Creative Interventions for Older People: Using creativity in facilitating recovery Louise Woolf Clar

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Creative Interventionsfor Older PeopleUsing
creativity in facilitating recoveryLouise
Woolf Clare Cottage, MHSOA, Waitemata DHB
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Introduction

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What is required?

• Passion for the task
• Compassion and Care for clients acknowledging
  the privilege
• Willingness to embark on a journey of discovery

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An example of working creatively

• Mrs T
• the quilt of strengths

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Why creative interventions?

• A picture paints a thousand words
• Words and cognitive understanding alone often not
  enough to create change
• We need to both understand and experience.
• Often something that takes us out of mental
  understanding can provide another perspective or
  useful insight

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Overview

• Journey of discovery
• Practical applications
• Own creativity and imagination
• Group and individual methods
• Cognitively impaired to higher functioning
• Fluidity of process, adaptability
• Evidence base

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The Context

• To work therapeutically we must endeavour to work
  efficaciously our treatment methods need to be
  evidence based
• While there is much, and increasing evidence for
  the efficacy of CBT with older adults, and in
  general there is less evidence for other
  therapeutic methods partly due to lack of
  research

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What is the Evidence Base?

• Very little research specifically for creative
  interventions with older people
• There is growing evidence for cognitive skills
  groups in dementia care
• Evidence in work with children that play therapy
  has similar effect sizes to other forms of
  therapy
• Play therapy, and sandtray frequently used in
  treating trauma

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The Context

• My own approach is grounded in CBT as a treatment
  approach but with the adaptations and
  flexibility necessary when working with real
  life people particularly older adults and some
  of the complexities they present us with

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The Context

• Creative Interventions can be used as an adjunct
  to a CBT based approach.
• They may be used in a variety of forms within
  this general framework for example role plays,
  two chair work, and a variety of other techniques
  are in fact creative applications

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What is Creativity?

• Creativity is fundamental to life.
• We all have the ability to be creative
• We see this in work, in recreation, and in play
• Every child is an artist. The problem is how to
  remain an artist once he grows up Pablo
  Picasso

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What is Creativity?

• Creativity takes many different forms
• Art
• Music
• Writing
• Gardening
• Baking
• Designing
• Building

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What is Creativity?

• What would you say are areas of life in which you
  are more creative?

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What is Creativity?

• A guided imagery task
• The Rose Bush

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Creativity Older Adults

• We do not lose our ability to create with age.
• While our ability to do some things may change
  we are still at heart able to create in some
  capacity.
• To rediscover lost creativity can bring life, joy
  and healing.
• We can encourage the use of creativity in many
  ways.

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Creativity Older Adults

• Essential in working with people is knowing who
  they are their personhood or their story.
• Strengths, joys, and things which have helped
  people to be resilient in life are often cues to
  creativity.

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Working Creatively

• Can be undertaken on an individual basis, as an
  adjunct to therapy
• Can be done in small or large groups
• Can be specific or may be more general
• Needs to be targeted to the individual in
  question
• Aim is to view all interaction as an opportunity
  for learning and growth eg games, cognitive
  skills

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Paths to Creativity

• Stories and Metaphors
• Art
• Craft
• Clay
• Music
• Dance/Drama
• Reminiscence
• Games
• Play Sandtray

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Working with more cognitively impaired Older
Adultsindividually and in groups
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Working with more impaired Older Adults

• What does it mean to work therapeutically?

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Working with more impaired Older Adults

• Even small moments count
• Progress may be slow
• The value of stimulation and interaction
• Quality of life
• Meaning
• The balance of working with ability yet not
  demeaning the older person

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Working with more impaired Older Adults

• Groups/Activities at Glenburn
• Reminiscence
• Art and Craft
• Music
• Brain Gym
• Relaxation
• Travel
• Games
• Using stories

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Working with more impaired Older Adults

• Groups
• Specific - may be selective have a small group
  of similar ability and a specific goal (eg.
  Cognitive Skills Group)
• General such as on Ward changing population,
  varying ability (requires more adaptability,
  thinking on feet, and facilitation)

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Working with more impaired Older Adults

• Individually
• Can target strengths
• Set goals for each individual client
• Can also then have people work alongside the
  individual in a group situation
• The therapeutic role of caregivers working
  together to facilitate quality of life

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Working with higher functioning Older Adults

• Often use creative techniques as an adjunct to
  more cognitive therapy
• Useful in illustrating, or helping in areas where
  stuck or difficulty with grasping a concept
• Determined by areas of clients interest or
  strengths
• Presentation of ideas is important in
  activities/ideas not being demeaning

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Working with higher functioning Older Adults

• In group work such as Anxiety Groups can use
  stories, metaphors, etc to illustrate and to
  encourage deeper level understanding

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Using Reminiscence

• Can enable memories that are easier to access to
  be brought to mind
• Gives people a stronger sense of themselves
  helps us to know the person
• Can be adapted depending on ability from a
  topic of discussion to tactile or visual cues to
  aid discussion and memory

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Overview of Techniques
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Using Reminiscence

• Can have a set topic for discussion each session
  or week
• School days
• Places have stayed on holiday
• Clothes
• Use of props and tactile objects to aid memory
• Use of stories

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Using Music, Dance Drama

• Music can often unleash potential where words
  cannot be expressed.
• Can be a very strong and effective intervention
  for people with limited physical and mental
  capacity
• Even simple movement, and listening to music can
  be beneficial for people

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Games

• Can enhance physical skills and mental skills
• Can encourage participation with others
• Can use games specifically designed for older
  adults or dementia or adapt games in various
  ways
• 20 Questions
• Memory
• Quizzes
• Kids games

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Using Stories Metaphors

• Can be used to help identify with an issue or a
  transition that may be happening for a person
• Can choose to identify with a particular person
  or object in the story
• Can ask how is this story similar to their own
  experience
• Can ask for their own image, picture, or metaphor
• Can begin a story or ask them to tell a story

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Using Stories Metaphors

• Poetry
• Playing God
• Not Understood
• Excerpts from novels that capture themes
• Mister Pip
• Captain Correllis Mandolin
• The Poisonwood Bible
• Movies
• The Notebook
• Awakenings

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Using Stories Metaphors

• Sophisticated Picture Books
• The Short and Incredibly Happy Life of Riley
• The Quiltmakers Gift
• Grandads Prayer of the Earth
• Little Bears Grandad
• The Little Prince
• The Red Tree

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Using Stories Metaphors

• The Incredible Journey of
• Edward Tulane
• Captain Correllis Mandolin

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Using Art Craft Activities

• Art and craft can help with fine motor skills and
  encourage creativity
• Can be targeted to skills for daily living
  (such as cooking), and easily adapted to suit the
  various ability levels of a group (i.e. card
  making)
• Can also be used to work together as a group
  collage, large art work
• Useful in dealing with trauma, loss, adaptation
  and change

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Using Art Craft Activities

• Craft activities can also be designed to be more
  specifically therapeutic
• Specifically targeted art work Rose bush, anger
  drawings, collage of life (tree of life)
• People in my world collage or tree leaves of
  important people what remains on the tree, what
  has fallen
• Clay creating something specific working
  through a trauma or memory

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Using Art Craft Activities

• Working with Grief Loss, transitions,
  adaptation and change
• Shadows Cards
• Strengths Cards
• Optimism Boosters
• Tree of Life

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Using Art Craft Activities

• Clay
• Tactile
• Uses our senses
• Can facilitate unconscious processes
• Can be self-soothing and calming
• Can be helpful with aggression and anger
• Can be directed or free to experiment
• Can be used in groups to create a scene
• Can be used as a mindfulness exercise

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Clay

• Come forward and break of a piece of clay the
  size easily able to fit into the palm of your
  hand.

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Break
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Sandplay
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Sandplay

• Sandplay or sandtray refer to the technique of
  using miniatures in a shallow box partially
  filled with sand.
• The box measures 73 x 60cm, and is approximately
  12.5cm deep. It is usually painted blue on the
  inside to depict water or sky.
• Miniatures are placed in the tray to depict a
  scene or small world

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Sandplay
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The History of Sandplay

• HG Wells
• Emerged out of psychoanalytic work with children
• Psychoanalytic/Jungian in form
• Later used by Educational Psychologists
• Developed and adapted over time
• Frequently used in work with children,
  particularly with abuse/trauma

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Sandplay Today

• The practice of sandtray/sandplay today usually
  includes two trays (one wet, one dry).
• After the therapist has introduced the procedure
  and given the client an opportunity to engage
  with the objects, miniatures on shelves or
  baskets are selected and placed in one of the
  trays to form a scene.

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Sandplay Today

• While each tray is taken on its own merit, often
  themes and stories emerge from a series of trays
• Photographs are taken of trays in order to
  observe the development of the trays

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Sandplay Today

• Current practice is to introduce concept of the
  sandtray. For example This is a sandtray. The
  aim of todays session is to use any of the
  objects on the shelves to create a world or a
  picture in the sand. Look over the shelves until
  you find something that speaks to you and put it
  in the tray and then add to it as you wish

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Sandplay Today

• The sandtray can be used in either
• Non-directive ways free way such as described
  perviously make a scene or picture in the tray
• Directive ways find some objects that represent
  you, your family and what has happened or find
  some objects that show in some way your different
  feelings. Or find some objects that we can tell
  a story about what is happening for you right
  now.

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Sandtray Today

• In deciphering of trays therapists draw upon
  all psychological training and abilities
  including
• Theoretical understanding
• Symbolism
• Observation of process
• Intuition and empathy.

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Sandplay Today

• While there are many possible levels of
  understanding when a tray is created it is
  important not to over-analyse a tray with a
  client but allow their own processing of what is
  occurring to unfold over time

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Sandplay Today

• Key considerations are
• The title the tray is given
• The story that is told with the tray
• Any changes or adjustments that are made
• Themes that emerge across trays
• Their own understanding or meaning attributed to
  the objects used in the tray
• What does the process of making the tray help
  them to see or understand (some of this may be
  subconscious)

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Sandplay Today

• In current Sandplay literature five main
  considerations dominate the field
• How the sand tray is created
• The content of the tray
• Developmental perspective of a series of trays
• The sandplay story
• The therapists feeling response

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SandplayExperiencing the medium
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Sandplay Experiencing the Medium

• Take time to come up and look at the miniature
  objects on display. Try to leave your
  professional self behind and not try to analyse
  or think about it too much
• Choose a miniature object which appeals to you
  perhaps stands out from the others in some way
  and take it back to your seat

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Sandplay Experiencing the Medium

• Share with the person next to you what appealed
  to you about the object
• Does it have any particular significance to you
  currently your space in lifes journey,
  decisions you need to make, or thoughts about
  yourself?
• Invitation to share your thoughts/experience of
  choosing an object with wider group.

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Sandplay Experiencing the Medium

• I have created a world in the tray. I would like
  you to think of life as a journey. There are many
  different terrains we have to cross along the way
• Forest
• Seas
• Rivers/Lakes
• Desert
• Open field
• Mountains
• Rocky places

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Sandplay Experiencing the Medium

• Bring your chosen object to the front and
  consider where in this scene you would place
  yourself.
• It may be that your chosen object doesnt easily
  fit into any place. If not, consider what other
  object you might need to make it feel right, or
  if you need to change the scene somewhat to place
  your object.
• If that object is not here either improvise, or
  keep a mental note of what you would like to use.

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Sandplay Experiencing the Medium

• Share your experience with the group

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Sandplay Examples
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Sandplay ExamplesChildren Trauma
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Sandplay Examples

• Children and Trauma
• The unfolding story
• Childrens own unconscious process
• The second tray healing of self
• Key objects
• Discovery
• Dealing with trauma
• Finding a future and hope

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Sandplay Examples

• Work with an Older Adult Grief
• Understanding Grief
• Adjusting to Loss
• Denial and Acceptance
• Finding a future and hope

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Understanding Sandplay

• The unfolding story
• Themes which emerge
• Key figures or objects
• Symbolism
• Jungian analysis
• Gestalt work
• The quadrant theory
• CBT applications

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The unfolding story

• Reflect on the story that is told
• How is it representative of the clients current
  experiences
• What themes emerge
• Would they like to change the narrative in some
  way if so what is needed to change the story

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Themes which emerge

• After a series of trays certain themes may
  consistently emerge
• Struggle/Adaptation/Change/Transition
• Uncertainty/Decision making
• Loss/Grief
• Relational issues
• Unresolved issues
• Discuss the themes which have emerged, what does
  the client take from this, are the themes
  positive and helpful or do they need to be
  changed in some way

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Key figures or objects

• In what ways are key figures or objects
  reflective of the person or their current
  experience of life
• Does the key figure need another figure to be
  helped towards wholeness
• What is missing
• Are the key figures beneficial or harmful

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Symbolism

• Clients can choose objects that have particular
  meaning for them
• It is important to gain an understanding of what
  items mean to the individual
• However, there are also Jungian perspectives on
  the meaning of objects, and this might enable
  some clients a deeper understanding of underlying
  subconscious processes occuring

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Jungian Analysis

• Relies on unconscious communication of the psyche
• Aim is to allow unconscious process to unfold
  and for the ego and self to be in relationship
  which facilitates healing and wholeness
• Jung the development of the individual can be
  brought about only by means of symbols which
  represent something far in advance of himself

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Gestalt Work

• Based on personality therapy which aims at
  striving toward individuals state of harmony and
  balance with environment.
• Promotes heightening of individual awareness of
  responsibility for behaviour, feelings and
  thoughts
• Encouraged to experience in the present
  unfinished business of the past

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Gestalt Work

• Within sandplay idea of owning each item and
  speaking to each as an expression of part of self
• Take each item used in tray and be that item
  what does it feel like to be this item, in what
  ways are you like this object etc
• Can also be acted out moved around etc
• Can then be adapted or changed as insight and
  understanding gained

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Quadrant Theory

• The quadrant theory
• Divides tray into parts based on psychoanalytic
  principles of conscious and unconscious
  principles
• Considers the symbols and work going on within
  each quadrant and persons own understanding of
  that quadrant
• In the centre is the area of activity development
  what is currently happening for the client in
  their world, issues being addressed etc

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Activity Development
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CBT applications

• Feelings tray
• Use the tray to facilitate uncovering thoughts
• As an alternative to a role play ie place key
  figures in the sandtray and role play possible
  options
• Working through a traumatic memory or event
• Supervision of cases

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