Chapter 11

The Under-utilization of Arts Therapies in Non-urban Care Settings

By Steven M. Snyder, M.A., MAL.  Kyushu University of Health and Welfare



In the summer 2001 issue of the Eden Alternative Journal, William Thomas, M.D., the founder of the Eden Alternative, stated in very exact terms the crises in long-term care: there was a financial crisis, a workforce crisis and a liability crisis.  As I write this report in the early part of the year 2003 these three crises appear to be still in full force in the United States Japan and a similar situation is developing in Japan.  It is my position that these three crises are not specific to long-term care in nursing homes but also effect other services as well, such as adult day centers and social support programs. Throughout the health and wellness systems in developed countries there seems to be these three crises, although it is in the United States where the liability crisis is most acute.  These three crises are often put forward as the reasons for not pursuing aggressive reform of the health and wellness systems, and specifically as reasons for not hiring arts therapists or having dedicated arts-related programs.  Presumably, with too little financial resources, too few qualified workers and rising insurance costs and constraints, reform must come after these crises are resolved.  In the William Thomas (2001) article he asserts the exact reverse-- that the financial crisis, workforce crisis and liability crisis are the result of the way services are managed and delivered and that only fundamental reforms in nursing home services and social environments will resolve the situation.


Thomas advocates a humanizing of facilities, emphasizing that care through human contact is more important than care through medical approaches.  Using the arts is an obvious way to humanize environments and interactions in these setting.  After all, human expression is precisely what is missing in dehumanized settings.  There is, however, one area where there is not a workforce crisis-- there are many highly trained arts therapists that are currently underutilized in programs for the aging.  This report will discuss the reasons why these therapists are not fully used and what benefits occur when arts-related therapies are employed. 


Other members of this research team reported on wonderful possibilities, of real programs that are doing genuine good for very needing individuals. I will be doing the same here.  I did observe arts therapists working in care settings and they were having an impact.  The use of the arts for health and wellness is logical, sensible and supported by empirical evidence (e.g. Kaye and Blee, 1997). 


There really should not be a need to justify the arts in terms of human well being, because human history is filled with evidence of the human need for the arts (Dissanayake, 1992). Humans need the arts.  The arts, very broadly defined as human expression and human imprint in our living environments, are most often characterized as the forms they are associated with (e.g. painting, sculpture, music, dance, drama, etc).  For some individuals this leads to a marginalized view of the arts as mere decoration or recreation.  There is a greater functional reality to art-- humans need to share self-expression and they need pleasant and stimulating objects and experiences in order to become or remain healthy.  Unquestionably, the arts are essential to what we refer to as culture.  Certainly, the enjoyment of viewing works of art and the enjoyment of performances are life-enhancing experiences that we all enjoy.  It can be said that these experiences are necessary to our quality of life, perhaps even necessary to maintaining life itself.  If we took away the ability to choose how an individual wished to spend time, and then took away opportunities to enjoy or create any kind of art, we would have made that individual depressed, frustrated, isolated and sick. We can also take depressed, frustrated, isolated and sick people and help them by giving them opportunities to enjoy and to create art.  The active creating of art requires decision and reflection.  That process greatly facilitates self-expression, self-exploration, and communication with others, and ultimately healing. 


There is an old story about Sigmond Freud that I will relate here.  I have not been able of find out if this story is true or not, but it is an illuminating story, nevertheless.  Freud was being interviewed by a journalist.  The journalist asked, "What are the most important things in life?" expecting a complicated answer from the famous doctor.  Instead, Freud simply replied, "Love and work." 


At one point in my career, I encountered a philosopher who felt compelled to find a third item to add to Freud's reply.  That philosopher had come up with "art" as the third item of greatest importance in life.  I congratulated this person and agreed that art was essential to life.  Then I asked the philosopher what single word would describe the joined concept of "love and work."  After some amusing suggestions, the philosopher asked me what word I would use to describe "love and work."  I said, "Art."  In our discussion it was hard to imagine having or creating an aesthetic experience (art), without both genuine caring and passion (love), and practice, experience and effort (work).  Can you imagine living without either love and work in your life?  Certainly, Freud was correct in this simple statement.  Now try to imagine living in an environment where the people around you do not love their work.  Imagine living in an environment where the people around you are working for you, but devoid of any feeling for you.  Imagine living in an environment devoid of any kind of artistic expression. 


Now reflect on these selections from the "Ten Principles" as they appeared in the Eden Alternative Journal (2001, p.4). "The Three Plagues of loneliness, helplessness and boredom account for the bulk of suffering in a human community."  "Loving companionship is the antidote to loneliness."  "To give care to another makes us stronger.  To receive care gracefully is a pleasure and an art." "Meaning is the food and water that nourishes the human spirit…The counterfeits of meaning tempt us with hollow promises." "Medical treatment should be the servant of genuine human caring, never its master."


Am I saying the problems are money, workers and insurance, and the solutions are love, work and art?  No, not exactly.  Nor am I specifically advocating the Eden Alternative; however, I am advocating that paradigminal changes, like those espoused by the Eden Alternative, are the way to reform services for the aging.  The Eden Alternative addresses the situation in long-term care facilities. I envision a reform that would involve a much larger population, including elders living independently, participants in adult day centers, and support for care giving family members and care giving staff.  My particular advocacy is the use of trained arts therapists doing not only group sessions, but doing individual interaction in a variety of settings: with residents in nursing homes, at retirement centers, with participants in adult day centers and in individual's homes.  I am not advocating visual and performance art as merely part of the activities program in a health setting, although I do feel that the presence of visual art and the opportunities for performance art are of great importance.  However, I believe that these should be events that can be shared with the larger community and with family and friends whenever it is possible.  Loneliness and boredom need to be addressed, but cannot be addressed in isolation.  People in facilities are isolated.  Many older persons living independently are isolated as well.  Family members, most often the women, provide much of the care giving.  In a recent "Forum on Caring for the Care Giver" that I attended, it was stated that one in four persons are engaged in care giving to a family member in the United States.  The stress on care givers in this situation can be tremendous and they generally receive no support, neither emotional nor instrumental.  Care givers in facilities also could benefit from therapeutic intervention, and the most natural choice would be arts-related therapies.  What is needed is not just a solution to problems in facilities, there is a need for a community-wide solution.  This is the kind of work that expressive arts therapists and social workers can provide immediately.


Indeed, the arts have been used successfully with emotional and health problems for many years, so it is only reasonable to expect that the arts would be used with the elderly. However, there seems to be a pattern of delay in the use of arts-related therapies with elder populations.  For example, drama therapy and movement  therapy were successfully used with patients who had severe emotional problems before they were used with elderly residents in the ground breaking study Waiting at the Gate (Sandel & Johnson, 1987).  Snoezelen  rooms were originally developed for use with learning disabilities and only in recent years have they found use in nursing homes. The same can be said for horticultural therapy, movement therapy, art therapy, and music therapy.  In the health and wellness systems of this world, the elderly come last.  Why the delay?  Why do the needs of older persons get attention in our societies only after other groups have been attended to first?  It might be that the frailness of some of the elderly misguides us into believing that all older persons are frail.  It might be that there is more research money for the problems of younger populations and this drives work in those areas. Yet another possibility, and perhaps a more truthful one, is that people find it easier to turn their backs on older populations.  In the modern world we do not think of aging in a positive way, and this has far reaching consequences.  One thing is certain, if younger persons are receiving services for similar needs while older persons are not, then the society is neglectful to that segment of the population.


Is it the case that because there are not funds available for aging programs, we cannot offer therapeutic services?; or is it the case that we are not fully informed of the needs and possibilities of the aging, that we do not make the funds available?   Knowledgeable and caring people have for very many years sought better environments for every kind of care receiver. In many respects the crises in funding, workforce and liability were present in 1992 when the first Eden Alternative site, Chase Memorial Nursing Home, was initiated.  A study of effectiveness of the Chase Memorial Nursing Home found a general reduction in medications when compared to a control facility.  The use of psychotropic drugs was reduced after the Eden Alternative was initiated, especially in the residents receiving one or two psychotropic drugs.  The percentage of residents using psychotropic drugs at Chase Memorial Nursing Home moved to well below national percentage levels. The study also found that deaths and infections reduced after reforms in the nursing home. These declines in medications directly brought down costs of operations and improved the financial situation of the nursing home.  In the 2001 Eden Alternative Journal there were claims of reductions in staff turnover, absenteeism, and medications as well as a rise in family visitations, resident satisfaction and longevity at Eden Alternative facilities. This approach has been introduced to Sweden, Australia, New Zealand and Switzerland.


Some of the new ideas we have today have been around for a long time; today, however, more people know about them.  We can point to a number of outstanding examples of innovative care giving, yet the general progress has been confined largely to new attitudes and a growing awareness within the field.  The expanding awareness throughout the field, emphasizing quality of life rather than the operation of the institution, has resulted in some notable physical changes.  New long-term care centers are in many cases well designed and inviting. They incorporate much of what has been characterized as "best practices." I will also be reporting that I found site managers and staff to be very caring, dedicated and have pleasant, caring staff. Alternatives to long-term care facilities have developed. Yet the three crises in this field remain. 


We are, I believe, in a critical time of transition.  Change has been coming for sometime, and we are indeed seeing important changes beginning to take place.  This is only the beginning.  As innovative approaches come forward, the conditions that create a need for them have gotten worse-- a situation that may possibly undermine the process of reform. In the balance is whether greater improvements in services can be achieved on a much larger scale and at deeper levels.  If reform fails, how can we maintain a system that does not work? 


It is against this backdrop that I will describe my contribution to the present study.  Other members of this research team have investigated a great number of aspects related to aging, independent living, physical settings, various approaches to providing care and, most importantly, how the arts are a part of this process.  Generally, their emphasis has been on art and aging in environmental and cultural contexts, rather than on the direct therapeutic use of the arts. To my mind, arts-related therapies are the most overt expression of the arts in healing and the most direct application of the arts to aging and well being.  Arts-related therapies (e.g. expressive therapy, art therapy, music therapy, drama therapy, dance therapy, writing therapy, etc.) are also of interest here because they center directly on the very issue underlying the connection of art and health-- the mind-body connection.  I chose to investigate how effectively various arts-related therapies have penetrated into rural and small town settings.  This choice was calculated, for the crises in care for the aging and in long-term care are equally as serious in the country-side as in the large cities, but the country-side often lacks the political and economic strength of the cities. Arts-related therapies offer tremendous potential benefit for care receivers in minimal as well as maximal care settings.  Thus, I felt that the presence or lack of these therapies in care settings would reveal something about the commitment to quality care given the current crises in care for the aging. 


My report begins with a general view of the situation in the communities I visited. This is followed by descriptions of specific situations and interviews taken.  I chose two general locations for my visitations in the United States: towns outside of Knoxville, Tennessee, and towns outside of Denver, Colorado.  I had not been in eastern Tennessee previously, but I had learned that the Alzheimer's Association in this region was very active and had sponsored a symposium on Snoezelen therapy during the previous year. Although Knoxville is a large city, in many respects towns in eastern Tennessee are representative of the countryside in the eastern half of the United States.  Denver, Colorado was chosen for similar reasons.  Following the review of my visitations in the United State will be a section on discussions with a few therapists working in Japan.  In the final section I will reflect on what the possibilities are for future use of expressive arts therapies with the aging.


The General Perspective

In 2001, Thomas claimed, as he had previously in his 1996 book Life Worth Living, that the solution to these crises required a shift from a hierarchical medical model of long-term care, to a client- and staff-centered approach.  Interestingly, this is not unlike the shift in European and North American psychotherapy many years ago, which deeply informs the arts-related therapies.  In North America, governmental funding of care programs has long been seen as inadequate to the need. According to Thomas (2001), government funding problems had resulted in a decrease of facilities.  This is occurring at the same time that facilities are facing increasing operating costs.  The potential implication to Japan, which has also adopted a medical model, is that similar crises are on the horizon.  The problems that are a consequence of government funding are beyond the range of this study, as are the complex influences of insurance and support organizations.  Nevertheless, it is impossible to dissociate the quality of care from the effects of funding on facilities and programs. 


In my site visits in the United States I found some directors that were answerable to absentee owners, often operating from another state.  Budget restraints and a lack of direct contact with programs also effects the other crises of workforce and liability.  Programs that would best benefit residents or participants by being offered every day are instead offered once a week.  Not only are care workers underpaid, the facilities have little funds available for training.  Staff turnover is a significant problem.  Whether or not managers felt that care workers were replaceable, low value employees I could not determine.  But given the lack of investment in training, the reliance on volunteers, the low pay and low status of this work, it is fair to say that these employees are generally not viewed as permanent or valued. Later in this report I will be reporting on one case where on-site training was provided, investment was made in additional programming, which resulted in increased staff retention and public recognition for the facility.  In this case, as in others, the change came from the bottom up-- that is, staff members of the facility took action toward change, action did not come from some higher level agency.  In other cases, I found facilities with informed directors that have employees who seem to be well treated and work in a pleasant setting.  In these cases, there are the beginnings of having care services for the care workers, a topic that is of great importance to the future of care for the aging. 


The workforce crisis was characterized in the Thomas (2001) article with the following features: high staff turnover, high rates of absenteeism, low morale, shallow recruiting pool, skill deficits in communication and in care competency.  Working in a nursing home can be hard work.  If the environments are depressing and employees are underpaid, it is not surprising that there would be problems in staff retention, morale and absenteeism.  In the United States, the low wages and a challenging work environment conspire to limit those who are willing to do this work to persons who have limited education and limited skills.  Many of these workers come from poorer backgrounds and many are immigrants.  Their language skills and cultural knowledge are limited.  One director told me of a surprising situation she encountered.  She had the opportunity to improve conditions at a nursing home, so she devised a number of environmental and procedural changes, informed by progressive ideas of reforming nursing homes.  One of the items was to offer residents grilled cheese sandwiches.  This plan met disaster because the care staff were from middle-eastern countries and found making the grilled cheese sandwiches baffling.  As I heard this story I thought to myself, "what kind of communications did these staff members have with the residents?"  I found out later that communications between the residents and staff were indeed a problem.  In Japan, one social worker characterized care giving as "older women taking care of older men."  This same social worker felt that care giving in both Japan and the United States were on sexist trajectories-- undervalued work because the work was allocated to disempowered women. 


I interviewed directors of successful programs that have been threatened by increasing insurance costs; costs that are largely unjustified and have a crippling effect on the opening of new programs and the expansion of existing programs.  Programs are restricted or prevented at a time when the need for new and expanded programs is greater than ever before, and will continue to rise in the future.  Unless deep and widespread changes occur reform may come too late. In the United States, insurance costs have taken money away from providing services.  At the same time, insurance companies help to define what cost are allowable and what services can be provided, with obvious consequences.


Certainly, the three crises identified by Thomas (2001) are real.  Each crisis synergistically worsens the other crises.  If more funding were available, then would wages increase?  If wages increased, would more competent workers come into the field?  If more competent workers were available, would insurance costs go down?  The likely answer to each of these questions is no.  Notice that the chain begins with funding, the scared cow of management.  All things good would come if only there were more money, is the great unexamined belief of nursing home directors. The directors I talked to implied that the main problem they faced was funding.  Facilities are expensive to run, yet revenues are barely enough to cover costs, so the explanation ran. However, my impression after many visitations and interviews was that two addition problems keep reform from gaining momentum: a lack of commitment to change and a lack of understanding at all levels of the care system.  In each of the interviews there were allusions to how the owners, or the corporate owners or the sponsoring church or agency that supports the program or facility could not understand why there was a need for things that the directors deeply wanted.  Repeated I heard about how the management did not fully understand what was happening within the facility. 


There are difficult financial realities and much of the problem seems to be systemic.  The United States still does not have a national public health insurance system.  Funding generally comes from a combination of private health insurance, family savings and government monies.  These government funds are subject to changes from time to time and are not used in the same way in different locations. In the case of Medicaid, the funds are directed by state authorities, so when the national government decreased the amount of funding for Medicaid, which happened just prior to my visit, state governments responded by reassessing how the money would be distributed. Disempowered groups who depend most on these government funds seem also to be those most dramatically affected by periodic redistribution.  Although, the crises in care for the aging are a national concern, the system does not have any protocols at the national level to insure that at least some portion of the funding is targeted for specific needs.  In this regard, the situation in Japan is more streamlined.  Funding is targeted for specific purposes and there is a system for distributing funds differentially based upon need. 


Nevertheless, funding will never be sufficient that there will be "money left over" for the arts and expressive arts therapies.  Should the facility buy a new van, or spend the money on an arts program?  And by extension, there are endless tiers of tradeoffs where building and equipment will be valued over human resources.  It was not unusual in interviews to hear a reference to "essentials" -- food service, bedding, building maintenance, nursing staff. Less essential things had to come from what was left over in the budget or else by volunteer services.  In one striking story, a music therapist lost a part-time job at one nursing home because "they bought a player piano, so they decided that they did not need a therapist any more." 


The assumption that some expenditures are basic is a pretense-- all expenditures are prioritized by an underlying value system.  These underlying values have to be reexamined before a genuine commitment to reform can take place.  This was brought home to me during an interview with one of the representatives of the Alzheimer's Association in Eastern Tennessee.  The Alzheimer's Association had sponsored a symposium on Snoezelen therapy the year before my visitation.  Snoezelen therapy involves creating a darkened multisensory room where lighting, aroma, images, music, tactile stimulation and relaxation are employed.  More about this technique will be mentioned later in this report, but for the present it will be enough to say that there are reasons to believe that Snoezelen rooms may be helpful to both residents and to staff. Despite the symposium the year before, I was unable to find any facility or program that had created a Snoezelen room or was planning to look into making one.  When I asked the Alzheimer's Association representative why there had been no reaction this technique, his first response was that there was a general resistance to change in that part of the country.  I responded by saying that directors claimed that they did not have enough money to create these rooms or to hire arts therapists.  There was a long sigh, and he said, "If they really wanted to do it they would find the money.  The problem is a lack of commitment."


I asked a simple question at every interview-- "if outside funding were available, or if funding was not a problem, would you make use of professionally trained arts therapists in your program?"  The universal answer was an immediate, unhesitating, yes.  In many cases the person being interviewed had just explained why trained arts therapists were not being used.  Clearly funding is a large part of the problem, but that is not the complete explanation.  There is reason to believe that a lack of funding is not the causal factor; rather it is ignorance and a lack of will to pursue reform. 


One might expect that insensitive administrators were to blame.  I did not find any insensitive administrators.  I found that directors of programs of all kinds were very welcoming and deeply committed to giving the best care possible.  Directors and administrative staff are friendly and actively welcome visitation and discussion.  They are proud of their work and generally knowledgeable about their field.  Many facilities are very conscious of their residents' habitat.  There were activities, planned times involving families and other visitors.  There were days for pet visits.  Rooms were decorated and the halls did not look like a hospital.  Gardens could be seen.  Many facilities are designed for free, but safe, movement of residents from indoors to outdoors.  Yet, when you visit these places, they seem empty.  There are many residents, but they are all in the dining room, or in an activity of some kind.  Activities seemed to be for groups, not individuals. Occasionally, a resident would appear that was not involved in a group activity and the director and staff would greet the resident by name. A brief visit to these newer facilities gave the impression that the quality of life for residents is better in these facilities. A great deal of thought and planning went into these buildings.  Newer buildings seemed to have more light, both natural and artificial.  Sections of these facilities were decorated thematically to increase the sense of orientation inside the building.  Private and shared spaces were planned.  Areas for visiting and large activities were well conceived. 


Of course, these are the very nicest of facilities.  There are places that have obvious problems, all of which were accurately portrayed by William Thomas and numerous other writers: hospital-like wards, residents treated like patients, or even worse like prisoners.  Yet, even at the nicest facilities, something seemed missing.  One thing that was missing was interaction. Residents would interact with the staff, but often I observed residents not interacting with each other. There was a need for more people from the outside. Residents in homes and participants in day care needed more choices and more opportunities for interaction.  The commitment problem was not that there were no activities or opportunities, but that there was too little of these things and too few people doing them.  Care facilities are a small population.  In a short time all of the faces become all too familiar, even with the constant turnover in staff. 


I saw empty walk ways and empty gardens.  I saw exercise rooms and special baths that were largely unused.  The better facilities had resources that seemed to be underutilized.  Why?  Was it over medication?  Was it that residents simply preferred to not go to make use of these resources?  If so, why?  Or was it that there was a generalized depression that had set in?  How could the use of arts therapies address these problems? Why weren't arts therapies being used in these locations? These are the questions that I hope to address in the following sections.


Visitations in Tennessee

One of the most memorable programs I had the pleasure of visiting was the Keystone Adult Day Program in Oak Ridge, Tennessee.  This program is a non-profit organization. The program was initiated 15 years ago by a remarkably committed individual, Jill Baker, who continues to be the director.  Finding this program proved somewhat difficult.  I wondered around trying to find the address, which seemed to be somewhere in the grass yard of a large church. As it turned out, the Adult Day Program was housed in the basement of that church.  The First Methodist Church donates rooms for the program. Once inside the building, one has to negotiate a series of corridors to find the rooms used by the program.  The several rooms used by the program appeared to be used on Sundays by the church.  Jill and her staff have an open office set off of the main corridor. 


One of the church charities is committed to the Keystone Adult Day Program, which provides only limited support.  There is almost no state or federal support available for adult day programs in the United States.  Medicare, Medicaid and most private insurance will not cover the cost of participation in the adult day program.  In Tennessee there was an attempt to allow Medicaid funding for adult care, but the state legislature chose not to support it.  Only persons with personal resources can afford this service. Keystone offers a sliding scale, based on the financial situation of each person and shortfalls are made up through fund raising activities.  Participants range in age between 45 and late nineties, although on my visit I saw only older participants.  Eighty percent of the participants can be categorized as have stage one Alzheimer's disease.


I was originally attracted to the Keystone program because it included music therapy and art activities.  Keystone also has pet visits, visits from children in the nearby day care center and an exercise program.  The avowed purpose of Keystone is to "keep people out of nursing homes longer, to help them continue to live with their spouses or their children."(Senior Living, 2003).  Jill Baker is very supportive of expressive arts therapies, and is actively trying to get other care facilities in the area to add music therapy to their offering.  She believes that music therapy may be of special value to persons with dementia.   I was allowed to observe one of the music therapy sessions, which was conducted by a very good therapist named Darcy Schrider.  Ms. Schrider's session on that day was oriented toward memories, in this session the focus was on songs about states and places.  Residents were given a map of the United States and were asked to think of state songs, or songs about places. Ms. Schrider drew out responses from the participants and then played a flute to accompany the songs.  Prior to the session, the participants were sitting quietly in the room, seated in a circle. The only talking occurred when a staff member initiated a conversation.  A few participants were clearly sleepy, as the session started in the late afternoon, while others seemed a little agitated.  In the beginning few participants took part or even reacted.  Soon, however, everyone in the room became more active and eventually everyone was participating by the end of the session.  Bodies that had been stiff in chairs began to move rhythmically and movement increased as the session progressed.  Singing got louder.  Faces were more attentive.  Suddenly, one participant who seemed very distracted began to talk about a memory that had come to her from the previous song.  The session ended with the usual "goodbye song" that ended every session.  Later, a staff member confirmed that spontaneous outbursts about provoked memories was a fairly commonplace occurrence in these sessions.  The assistant director reported that after sessions, and sometimes during sessions, participants with Alzheimer's Disease often wanted to talk about memories.


Ms. Schrider has been conducting these sessions at Keystone Adult Day Program for five years.  She is a graduate of the Music Therapy program at Tennessee Technical University.  She has wide ranging experience with Music therapy, including work in hospitals and prisons.  When I asked if she could give an illustrative account of a clear result of music therapy with a client, she mentioned the following story.  At a hospital she was working at there was a cancer patient who would not eat and was very depressed.  The situation was that unless the patient began eating again the hospital would be unable to let this patient return home to his family.  The hospital staff had tried everything to get this patient to eat, all in failure.  They asked Ms. Schrider to try working with him.  She too, found the patient very depressed and resistive.  Then she thought of a challenge: if he ate two bites of food, then she would play him a song.  This worked.  Once the patient began eating again, the eating became regular and eventually the patient left the hospital.


Despite her effectiveness and her qualifications, Ms. Schrider's work is part-time and spread out over a large area.  One of her stories was the one I mentioned in the General Perspective section of this report.  Ms. Schrider had taken maternity leave and when she began to start work again she found that she had lost a large number of her clients.  One of those clients informed her that they had a player piano and did not need a music therapist.


Clearly, the director of Keystone Adult Day Program understood the value of Ms Schrider's work, as did the staff in that program.  I happen to have interviewed the director who cancelled the contract with Ms Schrider because they had acquired a piano.  This was a very caring person who had moved up from beginning as a volunteer in her facility.  It was apparent to me that although well intentioned, this director was not well informed about expressive arts therapies or other alternatives. As I continued my interview with Ms Schrider, I was saddened to learn that the Music Therapy training programs throughout the state of Tennessee had been terminated by the state legislature, for financial reasons.  When I arrived in Denver, Colorado I was shocked to learn that the state legislature there had withdrawn Medicaid support for medical services for immigrants and made cuts to programs which serviced other unempowered groups.  Such was the atmosphere in those parts of the United States that medical and care support for less empowered segments of the population were the first to be eliminated. 


In a later interview with the Keystone director Jill Baker, she impressed upon me the dangers of ill-informed persons in authority within the health and wellness systems. Keystone is without question a model program, both in the sense that it was created to demonstrate the possibilities of adult day services and as an example of what a well informed, well managed program can do.  Even in a small town like Oak Ridge, there is a significant demand for adult day services.  Keystone has a waiting list people who want to participate in the program.  Keystone has outgrown the space it currently uses.  However, when Jill Baker contacted her insurance carrier regarding insurance for a large program, not only was the cost prohibitive, the insurance company actually threatened to withdraw insurance support for the Keystone program.  Apparently, the insurance company had forgotten about the Keystone program, so Ms. Baker's inquiry set in motion a reevaluation of the risk to the company of covering an adult day program.  Fortunately, Jill Baker was able to retain insurance coverage, but in the process she learned just how ill-informed the insurance administrators were.  Their greatest concerns where with wandering patients and possible patient injury, the worries most often associated with hospitals and long-term care facilities.  Ms. Baker had to inform them that wandering, which is associated with stage two Alzheimer's disease, was not an issue at her program, because persons who might wander where not allowed in the program.  The insurance company had not visited the program and seemed uninformed about the workings of adult day programs.  Their concerns were minimizing company exposure to risk and maximizing company profits.  At the present time in the Oak Ridge area there is a need for at least three more adult day programs, according to Jill Baker.  Although, there have been several attempts at starting new programs in the area, the extraordinarily high insurance costs have prevented any new programs from starting up, and has prevented this model program for expanding.


This was a tale of institution power politics.  The legislature at the national level was cutting funds, and the state legislature was forced to cut programs.  Institutional nursing homes continued to receive support, whereas programs designed to keep people out of nursing homes were prevented for receiving funds.  According to the National Adult Day Services Association (NADSA), there are over 3,500 adult day centers in the United States.  According to NADSA reporting, the average age of participants in these centers was 72, and two-thirds of these are female.  Only eleven percent of the participants lived alone, whereas fifty-five percent lived with a spouse, adult children or other adults.  Fifty percent of all participants were said to have some cognitive impairment.  In an earlier section of this report I mentioned the need for care for the caregivers.  As can be seen from the survey results, a sizable number of family caregivers receive some relief from the existence of adult day care services.  This allows family members to continue working at day-time employment and/or recover from care giving stress.  Adult day programs are a vital alternative to much more expensive long-term care.  These centers often offer therapeutic activities that not only directly benefit the participants, they serve to preserve their lifestyle and functioning.  They do not represent direct competition to long-term care facilities, rather they address a critical gap in the health and wellness system.  Yet, wealthy insurance companies with tremendous resources are positioned to prevent these services from growing.  Throughout the chain of power, there is a surprising level of ignorance that serves to block reform.  All of this to the disservice of the public they are supposed to serve.  According to a the Wall Street Journal (2002), a new study based on a census of adult day centers and the probability of disabilities in the population of older persons concluded that one third of the counties in the United States lack adequate numbers of adult day centers for the need.  As the majority of counties can be classified as rural or semi-urban, clearly the countryside is lacking sufficient adult day services, confirming what I learned in Oak Ridge.


It was difficult for me to assess how much impact Keystone had on elderly care in the area.  I noticed in interviews that there was communication between the various facilities and that everyone seemed to know about the programs in the area.  One facility that I visited was a very well designed combination of retirement center on one side and secure nursing home for dementia on the other side.  Here residents were encouraged to keep small dogs, although I only saw one example, and there were pet visitations like Keystone.  In both cases the pet therapy was only one day per week.  I was very surprised to enter the lobby to find a group of residents sitting in front of a fireplace.  The management had really made an effort to make an inviting environment.  Each window, and there were many, had views of courtyards and the surrounding country.  No one seemed to be in the offices adjacent to the lobby, so patiently waited for a few minutes.  Suddenly a nurse barged into the room snapping orders at another staff person.  When she saw me, she asked me what I wanted, in a barely controlled voice.   Having heard that I wanted to meet the director, the nurse told me to be patient or come back the next day.  The facility looked great, but at least one nurse was exactly what I was not looking for. I did come back the next day and met with the director and the program director.  I was pleased to discover that they were much more pleasant then the nurse I had met the day before.  I did observe a brief musical performance, by volunteers who visit from time to time.  Ten residents listened to a fairly good baritone sing old songs with his wife accompanying on the piano.  The residents clearly enjoyed the performances, which lasted around 45 minutes.  I learned later that performances of this kind were strictly volunteer and occurred about once a month. There was no other musical offering.  Physical therapy and any expressive therapy would be out-sourced and contracted by the resident or the resident's family.  There was some handicraft work done as recreation, and this was provided through volunteers.  Organized activities were mostly games and old movies.  The goals of the program director were mostly to promote socialization among the residents.  She noted to me that male residents tended to participate less than did the female residents. The program director had no background in the arts and was not aware of therapeutic uses.  The facility did have an exercise room and the program director as well as another facilitator did conduct exercise classes.  I was given the impression that they had some success with this exercise program, but that they had to overcome the fear of getting hurt that many female residents had.  There was a very well design bath with Jacuzzi jets, but I was told that residents did not use it.


Corridors were wide and carpeted.  Decoration of the building was very pleasant, but there were few works of art on the walls.  Often a long corridor would have no art or pictures.  The interspersed courtyards provided a good deal of sunlight and artificial lighting was adequate.  In the retirement section of the building, there were laundry facilities and individual cooking rooms, but most residents ate in the dining room. The locked section of the building was primarily for residents who were experiencing dementia and needed increased health care, in all other respects is was a mirror image of the retirement side.  In this facility, however, the courtyards were locked in the nursing care sections.  A member of the nursing staff would unlock the courtyard door when they felt a resident "was safe to go out." 


As I noted in the General Perspective section, in many facilities the buildings seemed empty. Of course, visitors are usually guided to unused areas so as not to disturb the residents.  Nevertheless, it felt as though the residents were hiding.  After the musical performance, the assembled women disappeared and I did not see them again.  There was one exception-- the woman who had a small dog.  She was clearly the most outgoing person I met.  There were bird feeders and interesting flora in the courtyards, and there were pleasant walkways and benches.  The rains had subsided that day, but perhaps the season was such that no residents went outside.  Except for the woman with the dog, who appeared in the parking lot.  There was no fire in the fireplace.  It was just a regular weekday.  Apparently, the day before was a major family visitation day.


Of the long-term care facilities I visited in this area, the one I just described was the nicest, at least physically.  It was also the newest.   This retirement home and a number of other facilities in the region were owned by a corporation in Florida.  I visited another of their facilities that was further out of town.  This site was a long-term facility, with residents who were suffering from cognitive disability and dementia.  Although older, this facility had many of the better features on well-designed buildings.  The most obvious difference was the amount of sunlight.  This facility was in a valley, but what restricted sunlight most were small perimeter windows with no courtyards and low ceilings.  This was an established nursing home for many years.  There were some pictures on the walls and the residents were encouraged to decorate their rooms.  There were no art programs, and no expressive arts therapies.  There was a volunteer pianist who came to entertain fairly regularly, but has since stopped.  The director told me that this pianist played familiar songs and the residents clearly enjoyed listening and singing.  At the present time there is only occasional piano performances, and the director noted that residents seem less response. The main thrust of programming at this nursing home consisted of planning special holidays and family visitation days.  I did observe the programming director giving a chair-based exercise session.


At both of these facilities, as well as others I visited, the reason for not having expressive arts therapy was lack of funding.  Although a large city is merely a thirty-minute drive away, many interviewees did not know of the Snoezelen symposium the year before.  Those that did know about it did not seem to understand how it would impact their facility.


Colorado Visitations


I came to the Denver area disappointed to have not found any Snoezelen rooms in Eastern Tennessee.  I was determined to find one and visit it.  I heard references to "quiet rooms" and "special rooms," but these did not turn out to be Snoezelen installations.  Helpful persons who thought they had heard of an installation sent me on fruitless searches.  I eventually found one site in southern Colorado, and I had heard of a Snoezelen room in Newton, Kansas before I left Japan.  The Newton, Kansas installation had received a national award for innovation in long-term care facilities, as well as some positive press.  However, due to the harsh and unstable weather of the great plains in winter, I was unable to travel to either of these locations, so I had to settle for a telephone interview with the woman who set up the Snoezelen room at The Friendly Acres Retirement Community in Newton, Kansas, Michelle Troyer.  Ms. Troyer, along with the executive director of the facility, wrote a proposal for a grant to create a Snoezelen.  She had encountered the idea and thought it might be worth investigating.  Based on her reading, they created an inexpensive multi-stimulation room with materials purchased at a local building supply store. This trail version cost them around $500.  This experiment convinced them to pursue the matter further, so they applied for funding from a church affiliated with their facility.  They were awarded a grant that covered the costs of creating the Snoezelen room and for training of several staff members.  Their training consisted of traveling to Canada and visiting sites that had installations, asking questions and collecting advice.  Materials for the actual room were purchased from a supplier familiar with Snoezelen therapy and items were selected for inclusion from a catalogue.  The final version of the Snoezelen room ended up somewhere between $25,000 to $30,000 US dollars.


Ms. Troyer was very helpful and enthusiastic.  I learned from her that they had originally thought that residents who were less affected by dementia would benefit most from the Snoezelen experience.  Instead, they found that with their residents who were in good health and less affected did not particularly enjoy the room.  On the other hand, those residents who were more affected seemed to respond better to the room. In general, residents experienced elevated moods and relaxation from the room.  Care taking staff also make use of the room and it helps to relieve tension and migraine headaches.  Interestingly, staff retention has increased by 10% and many staff now want to become trained in how to use the room with residents.  An additional unanticipated benefit was the interest generated by the creation of the room.  The nursing home has received many inquiries about Snoezelen therapy and there has been an increase in applications for residents.


When asked if there were any measurable outcomes from the Snoezelen room, Ms. Troyer provided me with two stories illustrating how the room has helped.  The first story involved a man in his 80s.this man was constantly tense and had to be heavily medicated.  He had begun falling and the falling episodes were increasing, which was a very bad sign.  Ms Troyer and the director took this man into the Snoezelen room. They seated him and began to give him massage; the director massaged his neck and shoulders, while Ms. Troyer massaged his hands and arms.  Things were going well, when suddenly the man went completely limp.  This shocked the two women who were afraid that the man had suddenly died.  As they examined the man, they realized that he had merely fallen asleep. They let him sleep for a long period of time and after he awoke the moved him up on to the floor where he was living.  Again, he fell asleep and slept for a several hours.  Once he awoke he seemed to be less agitated.  Once or twice a week he would visit the Snoezelen room. He did not fall anymore, and because he was more relaxed his medications were decreased and then stopped.  He seemed much more adjusted and continued in good health until his death sometime later.


A second illustrative story involved a woman in her 70s who was nonverbal and was experiencing eating problems. Before using the Snoezelen room, this woman had stopped feeding herself.  When she entered the Snoezelen room she began playing with the light columns and became very excited.  During the session in the room, she deeply enjoyed her self.  After this Snoezelen experience the woman started to feed herself again and continued to do so.


Here was a concrete example of how a facility could address more than one of its problems, and at the same time improve some aspect of the care given. It took knowledge and commitment.  A staff member had an idea, learned more about it, and took action. In this case the director and the supporting agency above were supportive. Instead of waiting for money to come in, or bemoaning the lack of funds, these people sought out a grant and applied for it.  On the other hand, this facility does not have any expressive arts therapists, and when I asked why I was told that they did not have enough money.


The money problem was solved in a very different way through an innovative program called Memories in the Making, the brainchild of Jean Boylan at the Colorado Alzheimer's Association.  Ms. Boylan believed in the value of art therapy for persons with Alzheimer's disease and learned about a program begun in 1993 by an artist named Sally Jenny whose mother had Alzheimer's disease.   Jean Boylan realized the value of Ms. Jenny's approach, but  also realized that it needed an effective way to implement it as a program.  Ms. Boylan's idea was to train volunteers to be facilitators of the Memories in the Making.  These volunteers would then visit day care and resident programs and work with a staff member during sessions.  The technique was very specific:  watercolors were used, sessions were once a week in the morning, and the art created was carefully archived.  Keeping the art produced had two useful outcomes. The artists could look back on their work, but more importantly families and staff could reflect on the art and this often revealed helpful information about the client.  Ms. Boylan gave me many instances where something in a watercolor led to a forgotten connection in the family. The second reason for keeping the art was that the art produced was often very interesting, so Ms. Boylan organized an annual art auction of these watercolors with the revenues being used to support the program.  The program started 8 years ago and has grown phenomenally.  There are now Memories in the Making programs in 30 states.  Ms Boylan is a very energetic and enthusiastic person, who obviously loves the art produced.  She met me on her day off so that I could conduct the interview.  In her office she displayed the truly remarkable watercolors that have been produced.  I was fortunate to visit just prior to the annual art auction, so I could see examples of the kind of work that was included in the auctions.  Ms. Boylan pointed out an interesting thing about Alzheimer's art-- often with expressive art therapy there are works that are angry, but with Alzheimer patients there was no angry art. 


Ms. Boylan arranged for me to observe a session at a adult day center in Arvada, Colorado, just outside of Denver.   The program I observed was atypical. This particular program had a new director who had not yet completed the training in Memories in the Making.  Also, there was no volunteer facilitator at that time, so the director of this small day center was doing the sessions on her own.  It was immediately clear to my why Jean Boylan had developed such a precise method.  The lack of an outside facilitator meant that this was just one more in a string of activities on that day.  I could see how a volunteer trained in this method would bring a refreshing energy to the session, whereas without another person helping the participants were sometimes adrift.  Also, the director had to leave the group from time to time and some participants would stop working at those times.  The training component was also important.  I could observe that the director in this case was unsure of what to do, and this lack of clarity was communicated to the participants.  Nevertheless, even with these problems the group filled the hour with painting. 


It was indeed fortunate that I could see not only the success work produced, but that I had the opportunity to see why Ms. Boylan had developed the program the way it is formulated today.  The outside facilitator with training in the program was an excellent motivation technique and added to the fun of these sessions.  At the same time I could see the weak link in the program-- dependence on volunteers.  The program generated its own revenues through the art auctions, which was Ms. Boylan's way of solving the lack of funds for art in these settings.  The program depended on volunteers because art therapists were thought to be too expensive.  On the other hand, using trained volunteers was bringing in a new face to these centers.  This was an innovative way of getting more people involved and of stretch resources.  The more I thought about it, the more I realized that Memories in the Making was a brilliant solution, yet at the same time it was not a substitute for having qualified art therapists.  This was a wonderful program and more programs of this kind are needed.  I came away from this thinking that this was really something that should exist along side of art therapy programs for Alzheimer's and dementia, rather than as a substitute for it.  Nevertheless, here was an example of how useful and important active art participation could be for the aging.  Here, too, was an example of what could be accomplished when someone was committed and innovative.


During my stay in Denver I interviewed a number of therapists who were using expressive arts to help people.  I interviewed a therapist who was using movement for clients with extreme traumatic experiences.  I interviewed an art therapist working with brain damage that was so effective that she was hired as permanent staff.  I interviewed a music therapist who was the only person that could successfully work with certain clients.  I interviewed psychotherapists who used art with children.  I interviewed a movement specialist working with adult muscular dystrophy, work that was inspired by a gerontologist who emphasized movement therapy for the aging.  What I was unable to do was interview anyone who was working as a therapist in a long-term care facility or an adult day center. 


Perhaps the most enlightening interview I had was with Megan Carnarius, the executive director of Balfour-Cherrywood Village in Louisville, Colorado.  Lousisville is a small town off the highway that runs between Denver and Boulder.  Ms. Carnnerius has consulted and designed numerous facilities, including Snoezelen rooms.  She teaches gerontology at the Naropa Institute in Boulder, Colorado.  Of the many long-term care facilities I saw, Balfour-Cherrywood Village was the best physical plant and very likely the most sensitively run.  There are four different decoration motifs for each wing of the residence.  The entry to the facility is faux village center, where residents can meet, have their hair done, do other activities.  This entry visually marks the transition between the inside residences and the outside world.  Art was displayed on corridor walls, large courtyards with walkways added light and natural views throughout the building.  All in all, it is a very nice facility.  Ms. Carnarius had trained in Europe in therapeutic massage and in aromatherapy.  She is very knowledgeable of the issues and trends in long-term care and is very committed.  There is one room devoted to massage at Balfour-Cherrywood Village, and it is available to both residents and their families.  Music from the early twentieth century is played in the background.  Balfour-Cherrywood Village does not have expressive arts therapists.  It does have a very good activities staff which I had the pleasure of observing, whose techniques were very similar to some movement and recreational therapy techniques.  


From Ms. Carnarius I learned a great deal about the problems encountered when creating facilities.  She conveyed how disheartening it was to start designs and programs only to find that they were not carried through.  As I had often heard before, constraints of budget and staffing were the greatest impediments to reform. Here was someone who had worked and fought, an entire career in reforming long-term care facilities.  I came away from her interview with a deep respect for her knowledge and perseverance.  I also came away with a challenging thought: if someone who is this well informed and this qualified has had a difficult time getting reforms in place, how difficult it must be to get a much more demanding change of having trained expressive arts therapists into these settings.  On the other hand, Ms. Carnarius is herself a therapist who is now directing a facility.  This was the only long-term care facility I visited that had former therapist at management level. Was it really surprising that the most impressive facility I encountered was being run by person with a therapeutic background?


Awareness in Japan

In the past year I also had the pleasure of attending two very informative events that should be mentioned here: a three-day workshop on expressive arts therapy with Natalie Rogers and the Forum on Caring for the Caregiver Japan-US Project. 


The workshop on expressive arts therapy was a revelation to me.  Educators, social workers and psychologists in Japan had repeatedly informed me that there is very little expressive arts therapy being conducted in Japan.  I was very surprised when I learned that my application to attend the forum was turned down because the event was already full.  I got on the waiting list and was fortunate enough to eventually attend the workshop.

There I met over 70 Japanese therapists, all of whom live and work in large urban areas.  I met a psychiatric nurse who was using expressive therapy in her work, I met psychotherapists who were interested in learning more about expressive arts, and many therapists whose practice was exclusively expressive arts therapy. 


The expressive arts therapy approach, often referred to at expressive therapy, makes use of multiple art forms, where as music therapy, dance therapy, art therapy, drama therapy, and some other therapies are oriented toward specialization in a particular art form.  However, it should be said that many therapists make use of more than one art form in their work.  Natalie Rogers' approach is based on the belief that one art form can be used to motivate deeper psychological reflection in a subsequent used of another art form.  For example, a dance could motivate deeper work on a subsequent painting.  This was certainly evident during the workshop, for I have not previously seen so many people working at such high levels of expression before.


One therapist I interviewed was working in an Alzheimer's treatment center in the Tokyo area in which various arts therapies were being used.  At this center, the arts therapies were presented in distinct sessions; that is, there was a dance therapy session, an art therapy session, but the arts were not combined.  When asked how effective these therapies where, my informant indicated that results were rather mixed.  With stage 2 Alzheimer's disease it was apparently very difficult to detect any improvement, although I was told that the participants did seem to enjoy the sessions.


Another therapist I met and interviewed had a group practice that included elderly clients.  This therapist felt that the elderly clients benefited as much from the expressive therapy as did the other clients in her practice.  In my discussions with other therapists, the idea of using arts therapies with the elderly was generally perceived as an excellent idea, but these therapists worked with different populations and did not know of any therapists who were working in care for the elderly.  When asked if there was much use of arts therapies outside of large cities in Japan, everyone said that they did not know of any instances.


I have never really doubted whether arts therapies would be helpful in the context of Japanese culture, but I have wondered if interaction techniques might need to be altered from western approaches in order to be most effective.  This workshop eliminated this concern.  All of the participants participated enthusiastically, although their background in therapy may have made them more receptive to active participation.  The energy level of the workshop, throughout the three days of all day and evening sessions, was very high.  The artwork produced was extraordinarily creative.  Music and dance were performed with abandon.  Without a doubt, these techniques seem to work very well with nearly everyone.


Certainly, one should be cautious about generalizing from a small sample, but I did come away from this experience realizing that there is indeed an active interest in arts therapies with Japan and that these therapies would be helpful in the Japanese cultural context.  I was not surprised that I was the only person not from a large urban area at the workshop.


The Forum on Caring for the Caregiver Japan-US Project was also a revelation to me.  This form was the result of committed efforts by Yasuo Harima and his associates to raise awareness of the need for caregiver support.  The forum was one component in a series of exchanges between interested parties in Japan and the United States.  The forum was held in three locations in Japan: Miyazaki, Hiroshima and in Yamagata.  I attended the Miyazaki forum.  I had anticipated that I would be encountering speakers whose backgrounds were in nursing or program supervision.  Instead, I found that several of the speakers had arts therapy backgrounds and much that was discussed as programs for caregivers made use of the arts and artists. 


Briefly, when a family member becomes seriously ill, the focus of care is on that individual, but the impact on family and professional caregivers is largely ignored.  As mentioned in an earlier section, family members provide most care.  These family members very often do not have available resources to compensate for the additional burdens of care giving.  A spouse of an older person experiencing cognitive problems can easily be overwhelmed by the work and responsibility involved with care for such an individual.  When a family member is diagnosed with cancer or other serious illnesses, the lives of the entire family change. This situation can set in motion a cycle of undesirable interactions that inflict further damage to the family and the illness-affected family member.  How can family members provide the kind of emotional support needed when they themselves are experiencing emotional stress and physical exhaustion?  At these times, financial resources become strained, tempers flare, and the needs of all members of the family are not met.   This negative cycle can have devastating effects on the family, and may be nearly impossible to reverse without outside help.  As the family suffers, so too does the illness-affected person-- the very person who needs support for survival. Professional care workers can be faced with a similar cycle and unless they can find some source of renewal they may quit or transfer to other work.  As in the case of family members, the emotional state of the professional care workers also can impact the patients they serve.


The forum sought to raise public awareness of the need for care for the care givers and to introduce ways of dealing with this problem.  The presenters gave examples of how performing and visual artists can be used to refresh both patients and care givers.  Most of the presentations were about the arts in active therapies.  One presentation was about a center dedicated to renewal workshops for professional caregivers and to promoting and researching arts programs for healthcare.  This center was created by two arts therapists who had worked in healthcare settings.  Another particularly memorable presentation was about an inner-city intervention program that was based on the arts.  This center provides a gallery, training and special programs for families and schools. One of the services offered is performing musicians who can visit homes where a family member is seriously ill. 


One presentation had particular significance to the present topic.  Georgetown University Medical Center has a special arts program in the Lombardi Cancer Center.  Performing artists and visual arts are brought into the center and their works are displayed and performances are given.  The director of this program is Nancy Pierce Morgan, who also conducts a writing therapy component at the Center.  I would like to dwell on Ms. Morgan's presentation here because she not only testifies to the importance of using expressive arts in terms of the family members, but also because she gave one of the most cogent explanations of why the arts-related therapies are more effective than more traditional spoken language-based therapies.  Ms. Morgan's program was called transformative language arts, which involves guided writing to cope with stress and feelings associated with serious illness.  Morgan maintained that the stress involved for both the patient with cancer and the family/caretakers was tremendous, yet it is precisely at times when people most need to express themselves that language fails.  Either they can't bring themselves to communicate or it is that they simply cannot put their feelings into words.  Morgan and her staff employ art-related activities that are then followed by a writing activity.  She has found that the activities with arts help to soothe patients and caregivers so that when the writing activity begins these individuals are able to express themselves poignantly in writing.  It was clear from her presentation that before the introduction of art-related activities these patients and their caregivers felt tense, anxious, afraid and distressed.  It was only after the initial nonverbal self-expression took place that verbal expression came, and, at that, it came in a creative writing context.  Here too, we see Natalie Rogers' thesis in action: art activities of one kind motivated deeper expression in another art form.


Some speakers did touch on issues involving care for the elderly, but mostly in terms of the difficulties that care workers for the elderly face.  As noted previously, arts-related therapies are becoming more valued in the healthcare system.  This forum showcased several impressive programs of this type.  But there were no presentations about using arts-related therapies with the elderly or for care givers of the elderly.  All of these wonderful programs showcased were in large cities.  The forum did provide me an opportunity to talk with these presenters, and all agreed that arts-related therapies would serve the elderly and their care givers very well. 




There are examples of how art-related therapies have helped other populations in medical settings, yet there is very little use of these therapies with the elderly.  There is every reason to believe that such therapies would greatly benefit older persons and their families, but there is a lack of awareness and commitment that has prevented these therapies from being employed.  I did find examples of the good that arts therapists can do for aging needs, and I found examples of how very serious, committed people are trying to use the arts with the aging. These examples, however, are having little impact on a huge system that needs reform.  Interestingly, I did find examples that were in the countryside.  Clearly, better care programs and interventions can take place in the countryside on a much wider scale than we are seeing today.  This in turn suggests that it is not the financial and insurance barriers that keep the situation as it is, rather it is ignorance and a lack of commitment.


Let me suggest some simple ways of decreasing the ignorance and getting more arts-related therapists working in services for the elderly.  An immediate step in the right direction would be for some therapists to get qualifications for working with the elderly and for some care workers to become knowledgeable about expressive arts therapies.  It would also help if training in arts-related therapies included working with aging populations.  The education of professionals involved in care for the aging, such as social workers, nurses, gerontologists, and administrators, should include more about how the arts can be used in healthcare.  It is possible that care centers could apply for grants which could employ arts therapists in these settings.  There are exemplary programs of the arts with other needy groups in Japan at the present time. We need exemplary care programs for the elderly in Japan that make use of arts therapists to demonstrate the viability of this kind of service. 





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