

to
ry

an
d

au
d
it

o
ry

co
n

tr
o

l
•

N
oi

se
an

d
st

af
f

w
or

ki
ng

in
th

e
ki

tc
he

n
pr

om
pt

s
th

e
u

se
of

sc
re

en
s,

w
hi

ch
w

er
e

u
se

d
as

pr
op

s
fo

r
in

fo
rm

at
io

n
as

w
el

l.
•

B
an

n
er

s
hu

ng
fr

om
th

e
ce

il
in

g
ca

u
se

d
no

co
m

m
en

t:
w

er
e

th
ey

no
ti

ce
d?

6.
O

v
er

p
o

p
u

la
te

d
ac

ti
v
it

ie
s

•
E

as
ie

r
to

ap
p
ro

ac
h

p
ar

ti
ci

p
an

ts
fr

om
th

e
fr

on
t.

•
E

as
ie

r
fo

r
p

ar
ti

ci
p

an
ts

to
fo

llo
w

in
st

ru
cl

io
ns

.
A

cc
or

di
ng

to
o

n
e

pa
rt

ic
ip

an
t:

“s
ee

in
g

m
ak

es
h

ea
ri

n
g

b
et

te
r.

•
E

as
ie

r
to

m
ai

nt
ai

n
di

re
ct

ey
e

co
nt

ac
t

•
E

qu
al

d
is

ta
n
ce

to
ea

ch
pa

rt
ic

ip
an

t.
T

h
re

e
o
u
ts

ta
n
d
in

g
is

su
e
s

ar
e

st
il

l
u
n
re

so
lv

ed
:

•
G

ro
u

p
is

to
o

la
rg

e.
•

L
ac

k
of

ap
p
ro

p
ri

at
e

sp
ac

e
fo

r
co

nc
ur

re
nt

ac
ti

vi
ti

es
.

•
N

o
sp

ac
e

to
di

vi
de

th
e

gr
ou

p
in

to
hi

gh
er

an
d

lo
w

er
fu

nc
ti

on
in

g
in

di
vi

du
al

s
as

n
ee

d
ed

.
7.

F
ac

il
it

at
o
r’

s
is

su
e
s

•
D

if
fi

cu
lt

ie
s

in
m

ov
in

g
ch

ai
rs

ar
ou

nd
.

•
U

-s
h
ap

ed
ta

b
le

ar
ra

n
g
em

en
t

se
em

s
to

w
or

k
w

el
l.

C
re

at
iv

it
y

,
D

em
en

ti
a

an
d

th
e

T
h

er
ap

eu
ti

c
E

n
v
ir

o
n
m

en
t

D
al

ia
G

o
tt

li
eb

..
T

an
ak

a,
M

A
rc

h
In

te
rd

is
ci

pl
in

ar
y

P
ro

gr
am

U
ni

ve
rs

it
y

of
B

ri
tis

h
C

ol
um

bi
a

V
an

co
u

v
er

,
B

C
.

L
E

G
E

N
D

C
lo

se
-U

p
P

ro
bl

em

C
am

er
a

,
‘

V
is

ua
l

W
i
d
e

S
ho

t
%

!q
)

D
is

tr
ac

ti
on

C
am

er
a

L.
L

on
g

T
ab

le

C
am

er
am

an
(2

9
.5

x
7

1
”)

M
M

ed
.T

ab
le

M
us

ic
ia

n
(2

9
.5

x
4

7
”)

R
es

ea
rc

h
er

c
C

ar
d

T
ab

le
(3

6
x
3
6
”
)

P
A

R
T

IC
IP

A
N

T
S

Q
U

O
T

E
S

S
o
n
ia

:
I’

m
on

e
of

th
e

gr
ou

p.

Ja
ck

:
T

hi
s

lo
o

k
s

li
ke

m
y

w
if

e’
s

pi
an

o;
sh

e
h

ad
a

p
ia

n
o

li
ke

th
is

w
he

n
sh

e
w

as
12

y
ea

rs
ol

d.

T
o

b
y

:
It

’s
n
o
t

di
st

ur
bi

ng
us

,
I

th
in

k
ft’

s
w

on
de

rf
ul

...
f e

el
s

co
si

er
(c

o
m

m
en

t o
n

ta
b

le
al

ra
n
g
em

en
t)

.

B
ar

n
ey

:
I

th
o

u
g

h
t

it
w

as
ve

ry
g
o
o
d

an
d

th
e

m
o

v
em

en
t

w
as

ve
ry

in
te

re
st

in
g.

...

L
’C

ha
im

A
d
u
lt

D
ay

C
ar

e
C

en
tr

e
V

an
co

u
v

er
Je

w
is

h
C

o
m

m
u
n
it

y
C

en
tr

e
S

E
S

S
IO

N
2
-

R
E

P
E

A
T

E
D

M
U

S
IC

Ju
n

e
27

,
20

05

U
-

S
H

A
P

E
D

R
o
o
m

di
vi

de
r

L
C

-2
(i

n
d
is

se
rt

at
io

n
p.

13
4)



Session Three — Friendship

13
RA1rAN
SCREEN 1 RESTING)

AREA i,i
p

Ii

cIwS
2

‘ CARPET

RESEARCHERS
TABLE

c

.

C C 6:

t 4
STORAGE

32G’

Figure 23: Session Three — Friendship
See Drawings LC — 3A and 3B
3A — Detached dining tables
3B — Back to a U-shape arrangement with opening

facing main entrance.

14 • 1
...I C.

13 2

.•12.c C
—

:11. SL L :..:

10 98 7 6 5
4? • 4 • 4J 4?

U-SHAPE3B

1. Environmental cues
Smaller tables detached from each other resemble the setup for a dinner activity, a restaurant or
other social gathering

2. Safety and security
• Difficulties in negotiating access to the various tables

135

KEYBOARD

FLIP CHART

FISHTANK
-

P -14-

LINOLEUM —

JNEW LOCATION
flOP NOTICE

.4’ R rARD

_P1 ‘-
C 12

— •. . ,_ •• -
-4 C

4

SESSION 3A

FOOD TROLLEY

S

GARBAGE

SIDE TABLE

KITCHEN
F

LOUNGE AREA

CARPET

I
/

25’-O

•

4 —.• -,

“t-k

I

/



• The seemingly chaotic layout caused some confusion and lingering decisions about where to sit
and with whom

3. Familiarity and continuity of self and social interaction
• Detached tables seemed to create artificial groupings that affected the social needs of the

participants. This layout seemed to inconvenience some participants who were reluctant to sit
with some and happier sitting with others

4. Quality stimulation
• Difficulties in reaching participants who sat in various directions and distances
• Difficulties in seeing each other or seeing the researcher comfortably
• This arrangement is not efficient for distributing art supplies
• Limitation in how much participants are exposed to one another when engaged in creative

expression activities; limited opportunities for interaction

5. Difficulties in visual, olfactory and auditory control
All previous difficulties remain:
• No sound or visual separation from the kitchen
• No sound or visual separation from main entrance
• No visual or discreet access to the washroom
• No clear location for the notice board, the flipchart or the facilitator

In addition to these difficulties, it seems that the detached tables only increased the intensity of the
problems.

6. Overpopulated activities
• Detached and scattered tables seem to give an impression that the group is bigger, since ample

space must be provided for circulation around each table
• There was no sense of order since the tables were staggered to allow people to get in and out of

the chairs easily or with help from staff
• This arrangement was suited for small group interaction

7. Staff issues
• As a facilitator did not feel totally in control. There was very little eye contact with some of the

participants
• There were difficulties in moving from table to table
• There was a need to repeat instructions several times
• There was no atmosphere conducive to learning

As a result of the difficulties this arrangement produced, I decided to change the tables mid-session
back to a U-shaped layout (see drawing LC — 3B) to see if participants liked it better. Only one person did
not like the idea of getting up and waiting for the change to take place. That person later agreed it was a
good move.

136



N
o
te

s
F

ro
m

V
id

eo
A

n
a
ly

si
s

W
S

(w
id

e
sh

o
t)

S
e
ss

io
n

3
-

F
ri

en
d
sh

ip
Ju

ly
4,

20
05

1.
E

n
v

ir
o

n
m

en
ta

l
c
u
e
s

•
S

m
al

le
r

ta
b
le

s
se

p
ar

at
ed

fr
om

ea
ch

ot
he

r
ar

e
in

ap
p

ro
p

ri
at

e
fo

r
th

is
ac

ti
vi

ty
.

2.
S

af
et

y
an

d
se

cu
ri

ty
•

D
if

fi
cu

lt
ie

s
in

ac
ce

ss
in

g
va

ri
ou

s
ta

b
le

s.
•

C
on

fu
si

on
an

d
li

ng
er

in
g

d
ec

is
io

n
s

ab
ou

t
w

h
er

e
to

si
t

an
d

w
ith

w
ho

m
.

3.
F

am
il

ia
ri

ty
an

d
co

n
ti

n
u

it
y

o
f

se
lf

an
d

so
ci

al
in

te
ra

ct
io

n
•

S
ep

ar
at

ed
ta

b
le

s
se

em
ed

to
cr

ea
te

ar
tif

ic
ia

l
gr

ou
pi

ng
s.

4.
Q

u
al

it
y

st
im

u
la

ti
o
n

•
D

if
fi

cu
lt

ie
s

in
re

ac
h

in
g

pa
rt

ic
ip

an
ts

.
•

D
if

fi
cu

lt
ie

s
in

se
ei

n
g

ea
ch

ot
he

r.
•

L
ay

ou
t

no
t

ef
fi

ci
en

t
fo

r
di

st
ri

bu
ti

ng
ar

t
su

pp
li

es
.

•
L

im
it

ed
in

te
ra

ct
io

n
w

it
h

an
d

ex
p

o
su

re
to

o
th

er
s.

5.
D

if
fi

cu
lt

ie
s

in
v

is
u

al
,

o
lf

ac
to

ry
an

d
au

d
it

o
ry

co
n

tr
o

l
•

A
ll

p
re

v
io

u
s

di
ff

ic
ul

ti
es

st
ill

re
m

ai
n.

6.
O

v
er

p
o

p
u

la
te

d
ac

ti
v
it

ie
s

•
T

ab
le

ar
ra

n
g
em

en
t

g
iv

es
im

pr
es

si
on

of
a

b
ig

g
er

gr
ou

p.
•

N
ee

d
fo

r
am

p
le

ci
rc

ul
at

io
n

sp
ac

e
ar

ou
nd

ea
ch

ta
bl

e.
•

N
o

se
n
se

of
or

de
r.

•
C

ou
ld

w
or

k
fo

r
sm

al
l

gr
ou

p
ac

ti
vi

ti
es

.
7.

F
ac

tl
it

at
o

i’
s

is
su

e
s

•
V

er
y

lit
tle

ey
e

co
n

ta
ct

w
ith

so
m

e
of

th
e

pa
rt

ic
ip

an
ts

.
•

D
if

fi
cu

lt
ie

s
in

m
ov

in
g

ar
ou

nd
.

•
N

ee
d

to
re

p
ea

t
in

st
ru

ct
io

ns
se

v
er

al
ti

m
es

.
A

tm
o
sp

h
er

e
no

t
co

n
d

u
ci

v
e

to
br

ai
ns

to
rm

in
g

an
d

le
ar

ni
ng

.

C
re

at
iv

it
y
,

D
em

en
ti

a
an

d
th

e
T

h
er

ap
eu

ti
c

E
n
v
ir

o
n
m

en
t

D
al

la
G

o
tt

li
eb

-T
an

ak
s,

M
A

rc
h

In
te

rd
is

ci
pl

in
ar

y
P

ro
gr

am
U

ni
ve

rs
it

y
of

B
ri

tis
h

C
ol

um
bi

a
V

an
co

u
v

er
,

B
C

.

L
E

G
E

N
D

0
C

lo
se

-U
p

®
P

ro
bl

em

C
am

er
a

f
’

V
is

ua
l

W
i
d
e

S
ho

t
D

is
tr

ac
ti

on

C
am

er
a

L
L

on
g

T
ab

le

C
am

er
am

an
(2

9
.5

”x
7

1
)

M
M

ed
.T

ab
le

M
us

ic
ia

n
(2

9
.5

x
4
r)

R
es

ea
rc

h
er

c
C

ar
d

T
ab

le
(3

6
x
3
6
’)

P
A

R
T

IC
IP

A
N

T
S

’
Q

U
O

T
E

S

T
ob

y:
W

he
n

yo
u

n
ee

d
th

em
,

a
fr

ie
nd

in
n

ee
d

is
a

fr
ie

nd
in

de
ed

.

S
o

fi
a
:

H
e

is
si

tt
in

g
w

ith
hi

s
b

ac
k

to
m

e.

A
n
it

a:
T

hi
s

is
w

h
at

!
w

an
te

d
to

sa
y

-
th

at
th

is
ki

nd
of

ro
om

is
no

t
g

o
o

d
fo

r
da

nc
in

g.
T

he
y

h
av

e
a

ro
om

w
he

re
th

ey
zi

p
up

th
e

ca
rp

et
an

d
th

ey
h

av
e

a
d
an

ce
fl

oo
r.

L
’C

ha
im

A
d
u
lt

D
ay

C
ar

e
C

en
tr

e
V

an
co

u
v

er
Je

w
is

h
C

o
m

m
u
n
it

y
C

en
tr

e
S

E
S

S
IO

N
3

-
F

ri
en

d
sh

ip
Ju

ly
4
,2

0
0
5

S
e
p
a
ra

te
d

T
ab

le
s

-
3A

U
-S

h
a
p
e
d
-3

B

S
p

a
c
e

Is
su

es
:

P
o
et

ry
se

ss
io

n
L

C
-3

A
&

3
B

(i
n

d
is

se
rt

at
io

n
p.

13
7)



Session Four— Bending Wires. Strength versus Weakness

Figure 24: Session Four — Bending Wires. Strength versus Weakness
See Drawing LC- 4
Triangle

The triangle formation was just a slight deviation from the U-shape layout but I got an uncomfortable
feeling when interacting with the participants. There was an unsettled feeling about it, which is hard to
describe. Perhaps the angles did not appeal to the sense of order and aesthetics.

3. Familiarity and continuity of self and social interaction
• Ira did not want to select a seat until Sonia arrived and then she joined her
• Participants seemed to have fewer problems in selecting a seat with this triangle-shaped

formation than in the detached arrangement
• I seemed to neglect the people on my right, which caused them to be less engaged. The two

people with dementia on the right seemed very quiet. However, the participant with no dementia
took initiatives to be part of the session

5. Difficulties in visual, olfactory and auditory control
• One senior with no dementia moved from his chair at the table to the window where he could face

the musician when she played the violin and the piano. Two seniors with dementia sat with their
backs to the musician and stayed in that position until the end of the session, except for one, who
did get up, moved around and went back to the same seat.

WASHROOM

cu

ADMINISTRATION
OFFICE

FOOD TROLLEY

FLIP
CHART

—

RESTING AREA WAS USED
AS A TEMPORARY
STORAGE PLACE

NEW LOCATION
!4 OF NOTICE

BOARD

R .
•1.

L

,;
‘ 14 P1

FISHTANK

- .12

RATTAN -
SCREEN

S r ‘.•. N 4—

RESTING
AREA

h — —

A

_____________

CARPET LINOLEUM
GARBAGE

SI DE TABLE

KITCHEN
F

.1
87 ‘“

A CARPET

I

STORAGE -‘

I
DECK 32-O

‘1
1. -

LOUNGE AREA

138



6. Overpopulated activities
Due to the large number of participants, not all participants with dementia got the attention they
needed. One participant with dementia, who was struggling with bending wires into a 3-
dimensional shape, insisted on anchoring the edges of the wire into the table top she was working
on. Although I came prepared with foam blocks for such a situation, I did not remember to offer
them to her. The intention was to see if the participant could manage without the blocks. I was so
busy due to the large group that I did not follow up on the participant’s progress when she needed
help.

7. Staff issues
• I was not at ease with the furniture arrangement in the shape of a triangle. The angles did not

appeal to her sense of order. There was a constant need to push the tables from the 60 degree
formation back to a U-shape arrangement of 90 degrees.

139



0



N
o
te

s
F

ro
m

V
id

eo
A

n
al

y
si

s
W

S
(w

id
e

sh
o
t)

S
e
ss

io
n

4
-

B
en

d
in

g
W

ir
es

S
tr

e
n

g
th

v
e
rs

u
s

W
e
a
k

e
n

ss
Ju

ly
1
1
,2

0
0
5

S
p
a
c
e

Is
su

es
:

3.
F

am
il

ia
ri

ty
an

d
co

n
ti

n
u

it
y

of
se

lf
an

d
so

ci
al

in
te

ra
ct

io
n

•
T

ab
le

ar
ra

n
g
em

en
t

cr
ea

te
d

st
re

ss
in

se
le

ct
in

g
se

at
s.

•
P

ar
ti

ci
p

an
ts

se
em

ed
to

h
av

e
fe

w
er

pr
ob

le
m

s
in

se
le

ct
in

g
a

se
a
t

w
it

h
th

is
tr

ia
ng

le
-s

ha
pe

d
fo

rm
at

io
n

th
an

w
it

h
se

p
ar

at
ed

ta
bl

es
.

•
F

ac
il

it
at

or
se

em
ed

to
n

eg
le

ct
pa

rt
ic

ip
an

ts
on

h
er

ri
gh

t.
5.

D
if

fi
cu

lt
ie

s
in

v
is

u
al

,
ol

fa
ct

or
y

an
d

au
d
it

o
ry

co
n

tr
o

l
•

D
if

fi
cu

lt
ie

s
in

fa
ci

ng
m

us
ic

ia
n;

so
m

e
p

ar
ti

ci
p

an
ts

m
ov

ed
,

o
th

er
s

st
ay

ed
in

pl
ac

e.
6.

O
v

er
p

o
p

u
la

te
d

ac
ti

v
it

ie
s

•
D

ue
to

la
rg

e
n

u
m

b
er

of
pa

rt
ic

ip
an

ts
,

no
t

al
l

p
ar

ti
ci

p
an

ts
w

it
h

d
em

en
ti

a
go

t
th

e
at

te
nt

io
n

th
ey

n
ee

d
ed

.
7.

F
a
c
il

it
a
to

rs
is

su
e
s

•
Iw

as
no

t
at

e
a
se

w
it

h
th

e
fu

m
it

ur
e

ar
ra

n
g
em

en
t

in
th

e
sh

ap
e

of
a

tr
ia

ng
le

.

V
io

lin
H

ol
di

ng
0

C
re

at
iv

it
y
,

D
em

en
ti

a
an

d
th

e
T

h
er

ap
eu

ti
c

E
n
v
ir

o
n
m

en
t

D
al

la
G

o
tt

ll
eb

-T
an

ak
a,

M
A

rc
h

In
te

rd
is

ci
pl

in
ar

y
P

ro
gr

am
U

ni
ve

rs
it

y
of

B
ri

ti
sh

C
ol

um
bi

a
V

an
co

u
v

er
,

B
C

.

L
E

G
E

N
D

C
lo

se
-U

p
®

P
ro

bl
em

C
am

er
a

(
V

is
ua

l

N
i
d

e
S

ho
t

D
is

tr
aC

ti
O

n

C
am

er
a

L
L

on
g

T
ab

le

C
am

er
am

an
(2

9.
S

’x
71

’)

M
M

ed
.T

ab
le

(
)

M
us

ic
ia

n
(2

9
.5

x
4
r)

R
es

ea
rc

h
er

c
C

ar
d

T
ab

le
(3

6’
x

36
’)

P
A

R
T

IC
IP

A
N

T
S

’
Q

U
O

T
E

S

W
h

at
is

c
re

a
ti

v
it

y
?

T
o

b
y

:
C

re
at

iv
it

y
is

w
he

n
yo

u
cr

ea
te

so
m

et
hi

ng
th

at
m

ak
es

pe
op

le
ha

pp
y.

A
n

it
a:

R
ea

ct
in

g
to

a
si

tu
at

io
n.

Ju
n
e
:

W
e

ca
n

se
e

th
e

o
th

er
s

an
d

w
e

ca
n

se
e

yo
u

(c
o
m

m
en

ta
ry

on
fu

rn
itu

re
ar

ra
n

g
em

en
t)

.

M
ic

he
l:

T
he

o
ld

er
y

o
u

b
ec

o
m

e
th

e
m

o
re

cr
ea

ti
v

e
yo

u
b

ec
o

m
e.

L
’C

ha
im

A
d
u
lt

D
ay

C
ar

e
C

en
tr

e
V

an
co

u
v

er
Je

w
is

h
C

o
m

m
u
n
it

y
C

en
tr

e
S

E
S

S
IO

N
4

-
B

E
N

D
IN

G
W

IR
E

S
S

T
R

E
N

G
T

H
V

E
R

S
U

S
W

E
A

K
N

E
S

S
Ju

ly
1
1
,2

0
0
5

T
ri

an
g
le

L
C

-4
(i

n
d
is

se
rt

at
io

n
p.

14
0)

V
io

lin
H

ol
di

ng
V

io
lin

H
ol

di
ng

-I
B

en
di

ng
W

in
es

B
en

d
in

g
W

ir
es



Session Five — Designing Creative Expression Studio

Figure 25: Session Five — Designing Creative Expression Studio
See Drawing LC -5

2. Safety and security
• Wood floor is preferable to carpet
• Washrooms need to be close by

3. Familiarity and continuity of self and social interaction
• Participants prefer to see the researcher sit and not stand

4. Quality stimulation
• Being tucked away and separated temporarily by a rattan screen reduced interruption from

visitors
5. Difficulties in visual, olfactory and auditory control

• The intensity and direction of the lights brought comments such as:
— an object against the light looks dark with no details
— sharp lights cause pain and glare
— seeing improves hearing
— windows are important but where to place them depends on the use of the space
— when working on white surfaces such as white paper, lights need to be dimmed

6. Overpopulated activities
A need to reduce the number of tables to fit a smaller group

7. Staff issues
• Closing the distance between a facilitator and the participants plays an important role in

establishing better interaction

KEYBOARD RADIO STAND — RATTAN

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141



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20
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L
C

-5



L’Chaim Centre — Suggested Design Resolutions

Drawing LC — 6 is the result of all the knowledge and understanding accumulated thus far on
dementia as a medical condition, how it impacts the psychosocial behaviour of older people with
dementia, how it impacts families and caregivers and the facilities that serve dementia clients. While it
would have been highly desirable to design a new centre for L’Chaim’s clients, reality calls for very
modest changes that can be achieved in a reasonable time, within a tight budget and without having to
close the Centre. Some interior changes did take place during this study, which were based on preliminary
recommendations. What follows is a more extensive list of comments and design resolutions.

The following checklist is based on Moore, Geboy, Weisman and Mieziva (2001) and was adapted to
fit this study. While I agree with them on the importance of quality stimulation, I disagree with their
assertion that specific activities such as movement, thinlcing, psychosocial and spiritual activities (p. 77)
need to be undertaken separately and carried out in different spaces. For example, the program on creative
expression activities calls for the opposite approach, where the various activities are combined in one
session to allow a full exposure to all senses and abilities at the same time. In other words, instead of
moving the seniors from room to room, I chose to bring the activities to the seniors and change the
environment around them. Of course, there is room for flexibility and combinations of space and
activities. However, the main thrust of the creative expression activities program is to create a rich
environment with the most opportunities to be exposed to experiences that build upon each other. The
creative expression activities program can take place in small spaces so long as the main philosophical
approach is followed. Knowing the kind of activities and how they are conducted will shape the
architectural envelop and its design.

The final chapter in the Moore, Geboy, Weisman and Mleziva (2001) study is based on a
comprehensive evaluation guide for design considerations for adult day centres. I selected it to guide my
design resolution for the L’Chaim Centre as a framework or checklist. Some outdoor issues were omitted
although their inclusion in a complete and comprehensive design are very important.

Coming and Going
First impression
• Although the L’Chaim Centre has undergone major renovations in recent years, the entrance to

the Centre, which is located within the Jewish Community Centre, is too far removed from the
main entrance to the building. A back door is located closer to the Centre’s main entrance but it
remains closed for security reasons. Staff recognizes the problem and stands vigilant to open the
back door when the HandiDart bus arrives with the clients. It adds pressure since staff needs to
stop whatever they are doing when the bus arrives to let the clients in by the shortest route.

• This route is not weather protected and could use a canopy

Sense of arrival and departure
• There is no reception area that separates the entry from the main program space
• The existing corridor is too long and does not act as a buffer or transition zone separating the

public, semi-public and private areas
• The main doors are made of heavy metal, which is typical of institutions such as hospitals and

jails
• There are no welcoming architectural solutions. However, staff is extremely friendly and goes out

of their way to welcome the arriving clients
• Clients get help to take off their coats, only as needed
• There is no designated space to store walkers, wheelchairs or canes
• There is no direct and immediate space for hanging coats
• There is a toilet near the entrance

Suggested design resolutions

143



• Create a reception area that welcomes the clients or anyone visiting the Centre
• Provide space for coffee or tea, which clients could serve themselves under the supervision of

staff
• Provide a semi-private place where clients could meet their visitors or take a break away from the

main activity room
• Provide control of the security and safety of the Centre by technology or by staff monitoring the

people who come into the Centre
• Change the front doors to glass doors to allow light and visual contact with the outside

Activity Settings
General features of actiWty settings
• There is a pleasant view to the outdoors
• There is no efficient separation of spaces for various concurrent activities or for various group

sizes
• Extra chairs are lined up along the periphery of the room
• Toilets are easy to find and located nearby; however, access to them is not discreetly designed
• There is plenty of natural light. Glare from outside is controlled by blinds
• The interior glare due to poor lighting is a major issue
• There is very little attention to plants and their maintenance
• Recliners are provided in the rest area and in the lounge area
• There is no specific area for clients to sit and observe an activity without taking part in it.

However, in an open space model, activities can be watched from every corner of the room. The
downside is the lack of privacy, even for an activity such as watching.

Suggested design resolutions
• Increase the amount of plants and their maintenance
• Remove old wood furniture on the deck or replace it with new easy-care outdoor furniture
• Find storage for extra chairs not in use
• Adjust the intensity and color of interior lights to suit the various activities, whether they are task-

oriented, or used for ambience and relaxation =
• The access to toilets needs to be designed more discreetly
• Add some space from the adjacent hail to ease the need for space division for concurrent

activities

Dining
• There is no separate space for dining

Suggested design resolutions
• Staff already does what it can to give a distinct flavour to the dining activity. They change the

positions of the tables, cover them with tablecloths and set them with good dishes and cutlery.
However, Moore et al. (2001) suggest that the furniture be arranged so that clients can choose
whom to sit with. This is similar to the furniture layout in session 3 in this study.

Kitchen and kitchen work
• Moore et al. (2001) suggest using an open kitchen plan, which is accessible to all and has a

residential feel to it. However, the activity in the kitchen may act as a disturbance when activities
outside the kitchen are in progress.

Suggested design resolutions
• Partially close off the kitchen area by providing pony walls that are not of full height
• Hide the garbage container yet make it accessible
B Change the kitchen look from an institutional one to a residential one
• Leave large openings to the kitchen with no doors

144



Indoor walking and wandering in combination with outdoor activity
• Walking is a much needed activity to relieve stress that contributes to “social stimulation ... and

environmental variety” (p. 179). The L’Chaim Centre was not planned to accommodate a
wandering path and the existing tight space is insufficient to allow it. However, many of the
clients live nearby and they walk over by themselves or with their caregivers.

Suggested design resolution
• In future plans for expansion, designs should take the walking and wandering path into account.

The existing deck could be adjusted to provide some of these opportunities:
— Secured outdoor walking and wandering path
— Comfortable seats to enjoy the outside
— Interesting and stimulating focal points
— Weather protection solutions
— Large pots to enrich the plant selections

Physical and related support activities
• Moore et al. (2001) suggest (p. 183) an open space suitable for use by up to 16 people for

physical and other therapies. The present space can accommodate this
• There is no efficient private space for private therapies
• There is not enough storage space available

Suggested design resolutions
• Provide a separate room for nursing activities
• Provide storage space wherever possible, whether in low cupboards under the windows, or along

the walls, or in linen closets. In general, upgrade all of the existing office furniture and kitchen
cupboards.

145



N
o
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p
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14
8)



Margaret Fulton Adult Day Care Centre

Identifying space problems. Margaret Fulton Centre is an appealing facility, which is nestled
within a beautiful setting. One visit to the Centre would not have revealed the minor problems that
surfaced when conducting the creative expression activities. The following comments need to be
reviewed along with drawings MF 1-5.

4

‘4

Furniture Arrangements: Sessions One to Four

FLIIOHMT /

Figure 26: Session One - Friendship
See Drawing MF — I (small room in the back)
Two tables are arranged into L shape (4 feet wide by 8 feet long)
Room size: 18 ft by 21 ft.

149

Session one — Friendship

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1. Environmental cues
• Cues for the topic were displayed on the tables. No other cues were provided
• No access to the outdoor which was very attractive
• No sufficient space for circulation, wheelchairs or walkers
• No sufficient air circulation. Southern orientation. Too hot in the summer

2. Safety and security
• No room to dance and turn safely, although floor finishes appropriate for dancing
• The researcher was in control of the room’s exist using the entry door
• Insufficient space for this activity for more than 4 participants unless some furniture was removed

3. Familiarity and continuity of self and social interaction
• Participants were divided into English and Spanish speaking women. No interaction was

exhibited
• Strong bond between the English speaking women with one of them leading the group
• Strong bond and gentle interaction between the Spanish speaking women
a Strong bond and familiarity with staff
• Only the Spanish women acknowledge remembering me. The sense of familiarity with the

English speaking women was not felt nor established

4. Quality stimulation
• Quality stimulation was under control since the room was closed to others and participants could

concentrate on their tasks to their best abilities

5. Difficulties in visual, olfactory and auditory control
• There were no difficulties in visual, olfactory and auditory control

6. Overpopulated activities
• No sufficient solutions to display objects close by
• No sufficient solutions to display extra sheets of the flipchart close by
• Too many participants (7) could be ideal under existing circumstances

7. Staff issues
• Staff had difficulties reaching participants from behind to help with art activity

150



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-1
(in

d
is

se
rt

at
io

n
p.

15
1)



Session Two — Music, Dancing, Poem Writing and Card Decoration
Designing a Dancing Floor

11

OUTDOOR THERAPY ROOM

WANDERING
PATHWAY

R

Ix I

l
z R
o IA%
o

rc

I I iS

PORTASLE
PA WASHROOM

Figure 27: Session Two - Music
See Drawing MF— 2 (art Therapy Room)
Two tables side by side creating one table (8 feet wide by 8 feet long)
Room size: l6ftby 20 ft.

1. Environmental cues
• There are appropriate cues for an art activity. All art supplies and art work are displayed
• A wandering path leads directly through the art room, distracting program participants from

concentrating on the topic or on their task.
• It is hard to reach participants across two combined tables
• There is no room for additional people to perform, dance, or to expand the group
• There is a need to reach a fine balance between having ample room for circulation and at the

same time providing a more intimate setting with a feeing of closeness
• The room needs movable partitions and movable furniture
• Good contact with the outside
• Access to the washroom is near by, however it opens directly into an activity area
• No observation area for people who would like to watch from a distance or work their way into

an activity at their own pace would be an asset

GARDEN FURNITURE
STORAGE C

ART THERAPY
ROOM

Cu Ws

[
SCREEN

w

i_i.i ‘S

4

REST S
ROOMMusicSTAND

— 2’

$ —I’

-4 -1

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FLIP CHART P

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-4-

/

WANDERING
PATHWAY

—I

WASHROOM

11.-a.

STORAGE

152



2. Safety and security
B It is not an issue in this Centre since it is being addressed through the whole facility
• It includes controlled main exist, fence around the garden, trained staff to watch for safety

problems

3. Familiarity and continuity of self and social interaction
• Same as in session one on Friendship. Except one English speaking woman who joined the group

only once did try to communicate with one of the Spanish speaking woman.

4. Quality stimulation
• No quality stimulation control until the walking ceased around the space

5. Difficulties in visual and auditory control
• Too many disturbances by other clients of the Centre
• There is very poor acoustic separation from other activities in the Centre

6. Overpopulated activities
• Area was too small for 5 participants, staff and musician

7. Staff issues
• A multi-activity program needs more than one person leading the session

153



N
o

te
s

F
ro

m
V

id
eo

A
n

al
y

si
s

W
S

(w
id

e
sh

o
t)

S
e
ss

io
n

T
w

o
-

D
es

ig
n
in

g
a

D
an

ce

S
p

a
c
e

Is
su

es

F
lo

o
r

1
A

w
an

de
ri

ng
pa

th
le

ad
s

di
re

ct
ly

th
ro

ug
h

th
e

ar
t

ro
om

,
di

st
ra

ct
in

g
pr

og
ra

m
pa

rt
ic

ip
an

ts
fr

om
co

nc
en

tr
at

in
g

on
th

e
to

pi
c

or
on

th
ei

r
ta

sk
.

2.
T

h
er

e
is

ve
ry

po
or

ac
o

u
st

ic
se

p
ar

at
io

n
fr

om
o
th

er
ac

ti
vi

ti
es

in
th

e
ce

nt
re

.

3.
A

m
ul

ti
-a

ct
iv

it
y

pr
og

ra
m

n
ee

d
s

m
or

e
th

an
o
n
e

p
er

so
n

le
ad

in
g

th
e

se
ss

io
n

;
th

is
ha

s
im

pl
ic

at
io

ns
fo

r
sp

ac
e

re
qu

ir
em

en
ts

.

4.
It

is
ha

rd
to

re
ac

h
pa

rt
ic

ip
an

ts
ac

ro
ss

tw
o

co
m

bi
ne

d
ta

b
le

s.

5.
T

h
er

e
is

no
ro

om
fo

r
ad

di
ti

on
al

pe
op

le
to

pe
rf

or
m

,
d

an
ce

,
or

to
ex

p
an

d
th

e
gr

ou
p.

6.
T

he
re

is
a

n
ee

d
to

re
ac

h
a

fi
ne

ba
la

nc
e

be
tw

ee
n

ha
vi

ng
am

p
le

ro
om

fo
r

ci
rc

ul
at

io
n

an
d

at
th

e
sa

m
e

ti
m

e
pr

ov
id

in
g

a
m

or
e

in
ti

m
at

e
se

ll
in

g
w

ith
a

fe
ei

ng
of

cl
o
se

n
es

s.

7.
T

he
ro

om
n
ee

d
s

m
ov

ab
le

pa
rt

it
io

ns
an

d
m

ov
ab

le
fu

rn
it

ur
e.

8.
C

on
ta

ct
w

ith
th

e
ou

ts
id

e
is

cr
uc

ia
l

to
fe

el
in

g
go

od
,

co
n

n
ec

te
d

an
d

no
t

im
pr

is
on

ed
.

9.
A

cc
es

s
to

th
e

w
as

h
ro

o
m

sh
ou

ld
be

pl
an

ne
d

in
a

m
or

e
d
is

cr
ee

t
w

ay
,

w
h

er
e

th
e

do
or

d
o
es

no
t

o
p
en

di
re

ct
ly

in
to

an
ac

ti
vi

ty
th

at
is

ta
ki

ng
pl

ac
e.

T
he

w
as

h
ro

o
m

ca
n

st
ill

be
si

tu
at

ed
ne

ar
by

,
bu

t
so

m
ew

h
at

re
m

ov
ed

.

10
.

A
n

o
b

se
rv

at
io

n
ar

ea
fo

r
pe

op
le

w
ho

w
ou

ld
lik

e
to

w
at

ch
fr

om
a

d
is

ta
n

ce
or

w
or

k
th

ei
r

w
ay

in
to

an
ac

ti
vi

ty
at

th
ei

r
ow

n
p
ac

e
w

ou
ld

be
an

as
se

t.

N 0

C
re

at
iv

it
y
,

D
em

en
ti

a
an

d
th

e
T

h
er

ap
eu

ti
c

E
n

v
ir

o
n

m
en

t
D

al
ia

G
o
tt

il
eb

-T
an

ak
a,

M
A

rc
h

In
te

rd
is

ci
pl

in
ar

y
P

ro
gr

am
U

ni
ve

rs
it

y
of

B
ri

tis
h

C
ol

um
bi

a
V

an
co

uv
er

,
B

C
.

L
E

G
E

N
D

S
ta

ff

C
lo

se
-U

p
P

ro
bl

em
C

am
er

a
p

V
is

ua
l

W
i
d
e

S
h

o
t

2
D

is
tr

ac
ti

on
C

am
er

a
L

L
on

g
T

ab
le

C
am

er
am

an
(2

9.
5”

x7
1”

)

M
M

ed
T

ab
le

M
us

ic
ia

n
(2

9
.5

x
4
r)

R
es

ea
rc

h
er

C

P
A

R
T

IC
IP

A
N

T
S

’
Q

U
O

T
E

S

M
il

dr
ed

:
T

he
vi

ol
in

is
a

be
au

ti
fu

l
in

st
ru

m
en

t.

D
aN

a:
M

ar
ga

re
t,

w
hy

do
w

e
n

ee
d

a
sm

o
o

th
fl

oo
r?

M
ar

ag
re

t:
S

o
yo

u
ca

n
do

w
h

at
ev

er
yo

u
do

(s
ho

w
in

g
tw

ir
ls

w
ith

h
er

ha
nd

).

M
il

dr
ed

:
S

o
m

e
m

us
ic

m
ak

es
m

e
cr

y.

M
ar

g
ar

et
F

u
lt

o
n

A
d

u
lt

D
ay

C
ar

e
C

en
tr

e
N

o
rt

h
V

an
co

u
v
er

S
E

S
S

IO
N

2
-

D
E

S
IG

N
IN

G
A

D
A

N
C

E
F

L
O

O
R

Ju
ly

5,
20

05

A
R

T
T

H
E

R
A

P
Y

R
O

O
M

O
ut

do
or

w
an

d
en

n
g

p
at

h
w

es
t

rr
le

w

R
O

O
F

O
V

E
R

H
A

N
G

P
a
tW

W
a
z
e
b

o
w

e
w

W
A

N
O

E
R

I
N

G
-
.-

-
-
-
-
—

PA
T

H
W

A
Y

M
F

-2
(in

d
is

se
rt

at
io

n
p.

15
4)



Session Three — Music and Drumming

9’-

9ZFO

COc4WD

—‘ —
19

—

C ) —
s,., .

-.-

H ‘ ,- *___
c’.3lJRTYA9

a

—

Figure 28: Session Three — Music and Drumming
See Drawing MF —3 (courtyard)
Two round garden tables (3 ft.)
Area size: same as the Art Therapy Room 16 ft by 20 ft.

L Environmental cues
• Drums and a musician provided the only cues for the activity

2. Safety and security
• Very little issues. However, wheelchairs and walkers were rolling away
• There is ample space for walkers and their storage.
• Being outside exposes participants to cold air, flies and other insects.
• The roof’s overhang provides protection from the weather.

3. Familiarity and continuity of self and social interaction
• Positive reaction to outdoor setting for an activity which is a nice change from indoor activity.

Participants comment on the fresh air, the larger space and being part of nature.
• Round table provided more opportunities for social interaction between the participants and

between the two groups

4. Quality stimulation
• The beauty of the surroundings was soothing and inspiring.
• The view of a beautiful garden ties in with the park and the wooded area.
• Being outside connects participants to the sounds of nature.
• Sounds of children playing bring positive reactions.

155



• There is ample room for dancing.
• Some participants could not see the performer.

5. Difficulties in visual and auditory control
• Expected and therefore it was planned for a noisy activity
• Children yelling in the park attracted one of the participant’s attention through the all session

6. Overpopulated activities
• Ample of room for 5 participants and could accommodate additional participants

7. Staff issues
• I did not feel enclosed

156



N
o

te
s

F
ro

m
V

id
eo

A
n

al
y

si
s

W
S

(w
id

e
sh

o
t)

S
e
ss

io
n

T
h

re
e

S
p

a
c
e

Is
su

es

1.
O

ut
do

or
se

tt
in

g
fo

r
an

ac
ti

vi
ty

is
a

ni
ce

ch
an

g
e

fr
om

in
do

or
ac

ti
vi

ty
.

P
ar

ti
ci

pa
nt

s
co

m
m

en
t

on
th

e
fr

es
h

ai
r,

th
e

la
rg

er
sp

ac
e

an
d

be
in

g
pa

rt
of

na
tu

re
.

2.
R

ou
nd

ta
bl

e
pr

ov
id

es
be

tt
er

ac
ce

ss
to

ea
ch

pa
rt

ic
ip

an
t.

3.
T

h
er

e
is

am
pl

e
sp

ac
e

fo
r

w
al

ke
rs

an
d

th
ei

r
st

o
ra

g
e.

4.
T

he
re

se
ar

ch
er

di
d

no
t

fe
el

en
cl

o
se

d
.

5.
T

he
b

ea
u

ty
of

th
e

su
rr

ou
nd

in
gs

w
as

so
ot

hi
ng

an
d

in
sp

ir
in

g.

6.
T

he
vi

ew
of

a
be

au
ti

fu
l

g
ar

d
en

ti
es

in
w

ith
th

e
pa

rk
an

d
th

e
w

oo
de

d
ar

ea
.

7.
B

ei
ng

ou
ts

id
e

co
n

n
ec

ts
pa

rt
ic

ip
an

ts
to

th
e

so
u
n
d
s

of
na

tu
re

.

8.
B

ei
ng

ou
ts

id
e

ex
p
o
se

s
pa

rt
ic

ip
an

ts
to

co
ld

ai
r,

fl
ie

s
an

d
o

th
er

in
se

ct
s.

9.
S

o
u

n
d

s
of

ch
il

dr
en

pl
ay

in
g

br
in

g
po

si
ti

ve
re

ac
ti

on
s.

10
.

T
h
er

e
is

am
pl

e
ro

om
fo

r
da

nc
in

g
or

m
ov

in
g

ar
ou

nd
.

11
.

S
o
m

e
pa

rt
ic

ip
an

ts
co

ul
d

no
t

se
e

th
e

pe
rf

or
m

er
.

12
.

T
he

ro
ot

’s
ov

er
ha

ng
pr

ov
id

es
pr

ot
ec

ti
on

fr
om

th
e

w
ea

th
er

.

13
.

T
h

e
gr

ou
nd

sl
o
p
es

aw
ay

fo
r

dr
ai

na
ge

;
th

e
sl

o
p

e
n
ee

d
s

to
be

ch
an

g
ed

to
pr

ev
en

t
w

h
ee

lc
h

ai
rs

an
d

w
al

ke
rs

fr
om

ro
lli

ng
aw

ay
.

C
re

at
iv

it
y
,

D
em

en
ti

a
an

d
th

e
T

h
er

ap
eu

ti
c

E
n

v
ir

o
n

m
en

t
D

al
la

G
o
tt

ll
eb

-T
an

ak
a,

M
A

rc
h

In
te

rd
is

ci
pl

in
ar

y
P

ro
gr

am
U

ni
ve

rs
it

y
of

B
ri

tis
h

C
ol

um
bi

a
V

an
co

uv
er

,
B

C
.

L
E

G
E

N
D

S
ta

ff

C
lo

se
-U

p
P

ro
bl

em
C

am
er

a
1

V
is

ua
l

W
i
d

e
S

ho
t

‘2
D

is
tr

ac
ti

on
C

am
er

a
L

L
on

g
T

ab
le

C
am

er
am

an
(2

9
.5

x
7
1
’)

M
M

ed
.T

ab
le

M
us

ic
ia

n
(2

9.
S

’x
47

”)

R
es

ea
rc

h
er

C
C

ar
d

T
ab

le

P
A

R
T

IC
IP

A
N

T
S

’
Q

U
O

T
E

S

C
ar

o
l:

T
he

re
ar

e
to

o
m

an
y

p
eo

p
le

in
th

er
e.

(M
ea

ni
ng

sm
al

l
ro

om
at

th
e

ba
ck

)

C
ar

o
l:

I
d

o
n

t
li

ke
th

e
sm

al
l

ro
om

.

D
al

la
:

D
id

yo
u

en
jo

y.
Y

ou
sa

n
g

al
l

al
on

g.
..

C
ar

o
l:

T
ha

t
w

as
w

ay
b

ac
k

w
he

n
no

w
I’

m
ju

st
no

th
in

g.

M
ar

g
ar

et
F

u
lt

o
n

A
d

u
lt

D
ay

C
ar

e
C

en
tr

e
N

o
rt

h
V

an
co

u
v
er

S
E

S
S

IO
N

3
Ju

ly
12

,
20

05

C
O

U
R

T
Y

A
R

D
-

M
U

SI
C

&
D

R
U

M
M

IN
G

M
F

-3
(i

n
di

ss
er

ta
ti

on
p.

15
7)

V

A
R

T
R

O
O

M

34
-0

”
w

R
E

S
T

R
O

O
M

N



ScWA

Figure 29: Session Four — Massage and the Walkout
See Drawing MF-. 4 (small room in the back)
One card table (36” X 36”)
Room size: 18 ft by 21ft.

1. Environmental cues
Massage creams on the table

2. Safety and security
No issue

3. Familiarity and continuity of self and social interaction
• No doubt the familiarity with the room sparked a walkout
• Strong presentation of self and one’s desires
• Strong leadership displayed by one participants influenced others

4. Quality stimulation

5. Difficulties temperature control
• The room was stuffy. We used a fan to move the air around.

6. Overpopulated activities
• Was not an issue

7. Staff issues
None of us wanted to be there.
The 3x3 ft. square table did not work well for physical interaction with participants

Session Four— Massage and the Walkout

C
Cl’

Q

/F’ ;:
6

ChA RS

4’

F

4

158



N
o

te
s

F
ro

m
V

id
eo

A
n

al
y

si
s

W
S

(w
id

e
sh

o
t)

S
es

si
o
n

F
o

u
r

S
p

a
c
e

Is
su

es

1.
N

on
e

of
us

w
an

te
d

to
be

th
er

e.

2.
T

he
ro

om
w

as
st

uf
fy

.
W

e
u

se
d

a
fa

n
to

m
ov

e
th

e
ai

r
ar

ou
nd

.

3.
T

he
4x

4
fi.

sq
u
a
re

ta
bl

e
di

d
n

o
t

w
or

k
w

el
l

fo
r

ph
ys

ic
al

in
te

ra
ct

io
n.

4.
It

w
ou

ld
be

he
lp

fu
l

to
de

si
gn

a
ne

w
ta

b
le

th
at

co
ul

d
an

sw
er

m
an

y
n
ee

d
s

an
d

u
se

s
w

he
n

in
te

ra
ct

in
g

w
ith

se
n

io
rs

w
ith

de
m

en
ti

a.

C
re

at
iv

it
y
,

D
em

en
ti

a
an

d
th

e
T

h
er

ap
eu

ti
c

E
n

v
ir

o
n

m
en

t
D

aN
a

G
o
tt

ll
eb

-T
an

ak
a,

M
A

rc
h

In
te

rd
is

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Margaret Fulton Centre — Suggested Design Resolutions

Coming and Going
First impression
• Good sense of arrival
• Appealing image and setting of the building
• Good protection from the weather
• Overall very welcoming

Sense of arrival and departure
• reception area that separates the entry from the main program space
• Clear designation of the public, semi-public and private areas
• Staff waits to receive clients and depart from them in a foyer located close to the main entry
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• There is designated space to store walkers, wheelchairs or canes
a There are toilets near the entrance

Activity Settings
General features of activity settings

a There is a pleasant view to the outdoors
a There is no efficient separation for some spaces for various concurrent activities
• Extra chairs are lined up along the periphery of the room
a Toilets are easy to find and located nearby; however, one is not discreetly designed
a There is plenty of natural light. Glare from outside is controlled by blinds

Suested design resolutions
a Find storage for extra chairs not in use
• The access to toilets needs to be designed more discreetly
a Separate the interior wandering path from the art Therapy Room

Dining
a There is a good dining room that works well

Kitchen and kitchen work
• Kitchen area is not accessible to the clients.

Suggested design resolutions
a Provide a kitchen facility that would allow safe involvement of clientele

Indoor walking and wandering in combination with outdoor activity
• Good outdoor wandering path, garden and ample room for outdoor activity.

Physical and related support activities
a There is an open space suitable for use by up to 16 people for physical and other therapies.

Overall the Centre is designed to accommodate seniors with dementia and architecturally answers
most of the needs and behaviour that rise due to the disease. Interviewing staff and the architect of the
Centre it became clear that the collaboration between them produced one of the best facilities in
Vancouver. Drawing MF-5, suggests minor changes to eliminate the interference of the interior walking
path with the Art Therapy Room and minor changes in the back room by providing access to a new
balcony and windows that can be opened wider for fresh air.

160



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162



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[She wrote under the paper image she glued down: “Playing piano.” It was pointed out to me by the
centre’s art facilitator.]

163



CHAPTER V: DISCUSSION

Through a!r/tographic inquiry I came to understand particular situations and found ways to create
changes to the environment that made use of the five design principles and new dimensions outlined in
Chapter 4: that is, the knowledge acquired through practical experience, the literature review of dementia
and the behavioural symptoms of this condition, and an understanding of the creative expression abilities
of seniors with dementia. Suggestions for architectural changes were accompanied by changes to activity
programs and the approach to them which emphasized the importance of the artistic process rather than
the final product itself. Actual physical changes based on this study occurred almost entirely at the
L’Chaim Centre and brought fundamental changes to the Centre, while Margaret Fulton Centre served as
a site for data collection only. Although observations there were important to the overall inquiry, the
Margaret Fulton Centre was already designed to meet many of the design principles. The inquiry at
Margaret Fulton Centre was conducted as a separate entity, independent of what happened in the rest of
the Centre. These two different organizational settings altered the milieu in which the data was collected,
although the data collection plans were the same for both.

Reviewing the Themes

The following are the five themes that emerged from the literature review in Chapter Two and their
relevance to the situations at the L’Chaim and Margaret Fulton Centres:

1. The person—centred approach to care, defined as personhood, is crucial in achieving positive
changes in problem behaviour, improving communication and independence.

From the beginning through the end of the inquiry, I followed a person-centred approach to
interact with the seniors with dementia. There was no intention to interact in any other way. The 27
films documenting the seniors’ behaviour show how this approach helped seniors stay engaged and
contributing during the various sessions at the two selected sites. In the literature and in personal
experience, the person-centered approach was developed as a reaction to the medical model, where
basic needs of seniors were met with little attention to the person inside the condition and every
deviation from what was considered normal was described as a disturbing behaviour. As the literature
review shows, a person-centered approach can contribute to improved behaviour.

2. The environment in which seniors with dementia reside can be considered therapeutic only jf it
embraces a comprehensive approach to care, based on preserving the person’s dignity, and
protecting the person’s rights.

Both Centres followed a model for care that preserved the seniors’ dignity and their rights. Both
directors and staffs were most concerned with these issues and made sure that this study was
conducted ethically and that the rights of the seniors were protected. It was a pleasure to see the
seniors make the effort to attend the Centres two to three days a week. The environment is a reflection
of its function. If designed well, it can be moulded to the needs of the users and by doing so become
therapeutic. However, if I ask: could the environmental changes be enough without a comprehensive
approach to care? My answer would be no, it would not be enough. The therapeutic environment
cannot stand on its own without the contribution of the way it is being used within the total approach
to care. Even if the environment is less therapeutic than desired, a comprehensive approach to
dementia care still remains the key issue in successful interactions with seniors with dementia. The
human element will overcome environmental difficulties. A non-responsive environment makes the
use of space difficult, but caring leadership may lessen the environmental hardship. However, to
arrive at an optimal situation, both the environment and the human element are needed to create a
therapeutic environment.

164



3. Caregivers need to understand the condition from a neuro-psychological perspective, be aware of
the social construct developing around the person, be sensitive to changing needs and be flexible in
treating the person as the condition progresses.

The issue of caregiving is much more complicated than this study is able to reveal. To understand
caregiving we need to distinguish between formal and informal care. Formal care takes place in care
facilities, informal care is provided by families and friends. In home interviews, I did witness a lack
of understanding of dementia and a lack of patience as family members became very frustrated over
time. Understanding the condition would help anyone to cope better with the situation. This condition
touches everyone connected with the person with dementia and demands collaboration from a support
system if it is to reduce the stresses imposed on everyone. This inquiry oniy strengthened my belief
that the more we know, the better we will be able to cope with difficult situations. The more we
know, the more flexible we may become in accommodating this unpredictable medical condition. In
the last seven years, I experienced this process of learning and I am at a point now where I could say
that my approach grew out of this evolving knowledge.

4. There is a lack of empirical research on appropriate creative expression activities specifically
designedfor seniors with dementia. With no appropriate studies available on assessing their
creative abilities, there is no clear understanding of what meaningful creative expression activities
for these seniors could be. With more studies on such activities, the more effective the therapeutic
environment will become.

This comment still stands. No specific information on this topic has been found to date that would
definitively characterize creative expression abilities of, or the activities for, seniors with dementia
within therapeutic environments.

5. There is a lack of inputfrom people with dementia who are capable ofcontributing their views
about how their space can be used. The scientific community has failed to involve their subjects as
equal partners wherever possible.

This theme comes up again and again in my architectural world. In an effort to improve their
environment, seniors are often forgotten. Experts from various fields, with the best of intentions,
combine their skills to provide a better place for seniors with dementia. However, the main users are
often left out. Many people in our society believe that older people with dementia are not capable of
resolving own their difficulties. The films produced during this inquiry show that seniors with various
levels of dementia, from mild cognitive impairment to moderate dementia, have wants, desires and
very clear opinions about what they like and dislike. At the L’Chaim Centre, seniors with various
levels of dementia helped contribute ideas to the recent renovations. Not all of their recommendations
were met; however, it was clear as we all interacted in an effort to design our dream studio, that
abstract thinking was evident, and the ability to transfer it into a drawing was there, regardless of how
it came out. I would have liked to get more input from the core group at Margaret Fulton Centre;
however, some of the seniors moved away or just were not capable of concentrating on the question.
The two Spanish ladies were difficult to understand and so, I did not pursue the project, knowing that
their Centre is one of the best in the area. Instead, I opted to work on physical changes at L’Chaim
Centre, which needed more help in many ways and provided an opportunity to review the five design
principles learned from the literature review.

Reviewing the Design Principles

The five design principles suggested by Cohen and Weisman (1991) which were discussed in
chapter four were sufficient to cover most of the environmental and behavioural issues that relate to
seniors with dementia:

Design principle 1. To provide clusters of small activity spaces to promote homelike atmosphere
Design principle 2. To provide opportunities for meaningful wandering
Design principle 3. To provide positive outdoor spaces

165



Design principle 4. Provide other living things
Design principle 5. Provide a variety of opportunities for movement from public to private spaces

These principles have merit because seniors need personal attention, chances to explore without
barriers, a connection to the outdoors and living things, and simple transitions that help orient them to
the space. As the inquiry progressed it became clear that something was missing from the five design
principles in terms of the creative expression experience. My observations of the seniors with
dementia led me to consider the various types of participation they exhibited. This led to
understanding the need for two more design principles.

Design principle 6: Provide opportunities for different levels of participation in creative
expression activities

I have come to understand that there are four different identifiable behaviours: active
participation, silent participation, distant participation and passive participation. These forms of
participation may have a significant impact on space design for seniors with dementia and should be
taken into consideration from the start of each project, or added when renovations are called for
where seniors with dementia live.

a) Active participation is defined as full engagement, including physical and verbal interaction with
others, making efforts to communicate in any way possible.
b) Silent participation happens when seniors are present at the activity, but choose or are not able to
express themselves verbally. Still, they may show interest through non-verbal indicators such as facial
expression.
c) Distance participation describes a person who may watch the activity from a distance. While this
person may or may not contribute to the ongoing activity, their interest is sufficient to keep them
close by.
d) Passive participation occurs when individuals view a video, television or movie. This is still a
form of participation and there is always the chance that it may progress later into any of the other
types of participation.

Design principle 7: Provide opportunities to celebrate one’s ethnicity

This principle may be incorporated into the design of a facility that might correspond to the
architectural style typical to a specific ethnic group, such as a facility built especially for Chinese or
Italian seniors. Wherever it is not applicable, it is up to the administration of the care facility to
incorporate activities and decorations during significant events, such as the Jewish or Chinese New
Years. In addition, based on my experience at the L’Chaim Centre, it is crucial to have staff who are
versed in the specific cultural milieu in order to enrich the world in which the seniors with dementia
live.

Both principles 6 and 7 are singled out here for the purpose of clarity. However, in practice, they
apply to each of the five principles presented by Cohen and Weisman (1991). The four types of
participations can be applied to clusters of small activity spaces, opportunities for meaningful
wandering, positive outdoor spaces, other living things and spaces from public to private realms. In
this context, the design may need to take into account various qualities of space that will
accommodate the four types of participation. This may affect the space requirements and call for
funding to train staff in spotting the behaviours and in directing willing participants as they move
from space to space in an attempt to be closer to the activity. These seven principles form the
theoretical basis for architectural considerations when designing for seniors with dementia.
Furthermore, they have been important to the sites within this study insofar as they have underscored
how an architectural flavour of any ethnic culture can be applied to each of the principles. For
architects willing to engage in ongoing living inquiry that involves an alr/tographic perspective, it
may be that other principles will come to light within other situations.

166



By adopting the five principles of Cohen and Weisman (1991) and adding two more principles to
their list, this study has accounted for the needs of seniors with dementia as they are engaged in
creative expression activities. I feel there is a better fit now between the seniors with dementia, their
remaining abilities, the spaces they operate within, and the approach we need to take when we
interact with them.

Up to this point there has been an emphasis on theoretical approaches to creativity, dementia and
the therapeutic environment. The following is a list of practical considerations architects may find
interesting. Although architects do engage in a process of inquiry, especially at the beginning of each
project, I invite them to continue to be engaged in action research that includes seniors with dementia
as much as the situation allows. Unfortunately, the architectural profession is often bound by financial
and time constraints and the need to produce a built entity, which is by nature a product that stays in
place for years. The only time architects are engaged again with their creation is when the building is
being assessed for its readiness for occupation. It would be better if architects were given an
opportunity to embrace their artistic inquiry in more depth and become more responsive to the needs
of seniors with dementia. Architects serve as the link between the clients/developers who hire them
and the users who may or may not have a say in the design process. The ideal situation would be if
developers of care facilities for seniors with dementia would allocate time and funding for a more
serious phase of inquiry in the contract and make it a communal responsibility for all the parties
involved.

Reviewing the Understandings Reached

The following understandings arose from the practical activity of working with the seniors
closely in various care facilities, in particular in the two selected Centres, observing their behaviour,
and recording their reactions to environmental manipulations. Information from the literature review
helped to inform these understandings, as did my reflections of my own role as an a/r/tographer. In
addition, reviewing the recordings of the videotapes added one more perspective that threw light on
realities sometimes hidden from us while being actively engaged in the study. The following review
is divided into the three domains of dementia, creative expression activities and the therapeutic
environment. It is hoped that this List will help practitioners who are working in environments such as
those studied in this dissertation.

- In Dementia

1. Ethical consideration must be the top priority when dealing with seniors with dementia.

2. We cannot expect seniors with dementia to make accommodations to the world around them, as they
lose their memory and control over their lives. Not only that, as their disease progresses, so does our
need to increase the adjustments we make to them.

3. Understanding the various levels of dementia from mild cognitive impairment (MCD to the most
advanced dementia as it manifests itself through psychosocial situations is crucial in interacting
appropriately with seniors with dementia.

4. Medical intervention is an important element in a comprehensive approach to dementia care.
However, without proper identification or diagnosis of the various dementias, seniors may take
improper medications, and expectations that the administration, staff, family and friends impose on
them may be too high or too low.

5. Biomedical research in dementia strives to unlock the neural mechanism that causes damage to the
brain cells that can lead to 72 different types of dementias. Prominent scientists in dementia research
suggest that cure is still years away. This study suggests additional ways to provide dementia care.

6. The majority of the medical establishment tends to ignore the practical contribution the arts play in
dementia care. Although employing the arts in health care in general is gaining acknowledgment in
the literature, the practical applications of the arts in dementia care is still in its infancy.

167



- In Creative Expression Activities

1. Appropriate and flexible creative expression activities encourage seniors with dementia to express
themselves and stay connected socially.

2. Seniors with dementia need more time to express themselves. Short sessions of less than one hour and
fifteen minutes do not provide the time needed for these seniors to get familiarized with a topic,
mentally digest the information and react to it.

3. Seniors with dementia need time to reflect and time to unwind, between activities. High level activity
needs to be followed by low level activity. Continuous exposure to demanding mental exercise will
defeat the purpose of keeping them engaged. On the other hand, appropriate challenges are desired
and welcomed by these seniors. It validates their desire to be recognized as individuals and treated as
members of society.

4. Seniors with dementia need program and environmental cues to engage them in creative expression
activities.

5. Programs need to be planned in advance and appeal to all the senses.

6. Knowledge of the past life of seniors with dementia is crucial to continuing communication with
them. Knowing intimately a person’s culture and customs through careful study, kinship or
membership of that group is extremely important in accessing early memories some seniors with
dementia can still recall.

7. A creative expression facilitator needs to know at least one or more areas of the performing and visual
arts well, needs to understand how dementia manifests itself as a medical condition, and needs to
appreciate how to manipulate the environment to meet the seniors’ needs.

8. Concerned family and friends need to be educated about what techniques can be used to continue to
communicate with a person with dementia.

9. Policy makers in dementia care, whether in government or in the private sector need to support
funding for the arts in dementia care. Administrators of care facilities need to understand the
importance of the arts in dementia care, not just from the arts aspect, but from the fundamental need
of human beings to stay creative as long as they can for their own wellbeing.

10. Working with seniors with dementia is most rewarding and can enrich the lives of everybody
involved. Even if we don’t understand everything they say, we need to be open to hear in between the
lines, and recognize their body language to interpret what is not being said. Communication occurs in
the silence too, and can be expressed through the arts.

11. The facilitator must relate personally to seniors with dementia and learn to gain their trust. It is also
important to empower and talk to them as equals, to continuously seek their input and not assume the
position of someone who knows better. We must remember that they have a wealth of knowledge and
we are there to help them express it in any way they can, to their best remaining abilities.

- In the Therapeutic Environment

1. One large open space can serve a group situation well, if no other activities happen at the same time
and interfere.

2. Smaller spaces are needed for private and semi-private activities. One way to make the separation is
to use room dividers with sound insulation built in.

3. Semi-private space needs to be provided for meeting a friend and family or staff.

4. Home-like atmosphere is important to the seniors with dementia. It provides a sense of security and
comfort when seniors are away from home.

5. Interior finishes are crucial to safe mobility, to prevent falls and contribute to social interaction.

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6. Access to weather-protected outdoor areas is important to seniors with dementia who feel trapped and
house-bound. Outdoor heaters, such as those used in restaurants, may offer one solution to moving
outside while staying warm.

7. There is a fundamental need to stay connected to nature that appeals to seniors with dementia. This
does not require specific memory. Nature provides familiar situations that give seniors with dementia
pleasure, a place to explore, wonder and wander without feeling inadequate or judged. Outdoor areas
and indoor spaces can be designed specifically to provide familiar surroundings.

8. Special furniture designs would benefit seniors with dementia and the people who interact with them.
Special desks could be designed that are deep and wide enough to accommodate art supplies and a
work area, with all the equipment in easy reach within the 4 ft bubble. Interaction should take place at
eye level and so should the hanging of artwork.

9. Based on typical tables of 4 ft. by 8 ft., a U-shaped arrangement proved to be the most convenient
arrangement in a group situation for seniors with dementia and the facilitator or staff.

10. The most used areas in each Centre proved to be the multimedia or multipurpose area, the outdoors
and the washrooms. Figure 34, is a model of interaction between space, equipment and function.
Based on my observations, I draw links between space and the use of space which immediately
pointed at the areas most in use.

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Function Accessibility to

Figure 32: Interactive Model for Space, Equipment and Function

Function

Most used areas

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Questions for Further Inquiry and Closing Comments

As long as there is no cure for dementia, its progression will eventually diminish creativity. At the
same time, we need to continue to treat persons with the condition with compassion and dignity, and
adapt activities to the level of their abilities. Based on medical evidence and personal observation,
symptoms of dementia are often unpredictable and vary with each individual and the situation. Creative
expression and dementia eventually become two opposing forces. The potential in human cognition to
create and express and to use creative abilities to face the challenges of life confronts the progressive
deterioration that results in impairment and eventually in death. These two forces intersect at
unpredictable crossing points that may change directions. Along the way, they travel parallel to each other
for an unspecified time and even result in enhanced creativity.

These unpredictable crossing points could be the focus of future study. Questions such as these arise:
(a) What happens psychologically, physiologically and socially to seniors with dementia when they
become engaged in creative expression activity? (b) What happens to seniors with dementia on an
individual level and within the social context when they become engaged with creative expression
activities? (c) What environments, other than those monitored in this study, are equipped to provide
appropriate spaces for creative expression activities for seniors with dementia?

When working in existing care facilities such as an adult day care centre, a seniors’ recreation
centre, or a home, researchers can alter furniture, interior colors, partitions, and creative expression
programs as they observe, describe and interpret what is perceived. This would need to be carefully
planned so as not to cause too much aggravation to the participants. Researchers need to be prepared to
stop the inquiry if participants react negatively, and be prepared to be responsive to the needs of the
participants at all times. The tolerance to negative reactions needs to be carefully monitored and
adjustments made according to ethical considerations. At no point should the research take priority over
the well being of the participants.

Even though this study focused on seniors with dementia, alr/tographic process could be used with
other seniors as well. For future inquiry, it would be interesting to observe a group of seniors with no
dementia and record their response to creative expression activities within different spaces. Further
inquiry will contribute to the pooi of knowledge and (a) expand our understanding of what happens to
people as they grow older, (b) investigate why some older adults experience a decline in cognitive
functions, while others do not, (c) and address the most challenging question: is it possible “to reverse or
modify the negative changes associated with aging?” (Hoyer & Roodin, 2003, p. 2).

If we can alter the physical environment to encourage the senior’s participation, creative expression
activities can be expected to contribute in the following ways: encourage persons with dementia to have a
sense of personal control as long as possible and help health service providers and formal and informal
caregivers understand the importance of the arts in the healing process, as a way for communication and
for maintaining the seniors’ quality of life.

This inquiry brought to our attention that the physical environment has the potential to attract seniors
with dementia to stay in the space and become engaged in creative expression activities. But the space
alone is not enough to engage the seniors in these activities. Success in implementing a creative
expression program is linked strongly with an understanding of the seniors’ physical and cognitive
abilities and with the commitment of the facilitator to implement a flexible pedagogical approach as they
interact with each individual.

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The Overall Significance of the Thesis

To understand the overall significance of the thesis, we must consider five areas: a) the theoretical
and methodological development of a/r/tography as a new approach within the domain of qualitative
research, b) the practical field of dementia care, c) the field of architecture, d) my personal, professional
and academic needs and, e) how this study and its context may resonate with other settings.

a) This study brought a new application to further the development of alr/tography as a theory
and a methodology. As I was contemplating whether to use alr/tography for this study, I
could see the clear connection between the artist as an educator and as a researcher. What I
needed to establish was whether or not my being an architect and a facilitator working with
seniors with dementia could fit within the philosophical approach of a/r/tography. To help
understand it better, I devoted time to self-reflection, asking why I was doing what I was
doing, how my multiple roles impacted my relationships with the other stakeholders of the
study and could my design endeavors qualify as a process of artistic engagement within the
various situations. The self-quest continued in parallel to the relational investigation of the
seniors with dementia. A/r/tography facilitated this process while emphasizing the
connections between the researcher/artist/educator and the participants of the study.

Using a/r/tography made the picture more complete. While I could have used other
methodologies to understand this topic in depth, none would have allowed me to explore my
art, and expose myself in a way that was equally as important as the understanding of the
other participants. At the beginning of my inquiry, other researchers asked me whether I was
aware that my research might be contaminated by my deep involvement with my subjects --
that the responses I got from the participants were perhaps correlated with my outgoing
personality. My reaction to these comments was: let’s see where this leads and discover what
in my personality made these seniors respond to me. I hope I do have an impact in the
situation. Using action research is an active inquiry process where I use what I learn through
re-searching, in a timely manner, that will effect the learning and well-being of those with
whom I am working.

b) This study initiated a chain reaction within the academic and professional worlds. I have been
giving workshops and training caregivers in the last several years in various places in North
America through the American Society on Aging. In seeking new perspectives, I developed
the conferences on creative expression, communication and dementia, which led to the
establishment of the Society for the Arts in Dementia Care. The main thrust of all these
endeavours, as well as of this study, is that we all need to share our resources in the common
interest of helping seniors with dementia use their remaining abilities through multiple forms
of creative expression. In addition, I have developed an academic course based on my topic
for third and fourth year students in a degree program at the BC Institute of Technology in
their architectural program. I also produced a documentary film on a senior with dementia.
The topic gained support from the Film Board of Canada. So, the two worlds of academia and
practice keep feeding and supporting each other as understandings develop.

c) Architects who design care facilities for seniors with dementia will find this study
informative and useful. My architectural training may attract their attention and hopefully
their interest in implementing some of the ideas outlined here. Along with architects, details
of this work may interest designers of furniture, interior designers, industrial designers and
landscape architects. As a result of this study, I was invited to give a workshop for 40
architects at an annual meeting of the Architectural Institute of BC about a year ago. The
workshop was an eye opener for all the participants; they wanted to hear more about
dementia from an architectural point of view. This inquiry helped form an understanding of

172



what furniture layout might be best in a group situation. It also strengthened the importance
of each room being connected to the outdoors.

The five design principles developed by Cohen & Weisman proved to be a solid basis for
architects who work in this field. The addition of principle 6 brings the design of space within
an arts room into prominence in accommodating seniors with dementia as they participate in
creative expression activities. There is also the need to understand the four types of
participation: active, silent, distant and passive. The four levels of participation can help to
determine space requirements, but these levels can also be taken into account for other
activities for which seniors engage. This last observation has a potentially significant impact
on how we design future environments for persons with dementia as they interact in creative
expression activities.

Another contribution to the architectural field could lie in the understanding that combining
various creative expression activities in one session may be the answer to successful
interactions with seniors with dementia. This may have architectural implications. Instead of
moving the seniors from room to room to participate in various activities, we may need to
change the environment around them and bring the activities to them. We may need to allow
for the various types of participation. This means a high level of flexibility in manipulating
combinations of space, equipment and activities. Knowing the kind of activities and
understanding the seniors’ abilities, emotional and physical needs can help shape the
architectural envelope and its design. As stated earlier:

The physical envelope that surrounds the seniors, spiritually, emotionally and
physically, embodies the reflection ofthe seniors’ world whether at home, in a
residential setting or in institutional care. This envelope could serve as a
therapeutic environment thatfits with one of my long-term goals: To provide
opportunitiesfor creative expression activities with educational components that
are supported with appropriate architectural planning and design.

d) My personal needs as a professional and as an academic are gradually being met. Doing this
study forced me to look into myself as an architect/artist, researcher, educator/facilitator and
understand the purposes of all these roles. It was a healing process for me as an adult student
looking to expand life experiences in a meaningful way. The usual cliché: the more we learn
the less we know, applies here as well. There is so much to investigate and explore in
dementia care that any quality information will benefit the general pool of knowledge.

e) AIr/tography basically sums up the reason for this dissertation and my work with seniors with
dementia in the last five years. I hope that lessons learned from. this study may inspire others
to continue the inquiry. My intentions in this study were to produce a document that provides
theoretical suggestions for space design that would lead to new understandings. I feel I have a
responsibility towards my peers and a commitment to improve environments for seniors with
dementia when they are engaged in creative expression activities. This commitment needs to
be translated into a language architects can use in a practical way in their designs. Above all,
I hope architects will be inspired to consider the understandings documented in this
dissertation as a way of reconsidering some of their own practices when designing spaces for
persons with dementia.

Although the group of participants was small in number at both sites, the participants
displayed behavioral symptoms seen in other situations outside this study. What this study
provided was an opportunity to suggest new space and furniture arrangements while the
creative expression activities program was conducted. Changing the table arrangements
allowed a favorable layout of tables in a group situation. This may seem like a small detail in

173



the context of dementia care in general. However, when we take into consideration the
hundreds of adult day care centres in North America and thousands of care facilities, where
seniors with dementia and staff struggle to maintain any art activities under trying conditions,
any change that could alleviate stress or improve the environment for seniors and staff would
be most welcome. The understandings that were gained can provide practitioners in dementia
care with a description of our experience showing that one arrangement may work better than
others and therefore ongoing inquiry is essential. In the program of creative expression
activities I developed and conducted at the two centres, the furniture layout and practices I
suggested were adopted at one, and some of the ideas outlined in this study were
implemented.

As this chapter comes to an end, it also opens up exciting new ideas for inquiry in the field of
creative expression, dementia and the therapeutic environment. I would like to thank the many seniors I
have been interacting with over the years for the courage and the dignity they have shown me. Even in
their darkest moments we see some glimpses of the self. Anyone who has experienced -- even for a short
time --the fear, anxiety and confusion these seniors with dementia must endure most of the time, cannot
help but know how much they depend on us to maintain some semblance of their former selves. These
seniors could be our parents, grandparents, spouses and friends and, until we find a cure, we must use all
our resources to develop our best new ideas and help them in any way we can.

174



EPILOGUE

I felt the need to give back something of myself that did not involve the roles of a researcher,
facilitator and educator to the seniors I had been working with. It was a reflection of the artist in me as I
interacted with the seniors and brought my ideas of creative expression into their space and into their
lives. This act was to satisfy my need to be remembered in the Centre long after I am gone. It culminated
in my proposed design for stained glass doors for the main entry at the L’Chaim Centre.

Ideally, if permitted, I would have spent time with several of the seniors and developed a design that
they truly had a part in creating. But involving them right from the start would have involved a much
smaller group in a different location where, hopefully, the director would have allowed us to work
separately from the rest of the participants. Since this was not permitted, it became an idea for a future
project.

Instead, I developed this design as my contribution, in appreciation for the love and care the seniors
and the staff have shown me. As it happened, I was able to show this design to the seniors and give them
the chance to express their opinions of it after it was done.

Proposed Design for Stained Glass Doors at
L’Chaim Centre

The following entry in my field notes explains how I
arrived at the design of the glass doors:

This session was specialfor me as an artist and
as an architect. Ifinally got to the point where I
felt good enough about redesigning the floor
plan for the centre to suggest some artistic
solutionsfor the suggested second set ofdoors. I
looked around and could not see too many
places for art display. In fact, there is very little
room to display art works anywhere, including
those made by the seniors themselves.

As I was coming through the main front
doors, I started to imagine the centre with the
changes I recommended. li would resolve the
problem ofpeople coming in and out at will. It
would create some private spaces and
contribute to a sense of belonging and provide a
homey feeling.

There was no question in my mind that
any proposed artworkfor the L ‘Chaim Centre

would need to reflect the Jewish culture, the Hebrew language, Jewish symbols and
motjfs, connection to the homeland in Israel. All ofthese elements are shared by Jews
from all over the world. Symbols may change and take on the flavour of the region, but
the content will stay the same, recognizable andfamiliar.

p-1I. A,
IN FW’tkI

In / c.
‘_ k

175



I have chosen arches that may represent old buildings, synagogues and the walls
of old Jerusalem. I also incorporated olive leaves and branches as a symbolfor peace
that goes back to Biblical times. There is a welcome message in Hebrew as people enter
the centre. I selected colors that have meaning in the Jewish culture: blue for the blue
skies in Israel and the Israeliflag, goldfor the gold aura that settles over the skies of
Jerusalem in the evenings. There is also a famous song, Yerushalaeem Shel Zaahv,
meaning Jerusalem of Gold. It comes from apoem written by Naomi Shemer, one of the
most beloved song writers ofIsrael, who passed away recently. This poem was written in
1967 during the Six Days’ War, when east Jerusalem was captured by the Israelis and
was united with west Jerusalem to become one city again. This was an historic milestone
in the Jewish psyche. Jewish people who were preventedfrom accessing the Western
Wall, which is the remains ofthe foundation walls ofthe Holy Temple going back to the
times ofKings David and Solomon, could once again pray next to it and touch it.

The glass panels will be made from hand-blown French glass and chosen for
their interest and beauty. The panels will then be sandwiched between two tempered
glass panels and inserted into commercial French doors with a bar across eachfor use
as an emergency exit. A brass panel on the bottom of each leafwill absorb any rough
handling. The doors can be open or closed. Forfull security, privacy and control over the
activity room, I would suggest having the doors closed. Then, the stained glass design
will be in full view as people walk in or out of the centre.

On September 9, 1am planning to bring the proposedfloor plan design and the
proposed artworkfor the glass doors to the participantsfor their input and comments.
Staffwill participate as well.

Figure 33: Proposed Stained Glass Doors at L’Chalm Centre

176



On September 9, 1 met with a few of the original group of seniors at the L’Chaim Centre. The design
for the stained glass doors was received positively, but was overshadowed by a pessimistic realization that
they may never be constructed. Although the seniors appreciated the design, they were worried about the
cost and who would pay for it. I had a difficult time separating the concerns they raised about finances
from the opportunity to freely express an opinion about the design. I thought that a couple of issues
prevented the seniors from expressing their thoughts: there were new people in the group who had never
met me before, and perhaps they did not like the design but were reluctant to say so.

A few days later I travelled to Israel. As I was visiting places all over the country, I was struck by the
images I came across. While I was sitting in Vancouver designing doors with a Jewish motif, thousands
of miles away from the source of my inspiration, I produced a design based on my perception and
memories of what was important in Jewish traditional artwork. I surprised myself. I must be carrying
those images deeply in my mind and heart. I took photographs to remind me of the artwork I produced for
L’Chaim. Here in Vancouver I felt out of place producing a clear ethnic design. But in Israel my design
was not unique; it fit in with many other windows just like it. It brought home for me the meaning of
belonging and fitting in. And it felt good. The understandings that came out of this situation opened a new
window for me into the lives of many seniors, who get uprooted from their familiar environment and lose
touch with the familiar objects that connected them to the past and to the roots of their souls and
spirituality.

177



14
p

-

Figure 34: Images of Natural and Man-made Arches in Israel

178



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APPENDICES

A. Samples of Field Notes and Inteiviews at Margaret Fulton and L ‘Chaim Day
Care Centres

Participant at the Margaret Fulton Adult Day Care Centre

July 28, 2005 Interview with Lucia and Margareta her daughter

I arrived on time at the apartment building where Lucia and her daughter Margareta lives with her family.
Lucia moved in with her daughter after her health deteriorated and she slipped into a depression. Since
she moved in she is better but still takes anti depressant medicines.

As I entered there were old photos of Lucia waiting for me on the kitchen table. The earliest photo
showed Lucia in her 3 Os or more. I asked where was Lucia and Margareta was asking me if Lucia was
welcomed to the interview. I told her absolutely.

Lucia came out of her room with a big smile and hugged me. We went over to the dinning table. We were
talking about Margaret Fulton Day Care Centre, about having to leave the original country and move to
another one and the health condition of all the three of us.

Margareta acted as a translator and was careful in her translations. Lucia most of the times understood the
question, however, at times she did not understand the question even if it was repeated and changed to fit
her cognitive abilities. This was the first time I could see for myself that the language was not always to
be blamed for her reduce cognitive abilities.

I asked Lucia if she was happy in Margaret Fulton. Lucia said she was happy. I asked her if there was one
thing she would like to change to make her happier and Lucia did not understand the question. Later on,
Lucia was asking about Cannel and said she really liked Carmel’s violin playing. So she remembered
Carmel.

Lucia used to join the Peruvian Association in Vancouver and meet other countrymen or other Spanish
speaking people. To day she would have liked still to meet them but it is not something very important.
Margareta explained that it was very difficult for her to take her mother to the association since she was
working and that it demanded a great effort to keep it up.

Margareta explained that Lucia was always a quiet person but speaks even less now. I stayed there for
about an hour and went back home. It was nice to see Lucia speak full sentences and be able to make
herself understood. She would have benefited a lot from being with others that speak Spanish. The only
person that speaks Spanish at the centre is Elena. However, Elena is suffering from Parkinson’s and her
voice is very weak and hard to understand.

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Participants at the L ‘Chaim Adult Day Care Centre

July 20, 2005 lnte,view with Avraham Goldstein

Avraham heard from other people at the centre that I was visiting people in their homes and interviewing
them. At the last session at l’Chaim, he came over to ask me when I was planning to see him. I was
leaving his interview to last since he has no dementia and I wanted to interview those with dementia first.
However, I decided to go and see him two days later. I brought my sister-in-law, June, with me

As we walked in, Avraham was teasing me saying that I brought someone along to make sure I was safe.
There was some truth to that. I was not afraid for my own safety, I just did not want to be blamed if
anything went wrong.

The visit with Avraham was very interesting. The first thing that surprised me was the cleanliness and the
pleasant arrangement of the furniture and the art work all over the apartment. I heard he did needlepoint,
but I had no clue about the extent of his work and commitment to this hobby. Later on, when we
discussed his hobbies, he told me that after his retirement at age 45 from the Israeli army, he took up
needlepoint and never stopped. Now, at age 79, he has numerous canvases with the most amazing work.
My surprise was linked to my pre-conceived idea that men usually don’t do this kind of craft,that older
people stay away from such precise work. Later, when Avraham showed us his photo album as a young
man in Israel, I was even more perplexed about his hobby.

Proudly, Avraham showed one album with photos of his life in Israel. The story of his life there was very
interesting. Avraham was born in Germany and arrived in Israel as a young boy. His mother was a
German Catholic who converted to Judaism. His father was a German Jew, whose father was a rabbi.
They arrived in Israel in 1933. In Israel, Avraham was involved in the defence forces long before the
state of Israel was born. Photographs showing him on a horse with a rifle protecting the Jewish population
were very impressive and Avraham was proud to talk about it.

Avraham enlisted in the Israeli army in 1948 and served there until his retirement. As a young man he
was very involved in sports. He was into body building, target shooting and training others for
international competitions. He was married twice. Both women died of cancer. He moved to Canada to be
with his daughter in 1991. He has great-grandchildren; he can see them at the Jewish Community Centre
when he comes to l’Chaim Centre.

Avraham’s brother, who served in the Israeli Navy, went back to Germany in the ‘SOs with his parents. I
asked Avraham how they could move back to a country that just murdered 6 million Jews. I have to admit
I was shocked to hear it. Avraham answered that was why he did not move with them.

I asked Avraham what he thought about my sessions. He answered that my sessions were interesting and
broke the centre’s routine. He also said that he liked the challenges and the intensity I brought to the
sessions. He felt I was giving him an opportunity to use his brain and his ability to think. He did not say
anything about the environment or the furniture arrangement and I did not ask. I plan to see him again and
ask him about it.

Before I left, Avraham asked me several times if I was planning to come back. I told him I might. It
depends on how much more I need to do for my study. If I have time I will definitely think about it.

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July 29, 2005 Inter/jews with Anita and her husband Bill at their home

This was an interview replacing one I had cancelled a week earlier when I became sick. When I called
back, Anita insisted that I should stay for dinner and asked me if! ate fish. I tried to talk her out of it, to
no avail. She would not take “no for an answer. I volunteered to bring a dessert with me.

Anita lives with her husband in the Oakridge area. All the homes around them were torn down and huge
homes were built in their place. Anita’s house is one of the last ones to keep its looks from the ‘60s. The
outside space is kept strictly as a lawn for minimum maintenance.

Anita came to the door to greet me. She gave me a big hue and invited me in. She was barefoot and wore
a kitchen apron. The table was set and the salmon was cooking in the oven. Anita called her husband to
come up from the basement. Bill, her husband, responded in an angry way that he was busy with the
laundry and he would come up when he could.

Anita invited me to sit down with her in the den while her husband was busy down below. She had a
house guest, her grandchild from Israel, a 15-year-old boy. I could see right away that the presence of the
boy was annoying both of them. Their major complaint was that he hardly talked to them and spent most
of his time in front of the computer. Later I found out he was on his way to a summer camp on Gabriola
Island and was just waiting for the day when he could leave to get there.

Anita sits next to me on the sofa and tells me about her 3 daughters and their families. She also tells me
about a man she would like very much to be in a romantic relationship with if Bill happened to pass away
before her. I was surprised at the ease with which she was sharing such intimate information with me. I
was even more surprised when she brought up the subject again when Bill came up from the basement. I
was not sure how to deal with it, since it could have been a behaviour resulting from dementia, or from a
very open and liberal relationship between her and her husband. I decided to stay out of it and see where
it would take us all. Bill was treating it lightly.

When we got ready to sit down, Bill prepared the salad from a premixed package. As he was making it,
Anita asked him where the bread was. Bill would not tell her. He got upset that she could not remember
where the bread would be. When he finally gave her some instructions, she still had a problem locating it.
I decided to help find it and finally got it down from the upper cupboard in the kitchen. Anita muttered
something that had nothing to do with the situation. I think she was trying to reduce the stress and the
unpleasant response of her husband.

As we sat down, I called their grandson to come and join us. Anita said a few things that made the boy
clam up, “he does not like me... I don’t know what else to do... he does not have any friends...” She tries
to hide her feelings but she has a hard time concealing them.

I decided to help Anita with the food distribution. It seemed that her somewhat restricted abilities were
annoying Bill. I dished out the salmon. As for the rest, we passed the dishes around. Anita had prepared
borscht, a traditional soup made of beets. I asked her if she made it from scratch and she said, yes. Later I
could see it came from a bottle.

As we were eating, Bill passed the salmon skin on to Anita. I was surprise to see him do this, especially
when she is so overweight. During the meal Anita would ask some questions and every once in a while,
her husband would mock her for not knowing the answer, or not asking the right way. Anita was reduced
to the role of a little girl trying to please Bill.

I was angry with the situation. I am sure that in better times, Anita would not have allowed Bill to talk to
her like that. On the other hand, perhaps she did go along with it.

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I got up to clear the table and started to wash the dishes. Bill asked me to stop and I did. Anita went to the
den and brought back a photograph published in a Jewish publication that included the person she might
like to be romantically involved. Bill added that that person was happily married. Anita said, so what.

I stayed a little longer after dinner as we reminisced about traditional Jewish food. It seemed a good topic
for Anita and Bill since it put them on an equal footing and the conversation became much more pleasant.

Through my whole visit Anita was asking me when I was going to interview her. I told her I was
interviewing her the all time, but through a normal conversation flow, and that I was getting the
information I needed.

She also wanted me to continue to come to L’Chaim and said that she would be missing me a lot. I told
her I would try, but at this time I was extremely busy. She remembered Cannel playing the violin. Anita
did not talk much about L’Chaim centre and I was not insisting on getting her opinion about my program
or the furniture layout — I had already gotten her opinion during the filming.

Anita accompanied me to the door; I said goodbye and left.

Interviewing Anita and Toby and their husbands brought home the message about how important it is to
work and train family caregivers so they know what to expect and can be prepared mentally and
physically to handle a person with dementia.

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B. Air/tography Field Notes at Margaret Fulton Adult Day Care Centre

July 5, 2005, Music Session

Legend

Floor plans

E-Mails

Problems

I I Ask David
Using knowledge from architecture

________

A point to check again

Present: Dalia, David, Joan Skeet (recreational facilitator), June, Carmel (violinist). Seniors: Lucia,
Margaret, Elena, Mildred and Betty.
Weather: Cloudy, rainy and muggy.
Transportation: My own vehicle. David came separately in his car. Cannel arrived separately with
Mineo. She is busy with preparations for her concert.

Researcher

State of my own mind: I was wondering how things will go in this session and whether I will be able
to engage the participants. Will I be able to hear any discussion or comments on the environment. I asked
David to make a copy of the dance of the King and I and for some reason I could not find it. I did not
mind it since I knew I was going to have Cannel playing today. Carmel has such a rich repertoire of
music from opera to classical music to Scottish dances that it was easy to change the music as we went
along to fit the moment. Her talent is apparent and it is very appreciated by the participants.

My physical and emotional state: I was relaxed but extremely hot. We were all sweating although
the doors to the garden were open. I thought to myself, things were running smoothly until I realized that
perhaps they are not as they seemed to be. Explanations will follow,

Preparation for the session: We decided to conduct this session in the art room. Joan Skeet, the art
coordinator, divided the art room into two. Half was allocated for the knitters and half was allocated for
us. We took partitions from another part of the centre and situated them in between the two spaces. June
hung our banners on the partitions with images of musical instruments. I thought it looked really good,
especially when participants looked at them and made some comments. Betty said she had a violin at
home she had played on for many years, but hers was a different kind. What she saw were electric guitars
on the partitions.

We also covered the tables with fabric with musical instruments printed on them. I spread pictures of
musical instruments everywhere that had been cut out of magazines, brochures, and catalogues from
music stores.

We brought the electric piano from the small room and situated it along the wall. We
were aware that the area was used as a pathway for the seniors for their afternoon walks. Cannel was

202



practicing inside the emergency room and brought all our bags inside there with her. She wanted the
space to look good for the camera.

I asked Joan to do the writing for me
during the poetry writing.

Joan and I started to gather the participants that had consented to be part of the study. Joan wanted to
make sure they went to the washroom first. As I was collecting them, those who sat down got up after few
minutes and left. They were sitting undisturbed until Carol joined them and encouraged them to leave the
room. Later I heard from Maureen that Carol had mental issues before she was diagnosed with dementia
and that she has many issues to deal with.

For a moment I stood there wondering if I was going to have a session at all. And then I had to
remind myself that whatever happens is part of the study. I had to remind myself of several things:

• I am a qualitative researcher and that we can learn from any situation
• Dementia is an unpredictable disease and that I need to be ready for the unexpected
• Not to take the difficulties of keeping the participants in place as a personal failure

I started to talk into the camera to explain what was going on. Just as I was ready to give up, Joan
started to bring back some participants and I stayed around to make sure that some activity is happening
to engage them in some interaction. I shortened the introduction to the session and asked Cannel to play
on the violin. I sat there in my chair letting the music relax me and collect my thoughts for the next step.

As I was sitting there it suddenly dawned on me that Cannel, my daughter, would be leaving in about
a week for Israel to study there for about one year at the University of Tel Aviv. Cannel was playing
Meditation, which moves me each time to tears. This time my emotions were overwhelmed with sadness
knowing that she would be gone soon. Mildred, one of the participants, commented on my tears and her
understanding of the situation.

Educator/Learner Facilitator

I came to the session completely ready. I had my session planned, David was ready to start shooting,
Joan Skeet was ready to help, June was hanging and decorating the area, Cannel was setting up her space
and practicing her music. It was a big production. My mind was totally focused on the activity that was
soon to start, and then I had the realization that we may not have anyone to work with. From my
experience working with seniors with dementia, I knew it could happen. Yet, I needed to address my owti
feelings of disappointment and failure. I soon turned to my crew to alert them that the session may not go
ahead.

I felt I had a responsibility to the people I work with and that they needed to understand the situation.
I felt responsible to Joan Skeet who worked hard to get the participants to sit around the table. My mind
was working hard analyzing what could be the factors in keeping the participants around the table.

• There was a question of trust. I was new to the seniors. There was no trust yet established
between me and the seniors. Betty saw me twice. Margaret saw me three times. Mildred was
seeing me for the first time. Lucia saw me twice, Helena knew me from the earlier time when
her granddaughter was studying piano from the same teacher as my oldest daughter.

• There was the issue of introducing something new to the programs at the centre. This session
did not follow the usual routine that was followed very carefully at the centre.

• The area of the activity was used by seniors and staff for walking after lunch and access to
the wasbrooms.

• Noise level. Need

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• We could hear everybody else in the centre, including a woman volunteer who played the
piano after lunch.

Architect/Artist

Setting up the room: In the process of writing this observation, I have already described many details
about the space. However, a few details are still missing. The area that was allocated to the session today
faced the garden. Although it was raining, the garden looked just lovely. The gazebo in the centre has
flowering pots hanging from each corner. The flowers were pink and white and it was the height of the
blooming season. The flowers were just cascading down and were ajoy to the eye. Plants on the ground
along the wandering path were blooming as well. The garden is situated at one corner of a grassy
playfield with big trees. Looking out from the art area, it felt like we were in the forest. The quality of the
light that came pouring in even on this cloudy day was beautiful. So the setting was very inspiring.

Maureen the director suggested that perhaps we should try the outside.

As I was admiring the flowers outside in the garden with my wandering glances while Carmel was
playing beautiful music in the background, I found myself framing imaginary still pictures in my mind. I
was actually looking around as if I had a camera in front of my eye. This is not the first time I became
aware of it, but I have never really written it down in so many words. I usually approach photography
from the point of view of an architect. I look for an interesting object, the composition as a mass in space,
how the light faLls on it, the color of the object and how it relates to the surrounding colors in the
environment and whether or not I want to convey a message or just stay with the aesthetic value of the
shot.

Joan and her new house

In the middle of our correspondence, Joan Skeet commented that she had bought a new house and she
was very busy decorating it. She also reported that she was leaving Margaret Fulton after 12 years of
working there. As I was arranging the tables for the session, Joan took paint chips and laminate samples
to be used in her new house out of her bag. I was drawn right away to the prospect that she was asking my
opinion and I really liked her choices. I came up with some suggestions for finishing materials. It felt
strange to look at colors alone without referring to the meaning they conveyed that could only be acquired
with more information about Joan, her family, her house and so on. Weeks later I visited her house and
helped with some suggestions although Joan has a great sense of color being an artist herself. It was more
like helping a colleague of the same field of design.

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August 29, 2005, Repeated Session on Bending Wires. Strength versus Weakness

Legend

Floor plans and furniture arrangement

F 1
Problems

__________

Ask David

Using knowledge from architecture

A point to check again

Participants divided into 2 groups. One group with dementia, the other without

Present: Debbie, Dalia, David, June, Pauline (nurse) 2 part time recreation employees, Seniors: Jack,
Ruth, Eera, Sonia, Avram, Michel, June, Edna (new person), Sara, Morris, Mm (new person), Anita.
Weather: Raining hard
Transportation: My own vehicle. David came with me.

Researcher

State of my own mind: I was worried about the results of the CT Scan I have gone through yesterday. At
the time of writing I learned that the tumor is not growing back. I wonder how long this remission is
going to last.

Preparation for the session: This is a repeated session on bending telephone wires, with discussions on
creativity and strength versus weakness. I brought along telephone wires as I did the last time. I called
Debbie and told her that I needed to have a session with the participants who were diagnosed with
dementia and whose MMSE indicates that there is some memory impairment. Debbie agreed and we set
the session for August 29, 2005, seven weeks after the first session on bending wires took place.

Why did I decide to repeat the session?

As I reviewed the video and the transcript of the first session on bending wires, I realized that
participants with dementia did not participate as much as the more able participants. I was very surprised
to learn that the analysis of the text did not correspond to my own perception of what transpired during
the session. I came out from facilitating the first session feeling that there was far more input from
participants with dementia. I was watching their verbal and non-verbal responses to my questions and to
the discussions. They all stayed around to listen. I did not feel any lessening of their engagement in what
was going on. However, I decided to go back for another session; this time I would divide the participants
into two groups. Participants who were diagnosed by their physicians, or scored low on their MMSE were
led to one side of the table and the rest to the other side of the table. I left an opening of 2 feet between the
tables that separated the two groups.

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Educator/Learner Facilitator

I had some concerns about to how to approach this experiment without making it obvious that I was
selecting participants according to their abilities. If I had permission from the L’Chaim director to work
with those with dementia only, and use a separate room, I would not worry about hurting anybody’s
feeling. Instead, I opted for a U-shaped furniture arrangement with a 2-foot gap between the two groups.
My introduction was oriented towards the two groups at the same time. However, I paId more careful
attention to the group with dementia and gave them priority over the group without dementia. I included
Anita in the group of participants with dementia since her condition was not that clear to me. I need to
discuss it with Dr. Feldman. Anita scored high on the MMSE, but has no control over her reactions and
antagonizes people around her. She does not always understand abstract concepts.

As the discussion about what is creativity went on, the boundaries that were meant to divide the two
groups started to unravel as both groups responded. There were some profound thoughts on what
creativity meant to the participants on both sides. In both groups there were participants who did not
elaborate on their answers, while at the same time Michel, June and Edna, seniors with dementia, gave
some responses that put into question the thought that there may be a need to separate participants
according to their cognitive abilities. The only difference I observed at this session was that participants
with dementia needed more time to digest information and more time to respond. This extra time would
be welcomed by some people with no dementia as well.

I was surprised when June, who has dementia, criticized Anita for describing a certain situation as a
creative act. I was of the same opinion as June but tried to be more diplomatic about it and give Anita
more time to get the point of what creativity means. Edna, a newcomer to the group, really did not want to
be there. All she wanted to do was go home. Bending over her knitting, smiling in the wrong places,
feeling uncomfortable, she said simply: Creativity is doing something nobody else is doing. I was not
expecting it from her. I asked her to repeat the answer since I could not believe my ears. I am waiting to
see her MMSE from Debbie. I was told Edna was diagnosed with dementia by her physician.

There is something very fundamental about us. We follow what we see and expect others to behave
according to the perception we have formed in our minds about them. No matter how long I have been
working with people with dementia and I have worked hard at sharpening my sensitivity towards their
needs, I am still surprised every once in a while at what I witness as a demonstration of cognitive abilities.
It reinforces the ideas that this is an unpredictable disease and therefore we should expect the unexpected.

Architect/Artist

We have set up the room 5 times before. I already knew that the U- shape worked
best for me and the participants. What I did find very helpful was the gap of 2 feet between the two
groups. Although I adopted it more for a visual separation, so people would know where their seats were
and for my own orientation and ease of filming, it turned out it gave the participants an opportunity to
shorten their route to the washroom without having to go around to the end of the U-shape. This should
be taken into consideration when planning furniture layout for an activity.

This session was special for me as an artist and as an architect. I finally got to the point where I felt good
enough about redesigning the floor plan for the centre to suggest some artistic solutions for the suggested
second set of doors. I looked around and could not see too many places for arts display. In fact, there is
very little room to display art works anywhere, including those made by the seniors themselves.

As I was coming through the main front doors, I started to imagine the centre with the changes I
recommended. It would resolve the problem of people coming in and out at will. It would create some
private spaces and contribute to a sense of belonging and provide a homey feeling.

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Proposed design for the stained glass doors

There was no question in my mind that any proposed artwork for the L’Chaim centre would need to
reflect the Jewish culture, the Hebrew language, Jewish symbols and motives, connection to the homeland
in Israel. All of these elements are shared by Jews from all over the world. Symbols may change and take
on the flavour of the region, but the content will stay the same, recognizable and familiar.

I have chosen arches that may represent old buildings, synagogues and the walls of old Jerusalem. I also
incorporated olive leaves and branches as a symbol for peace that goes back to biblical times. There is a
welcome message in Hebrew as people enter the centre. I selected colors that have meaning in the Jewish
culture: blue for the blue skies in Israel and the Israeli flag, gold for the gold aura that settles over the
skies of Jerusalem in the evenings. There is also a famous song, Yerushalaeem Shel Zaahv, meaning
Jerusalem of Gold. It comes from a poem written by Naomi Shemer, one of the most beloved song writers
of Israel, who passed away recently. This poem was written in 1967 during the Six Days’ War, when east
Jerusalem was captured by the Israelis and was united with west Jerusalem to become one city again. This
was an historic milestone in the Jewish psyche. Jewish people who were prevented from accessing the
Western Wall, which is the remains of the foundation walls of the Holy Temple going back to the times of
King David and Solomon, could once again pray next to it and touch it.

The glass panels will be made from hand-blown French glass and chosen for their interest and beauty.
The panels will then be sandwiched between two tempered glass panels and inserted into commercial
French doors with a bar across each leaf for use as an emergency exit. A brass panel on the bottom of
each leaf will absorb any rough handling. The doors can be open or closed. For full security, privacy and
control over the activity room, I would suggest having the doors closed. Then, the artwork will be in full
view as people walk in or out of the centre.

On September 9, I am planning to bring the proposed floor plan design and the proposed artwork for
the glass doors to the participants for their input and comments. Staff will participate as well.

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C. Session Planning

Music Session

Purpose: To explore the link between creative expression, dementia and the therapeutic environment.

Duration: About 90 minutes. Twice in each centre. Second time around with changes to the environment.

Supplies (we need to discuss what everyone has and can bring)
• Put music instruments on display
• Hang images of music instruments around
• Bring books and posters of music instruments
• Coloured construction paper 81/2” x 11”
• Coloured wrapping papers with instruments images on them
• Stickers of music instruments
• Felt pens
• Glue sticks
• Scissors at least for every two people
• White envelops to send cards

How

1. 20 minutes of socializing. Drinking coffee, tea, juice, cake and chocolate. This is a time to
socialize. No planned activity takes place.

2. Cleaning the tables in preparation for the planned activity.

• 20-30 minutes of topic presentation. Dalia will introduce the topic. That will include:
• Carmel playing popular music from operas
• Dancing to a waltz with a senior who wants to dance. Dalia, and staff inviting to dance.
• Asking who would like to hold a violin or a guitar and try to play it with the help of Sonia and

Carmel

Developing a discussion on the topic
a Do you like dancing?
• If yes, ask what kind of dances? What about the Waltz?
• Where did you go to dance in your youth?
Making a card

1. Drawing a music instruments or anything while Carmel is playing the music

2. Distribute the wrapping papers already cut to smaller pieces

• Distribute scissors and glue sticks

• Staff and Dalia to help write what ever the seniors want to write inside

• Put inside envelopes to be mailed to the families

Evaluation Sheets or comments from participants and staff:

1. How did you feel about the session today?

• Is there anything in this room that disturbed you during this session? What was it?

Schedules for Sonia (on guitar) and Carmel (on violin)

Sofia Landry’s Schedule

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At the Margaret Fulton Adult Day Care Centre

Tuesday, June 14, between 1 — 2:15 pm. Friendship session (includes music). Cancelled.
Tuesday, June 28, between 1 — 2:15 pm. Friendship session (includes music)

At L’Chaim Adult Day care Centre

Monday, July 4, between 10:30 — 12:00 noon. Friendship session (includes music)
Monday, July 11, between 10:30 — 12:00 noon. Friendship session (includes music)

Carmel’s Schedule

Monday, June 20, between
Monday, June 27, between
Tuesday, July 5, between
Monday, July 12, between

10:30 — 12:00 noon at L’Chaim Centre. Music session
10:30 — 12:00 noon at L’Chaim Centre. Music session
1:00 —2:15 pm at Margaret Fulton. Music session
1:00 - 2:15 pm at Margaret Fulton. Music session

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Friendship

Purpose: To explore the link between creative expression, dementia and the therapeutic environment.

Duration: About 90 minutes. Twice in each centre. Second time around with changes to the environment.

Supplies

• A flip chart 1 8”x24”. Or white board. The bigger the better. (centre’s)
• Felt pens, at least two colours, black and red, with extra wide tips. (Dalia)
• Tape, pins and laundiy pegs to dispLay the sheets around the room in viewing range and at the eye

level of a sitting person. (Dalia)
• Bring flowers that represent friendship and love that seniors can take back to their homes. (Dalia)
• Bring chocolates in the shape of a heart or home baked cake.(Dalia brings Chocolates, centre

brings cake)
• Video tape of the movie Casablanca. (Dalia brings tape)

Equipment: TV Screen and a VCR. (centre’s)

How

• 20 minutes of socializing. Drinking coffee, tea, juice, cake and chocolate. This is a time to
socialize. No planned activity takes place.

• Cleaning the tables in preparation for the planned activity.
• 20-30 minutes of topic presentation. Dalia will introduce the topic. That will include:

• Sharing Dalia’s experiences and staff experiences in friendships
• Talking about the tough times in friendship and the good times
• Have Sonia play 2-3 songs on friendship (see schedule at the end)
• Have Carmel play a love song on the violin (see schedule at the end)
• Ask the participants what did the music do for them
• Introduce the movie Casablanca and the last 5 minutes
• Show the last 5 minutes of Casablanca
• Discuss the scenes from the movie

Writing a group poem

a Key words — ask the seniors for key words that describe friendship and write them down on a flip
chart.

• As the sheets of paper fill up, display them side by side on vertical surfaces at the seniors’ eye
level.

• With a new sheet of paper on the easel, further develop the poem into sentences.
• Read the words aloud as sentences are called out. All suggestions are considered and all

participants are invited to contribute to the poem. Make an effort to incorporate even awkward
key words.

• The group needs to agree and approve the final product
• The finished poem is then distributed to the seniors the following week.
• Evaluation Sheets or comments from participants and staff:

• How did you feel about the session today?
• Is there anything in this room that disturbed you during this session? What was it?

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Optional questions:

• What does creative expression mean to you?
• In what ways can you express yourself creatively?
• How important is creative expression to you?
• When you look around this room, is there anything you would like to see changed to make it

easier for you to engage in creative expression activities?

Schedules for Sonia (on guitar) and Carmel (on violin)

Sonia Landry’s Schedule

At the Margaret Fulton Adult Day Care Centre
1601 Forbes Avenue
North Vancouver, BC
V7M 2Y4
Phone: 640-904-3550
Director of the centre: Maureen Murphy

Tuesday, June 14, between 1 —2:15 pm. Meeting with families at 7:00pm.
Tuesday, June 28, between 1 — 2:15 pm

At L’Chaim Adult Day care Centre
950 West 41St Avenue
Vancouver, BC
V5Z 2N7
Phone: 604-257-5111
Director: Rabbi Dina-Hasida Mercer

Monday, July 4, between 10:30 — 12:00 noon
Monday, July 11, between 10:30 — 12:00 noon

Carmel’s Schedule

Monday, June 20, between 10:30— 12:00 noon at L’Chaim Centre
Monday, June 27,between 10:30 — 12:00 noon at L’Chaim Centre
Tuesday, July 5, between 1:00—2:15 pm at Margaret Fulton
Monday, July 12, between 1:00 - 2:15 pm at Margaret Fulton

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D. Consent and Assent Forms

UI3C The University of British Columbia Curriculum Studies
Faculty of Education

Institute of Health Promotion Research, 2125 Main Mall
Interdisciplinary Studies Vancouver, BC Canada V6T 1Z4

Tel: (604) 822-5337 Fax: (604) 822-4714
Rita.Irwin@ubc.ca

Consent Form
Creative Expression, Dementia and the Therapeutic Arts Room

Principal Investigator: Dr. Rita L Irwin, Professor, UBC, Department of Curriculum Studies.
Faculty of Education. Telephone number: (604)822-5322.

Co-Investigator(s): Dalia Gottlieb-Tanaka, Doctorate Student, UBC, Faculty of Graduate
Studies, Institute of Health Promotion Research and Interdisciplinary Studies. Telephone: (604)
822-3814 at the office or (604) 986-6408 at home. This research is part of a thesis (public
document) for Ms. Gottlieb-Tanaka’s graduate degree. The people who will have access to the
study are: Dr. Rita L Irwin and Dalia Gottlieb-Tanaka, Doctoral Student,

Purpose: To explore the link between creative expression, dementia and the therapeutic
environment. Although some researchers would dispute the level and quality of creativity in
each person, the ability to express oneself continues through the stages of early to moderate
dementia. Areas destroyed in the brain show reduced cognitive ability but other areas may
continue to perform intact for a longer time. Through appropriate programs conducted in
responsive environments designed to accommodate their needs, these seniors may continue to
enjoy life to the best of their remaining abilities.

Study Procedures: You will participate once a week for eight weeks either in a group of 5
seniors at the Margaret Fulton Adult Day Care Centre or in a group of 12 seniors at the
L’Chaim Adult Day Care Centre. Each session is planned to last for 90 minutes. It begins with
socializing, serving coffee, tea and baked goods, open discussion and the introduction of
relevant materials. Next, a topic such as friendship is introduced, and the group composes a
poem based on the topic.

The sessions will be videotaped at both centres. At the L’Chaim Centre all seniors will be
included in the session. However, only 5 seniors will be filmed. At the Margaret Fulton Centre, 5
seniors will be selected to participate in the study.

You will not be filmed nor included in the study if you do not wish to participate.

Confidentiality: The subjects’ identity will be kept strictly confidential. All documents will be
identified only by a pseudonym and kept in a locked filing cabinet. Subjects will not be identified
by name in any reports of the completed study.

Version: May 16, 2005 page 1/2

212



Some data records will be kept on a computer hard disk and will be accessed with a security
code known only to Dalia Gottlieb-Tanaka.

However, the subjects and their legal guardians may want to be identified for their contribution;
for example, for the artwork they produced. In such case, the subjects and their legal guardians
may sign at the end of this consent letter to indicate their wish to be identified and credited for
their contribution to this study. Subjects and their legal guardians who agree to be identified
may withdraw their consent at any time during the study with no consequences to their
treatment or activities at their care centre.

Contact for information about the study: If you have any questions or desire further
information with respect to this study, you may contact Dr. Rita L Irwin, Principal Investigator at
(604) 822-5322 or Dalia Gottlieb-Tanaka, Doctoral Student, at (604) 822-3814 at the office or
(604) 986-6408 at home.

Contact for concerns about the rights of research subjects: If you have any concerns about
participants’ treatment or rights as a research subject, you may contact the Research Subject
Information Line in the UBC Office of Research Services at 604-822-8598.

Consent: Participation in this study is entirely voluntary and the participants may refuse to
participate or withdraw from the study at any time without jeopardizing their access to further
services from the adult day care centre they attend.

Your signature below indicates that you have received a copy of this consent form for your own
records.

Your signature indicates that you consent to participating in this study.

Subject Signature Date
(or Parent or Guardian Signature)

Printed Name of the Subject or Parent or Guardian signing above.

Your signature indicates that you wish to be identified in any narrative description of the
study. Your signature also indicates that you wish to be credited for the artwork you
create during the study. You may withdraw your consent at any time.

Subject Signature Date
(or Parent or Guardian Signature)

Printed Name of the Subject or Parent or Guardian signing above.

Version: May 16, 2005 page 2/2

213



(J13C The University of British Columbia
• [UBC Department Letterhead]

Institute of Health Promotion Research,
Interdisciplinary Studies

Assent Form
Creative Expression, Dementia and the Therapeutic Arts Room

Principal Investigator: Dr. Rita L Irwin, Professor, UBC, Department of Curriculum Studies.
Faculty of Education. Telephone number: (604)822-5322.

Co-Investigator(s): Dalia Gottlieb-Tanaka, Doctorate Student, UBC, Faculty of Graduate
Studies, Institute of Health Promotion Research and Interdisciplinary Studies. Telephone: (604)
822-3814 at the office or (604) 986-6408 at home. This research is part of a thesis (public
document) for Ms. Gottlieb-Tanaka’s graduate degree. The people who will have access to the
study are: Dr. Rita L Irwin and Dalia Gottlieb-Tanaka, Doctoral Student.

Purpose: To explore the link between creative expression, dementia and the therapeutic arts
room. The goal of this study is to document the experiences of seniors with dementia while they
are engaged in creative expression activities in particular therapeutic settings at these adult day
care centres.

Study Procedures: You will participate once a week for eight weeks either in a group of 5
seniors at the Margaret Fulton Adult Day Care Centre or in a group of 12 seniors at the
L’Chaim Adult Day Care Centre. Each session is planned to last for 90 minutes. It begins with
20 minutes of socializing, serving coffee, tea and baked goods while discussion on any subject
is encouraged. Next is a prepared activity lasting about 20 minutes. It includes a display of
relevant materials. Discussion is encouraged to draw on your own experiences. Following the
discussion an activity of about 30-40 minutes is introduced: it might involve talking about
friendship, making paper appliqué, listening to music and dancing. Free discussion usually
continues and takes on the flavour of the moment.

The two topics were selected. The first topic on friendship includes a discussion on various
types of friendship that will draw on your past and present experiences. The last five minutes of
the movie “Casablanca” is played, demonstrating how a new level of friendship is struck up
between the French policeman and the nightclub owner. An activity of poem writing follows the
discussion and the movie clip. The movie “Casablanca” may be replaced by the “King and I”
depending on the circumstances.

A second topic consists of listening to music, dancing to music, playing to music, painting to
music and reminiscing about the time when the music was composed. No restrictions are
imposed on the way you express yourself creatively.

Version: May 16, 2005 page 113

214



The sessions will be videotaped at both centres. At the L’Chaim Centre all seniors will be
included in the session. However, only 5 seniors will be filmed. The rest of the seniors will not
be filmed and their activity will not be affected.

You will not be filmed nor included in the study if you do not wish to participate.

Confidentiality: Your identity will be kept strictly confidential. All documents will be identified
only by a pseudonym and kept in a locked filing cabinet. You will not be identified by name in
any reports of the completed study. Records will be kept on a computer hard disk and will be
accessed with a security code known only to Dalia Gottlieb-Tanaka. However, if you wish to be
identified for your contribution to the study; for example, for the stories and artwork you
produced, you may sign at the end of this consent letter to indicate your wish to be identified
and credited for your contribution to this study. You may withdraw your consent at any time
during the study with no consequences to your treatment or activities at your care centre.

Risks and benefits: There is a very small risk of reliving a troublesome past that might
contribute to confusion. Extra care will be taken to avoid materials that may induce those
memories, such as in the case of Holocaust survivors. The director of the L’Chaim Centre will
be consulted well in advance of each step of the study to prevent such possibilities and so will
the director of Margaret Fulton Centre. In my six years of working with seniors with dementia, I
most commonly found that these seniors wanted to discuss a variety of topics including
sensitive ones. Care will be taken in the selection of potential subjects to make sure that any
risk is minimized. The directors will be advised to prepare counseling services in case such a
situation arises.

The subjects who participate in the program will enjoy fun, informative and stimulating activities
that will enrich the sessions and validate their experiences, It is an opportunity for participants to
socialize with each other, staff and the researcher. It is an opportunity to be heard and to be
valued.

Contact for information about the study: It you have any questions or desire further
information with respect to this study, you may contact Dr. Rita L Irwin, Principal Investigator at
(604) 822-5322 or Dalia Gottlieb-Tanaka, Doctoral Student, at (604) 822-3814 at the office or
(604) 986-6408 at home.

Contact for concerns about the rights of research subjects: If you have any concerns about
your treatment or rights as a research subject, you may contact the Research Subject
Information Line in the USC Office of Research Services at 604-822-8598.

Consent: Your participation in this study is entirely voluntary. You may refuse to participate or
withdraw from the study at any time without jeopardy to your access to further services from the
adult day care centre you attend.

Version: May 16, 2005 page 2/3

215



Your signature below indicates that you have received a copy of this consent form for your own
records.

Your signature indicates that you consent to participate in this study.

Your Signature Date

Please Print Your Name

Your signature indicates that you wish to be identified, including artwork produced, for
your contribution to this study. You may withdraw your consent at any time.

Your Signature Date

Please Print Your Name

Version: May 16, 2005 page 3/3

216



E. Sample of Inte,view Questions

April 22, 2005

Research Topic: Creative Expression, Dementia and the Therapeutic Arts Room

Sample of Interview Questions Addressed to the participants:

1. What does creative expression mean to you?
2. In what ways can you express yourself creatively?
3. How important is creative expression to you?
4. When you look around this room, is there anything you would like to see changed to make it

easier for you to engage in creative expression activities?
5. Is there anything in this room that disturbed you during this session? What was it?
6. How did you feel about the session today?

217