THE ROLE OF THE ARTS IN IMPROVING THE QUALITY OF LIFE
RESIDENTS OF JAPANESE ELDER CARE FACILITIES
By Bruce Darling
The problem of how to improve the quality of life for residents of Japanese elder healthcare facilities（１） calls for urgent responses, particularly in the national context of a rapidly aging society with an elderly population of increasingly discerning consumers with far greater economic and political power than past generations.
This discussion focuses on the role the arts can play in improving the personal lives of the residents of elder care facilities, beautifying the environment where these people live, and opening up ties between the elder care facilities and their residents with the surrounding community. Undoubtedly, many residents of these facilities throughout Japan would benefit from such improvements. Giving residents happiness and satisfaction, brightening up their surroundings, enlarging their social network--certainly if the arts can help accomplish any one of these, the quality of life of those concerned would be improved. First let us examine what we mean by quality of life.
"Quality of Life (QOL) is a multidimensional concept encompassing physical well-being, social concerns, psychological well-being and spiritual well-being." （2） Typically QOL concerns one's personal happiness or satisfaction as well as the living conditions of one's environment. Viewed with respect to the elderly, however, QOL may well depend on leaving stereotypes behind while becoming increasingly aware of how to age successfully, productively, creatively.
As the Quality of Life Newletter points out, we do not stop growing at a certain age, we do not stop learning at a certain age. To establish what QOL means for the elderly, we must re-examine many of our assumptions about aging; we must reinvent what it means to age. （3）
Today, as a result of recent improvements in health care and “self-care”(improved diet, exercise, etc.), our older citizens serve as voluntary policemen in their sixties, sky dive, travel the globe, take a wide variety of academic and art courses, including drawing nudes, in their seventy's, lift weights, start new corporations and write books in their eighty's. The list is seemingly endless and limited only by the imagination and ‘lust for life’ of our elders. Senior citizens do not merely go home and rest on their laurels anymore. These days many of them are pursuing life with the gusto of people much younger. Society as a whole and health and welfare policy- makers in particular must be made aware of the new character and potential of the aging society, and its implications. This applies worldwide, but is particularly important with regard to the treatment of the elderly in Japan, where regulatory categories are often so rigid, where procedures once established are so difficult to change, where outdated laws continue to be followed. Who and what the elderly are needs to be re-examined; new definitions must be put forth, new realities must be recognized, fresh approaches must be promoted. Otherwise, Japanese society will simply waste the lives of its elder citizens, and will incur the needless loss of the potential contributions of countless experienced, talented, and wise-with-years elder citizens. Of course Japanese scholars and commentators concerned with the social welfare of the ever-growing numbers of Japanese elderly citizens have not failed to notice this and urge reforms.
Regrettably, a gap seems to exist between the stated awareness of needed remedies by commentators and the implementation of such remedies by administrators. (The barriers are numerous but here we can mention three--budgetary considerations, medical prerogatives and turf battles, legislative delays.) Visits I have made to a number of Japanese elder care facilities, both old and new, have revealed that traditional approaches die hard. And though certainly some progress is being made, it is often only after a steadfast struggle. Japanese must stop treating old age homes as hospital-like institutions where the aged population who can no longer completely care for themselves are treated as sick patients and where daily activities are conducted as if for kindergarteners. The elderly must not be merely parked in these institutional settings, forced to endure their misery, until they die. They deserve much better than this- a far higher “Quality of Life.” And so do we.
To encourage still greater progress in this respect, we should give close examination to the current role of the arts in maximizing the quality of life for residents of care facilities in, for example, North America and Europe where they have been dealing with these problems for decades. As an art historian investigating a new field of study, my own introduction to the role that the arts can play in care facilities came from a report I read about a recent PBS special on a nursing home that was also officially recognized by the American Association of Museums as an art museum and which has an extensive studio program ― The Hebrew Home for the Aged at Riverdale.（4）
The video and other information I received from the home only increased my interest in the role that the arts played in the lives of the elderly. The Hebrew Home also has an extensive homepage that includes "Art at the Home, " a section with text, still pictures, video and audio, specifically treating the Home’s approach to art and the aged, "The Art of Caring." The following is a quote from this page:
The Art of Caring is the Hebrew Home"s assurance that total attention paid to the well-being of each individual receiving care - recognizing that quality care must also maximize each person's potential for fulfillment. Quality of life - a key component of this commitment - is achieved through intellectual, social, recreational and artistic pursuits with expertise, creativity and compassion at the heart of all that we do. （5）
To this end, the Hebrew Home's extensive art collection, the broad program in creative arts classes, exhibitions, lectures, happenings and receptions are all aimed to encourage active involvement by residents, staff and visitors. The installation of the art objects, both indoors and out, carefully considers the needs and feelings of the residents while enhancing the beauty of the buildings and grounds:
A key component (of the Home's total commitment to providing the maximum quality of life to its residents) is the art of caring which includes a belief that beauty in the environment lifts the spirit, creates joy, and keeps us involved in the world. Art can also elicit memories, and bridge the generations for all who live, work and visit the Hebrew Home.（6）
Susan Perlstein, director of Elders Share the Arts (ESTA), "a community-based arts organization (located in Brooklyn, New York) serving elders and their communities in and out of institutions," affirms the validity of the Hebrew Home's approach to the arts and its elderly residents. In her article "Really Caring: Why a Comprehensive Healthcare System Includes the Arts," （7） she criticizes the tendency in U.S. adult healthcare institutions (mentioning "senior centers for well elders, adult day healthcare centers for those still mobile, nursing homes for the frail, hospitals and hospices for the sick and dying") of treating aging as a disease rather than a natural process. This means that emphasis is often given to the medical rather than the social approach, to the disease rather than the individual. Perlstein further insists that a system that really cares for people should sustain their well-being from cradle to grave in their communities, and should provide a support system that attends to both physical and emotional needs. Furthermore, because arts programs can reach into the many facets of a person's being, the arts have an important role to play in such a social approach to elder care.
Perlstein discusses several ESTA programs that bring people together, celebrate life, and give elders a sense of identity and self-worth. She mentions specifically a program in Manhattan's East Harlem (El Barrio) and at a long-term care facility, St. Alban's V.A. Hospital in Queens. These programs are collaborations with people working together on murals, music, dance, and writing projects. In addition, these cross-generational exchanges between young and old celebrate community relationships and community identity. For example, Legacy Works "aims at creating artworks by integrating the stories from an elder's life. An elder works with a trained member of ESTA's staff to transform his or her memories into Life Books, collages and taped stories to pass on to relatives and friends." These could include a portrait of the elder drawn by an artist as well as images and works chosen by the elder for their special meaning. Even frail elders can participate and gain from such activities. ESTA also has a successful program that trains teenagers to interview elders and help them to share their personal histories, help them to create a Life Book or some other project. The elders now can be of real use to their community, the teenagers can learn about their history and get advice for their own lives.
Nursing homes in North America and Europe commonly provide therapeutic intervention for residents with dementia, depression, agitation, Parkinson's, Alzheimer's. Studies have shown that that the introduction of recreational items as diversionary interventions can provide stimulation and opportunities for interaction with others. （8） This is where the arts play a key role. Furthermore, the arts also function as part of elder education programs, therapeutic recreation programs, self-esteem activities. And although few Japanese elder care facilities have formal hospice programs, here, too, programs in music and art can provide a service as indispensable as the nursing and dietary. Such is the case with Connecticut Hospice Program, discussed by Andrea Sherman, where the Hospice arts program is built into the health care system as law.
"The philosophy behind the program is based on the belief that dying is as natural an event as being born. The arts are not taught in a traditional art therapy approach, but are taught from the standpoint of the arts. The product that is created is of special significance. Patients can create a product with the skills they that they have, so that the dying person can "leave something to remember me by" - a qualitative legacy."（9）
The story of octogenarian John Englehart, a victim of schizophrenia and aphasia and a resident of mental institutions since he was eleven years old, is a remarkable example of the power of art in opening up the soul. Diagnosed as retarded and heavily medicated with Thorazine, he had not spoken a word in over fifteen years before Ann Watts, a musician and nursing home volunteer, used her music and drawing to bring him out his shell. His outward journey began when Ann Watts, after first meeting him in 1986, handed him a piece of paper and a marker. He made an detailed drawing of a windmill, and even spoke the word "windmill" as well. Thereafter he produced numerous drawings and paintings. His speech also developed. John Englehart became a recognized artist who had a one-man show in Baltimore and sold some of his works. He died in 1992 at the age of 85.
Ann Watts' experience with John Englehart lead her to propose a project to Meridian Healthcare, Inc., wherein a group of Baltimore artists would "take art to places where it doesn't usually get to go", that is to nursing homes where people with Alzheimer's reside. And once again, it was not conventional art therapy with its group tasks that Watts was promoting. Her experienced group of artists were to work one-on-one with residents. The residents were to be given a freehand in choosing what kind of art they wanted to make. Improbably, her eclectic group of young, off beat artists clicked with the nursing home residents. The elderly residents began to mine their memories, forget their tiredness, overcome some of their fears. The young artists, too, gained from these encounters, opening up their minds and learning what it is to be human. One conclusion reached by the group as a whole is that too often the physical and mental capabilities of the elderly are under-estimated（10）
The above examples of the roles that the arts can play in improving the quality of life for the elderly are mostly from the United States. This is partially due to the overwhelming American content of the resources available to me for this brief survey--i.e. primarily the Internet. Nevertheless, the role of the arts is similarly recognized and appreciated all across Europe as well. Nightingale House, located in the East End of London, has an excellent arts and crafts center; testimonials speak of Swiss old age homes with their ateliers, Swedish homes with their looms, likewise for homes in France, Germany, Denmark. All share the goal of providing the highest quality of life for their elderly residents with art and creativity being given high priority as stimulant/therapeutic processes. Japan's late start in preparing to meet the needs of her aging society means that elder healthcare facilities and programs lag behind those in the West. On the other hand, the late start may enable Japan to by pass some of the earlier mistakes and misconceptions regarding the needs of the elderly population. The better elder care facilities and programs in North America and Europe have evolved in response to actual needs and practices over many decades. As such, in spite of cultural differences, Japan should closely examine such facilities and their programs in order to devise the best possible approach for her own elderly citizens, in order to provide them with the highest quality of life.
Generally speaking, this is clearly not being done today. However, we should acknowledge the few Japanese elderly care facilities that, to my knowledge, are finding significant roles for the arts to play in order to improve the quality of life of their residents. These facilities extend from the northernmost island of Hokkaido to the southernmost island of Kyushu, with others located somewhere in between. Two noteworthy examples are introduced here. The first is Asahigaoka no Ie, located in Hakodate, Hokkaido, and run by Father Philippe Gourraud. This is an elde healthcare facility that many observers, including those from the Ministry of Health and Welfare, hope that similar facilities in Japan ten years from now will be modeled after.（１1）
For Philippe Gourraud, who has been fighting for the improvement in the equality of life for Japanese elders ever since he established Asahiagoka no Ie(旭ガ家) in 1972, an elder healthcare facility should be a place of beauty, comfort, elegance; a place for one to have “the best vacation of one's life.” The site of Asahiagoka no Ie is on a mountain jutting out into the Tsugaru Strait. Gourraud has struggled to bring humanity and hominess to the typical Japanese formula for institutional old age facilities. To achieve the highest quality of life at the home, Gourrand believes that each resident should have his or her own room. At Asahigaoka no Ie, all the rooms have windows that open onto the surrounding natural scenery. Light open areas with comfortable chairs facing large fireplaces are located at the entrance and on the second floor. A restaurant and coffee shop provides another place for residents and visitors to share conversation. A powder room is set aside for women to apply their make up. The corridors are always decorated with the art of residents, staff and others; space is also set aside for special exhibitions. Monthly social dances are held in the large open atelier, where workshops and exhibits also take place. Gourraud decided, after having observed the important role art plays in the care of elderly citizens in Sweden, Switzerland, the United States, Canada, France, etc., that elder care facilities should naturally take on the role of cultural centers where regional interpersonal exchanges take place. Because residents are to be honored as individuals, they are not pushed into molds and forced into doing something they do not want to do. Residents hence have the freedom to pursue, if they are so inclined, whatever of the eighteen club activities they like--including a variety of music and arts. For example, regular and ongoing professionally taught classes are held in pottery, cloisonn_, embroidery, painting and drawing, weaving, collage, flower arranging, social dance, etc. There is also a chorus. Gourraud believes that an elder care facilities should be open to the community. Hence local senior citizens are encouraged to visit and to join residents in any of these classes, thereby providing an opportunity for increased social exchange and giving local non-resident seniors a chance to consult with the staff on any problems they might be encountering.
Of course, providing the facilities for such artistic activities costs money, and such services require trained personnel. Gourraud is able to accomplish so many of his goals because of his success in getting donations and the help offered by volunteers. In other words, Gourraud’s vision of what an elder care facility should be draws wide support because the humaneness of it strikes a cord among so many people, who then step in to help.（１2)
A second facility, Kaseda Arutenhaimu(加世田アルテンハイム), located in Kagoshima, Kyushu, and run by Atsuko Yoshii, shares an emphasis on the arts with Asahigaoka no Ie. （１3） In 1988 when Yoshii started her elder care facility, she went around looking at so-called progressive facilities only to find rooms with no views at all, old people doing nothing but lying in bed and staring at the ceiling. She could not help but think that any "progress" in these places was mostly illusionary. Yoshii wanted to make a unique home for the elderly that would be filled with paintings. In this she had the full support of her painter husband Yoshii Junji (吉井淳二). Today the Yoshii Gahaku Art Museum (吉井画伯の美術館) stands as a part of Kaseda Arutenhaimu.
When Kaseda Arutenhaimu first opened, many people came to visit. A supposedly knowledgeable director of another elder care facility told her that people with dementia don't know anything about paintings and they will probably ruin them. Another also criticized her for putting up lace curtains to brighten up the private rooms of those with severe dementia, saying that the curtains would soon be torn down. A psychiatrist, though, encouraged her by saying, "Even when old people suffer dementia, they can still feel gentleness and beauty. Please believe this as you work with these older people."
In the dining room hangs a large painting entitled "Family" depicting a mother holding a child along with the other children in her family. At one period, an elderly woman resident, who suffered slight dementia, would always sit near this painting when she ate. When asked if she liked it, pointing to the painting, she responded, "That girl in the painting resembles my daughter." This women passed away a couple years ago at the age of ninety-one. The director has given no thought to moving the painting.. You cannot tell Atsuko Yoshii that paintings mean nothing to the residents of her facility. Merely hanging paintings on the walls helps to both brighten up the home's environment and to raise the spirit of its residents.（１4）
The implementation of various arts programs in these Japanese elder care facilities highlights what can be accomplished in Japan and demonstrates the validity of such approaches across national borders and diverse cultures. Today the arts are being increasingly introduced into care programs at elder care facilities all across Japan - walls decorated with paintings or other works, music, dance and theatrical performances, arts and crafts courses and demonstrations, exhibitions. Time-worn excuses for the failure to implement art programs such as the lack of space, inadequate budgets, a dearth of personnel, and the belief that the residents are not healthy enough to benefit, etc., are shown to be just that, excuses. More to point, does it not seem to be rather dearth of imagination and a lack of resolve, along with perhaps an ulta-rigid bureaucratic mindset, that stand as barriers to implementing such innovative and life-nurturing programs.
And there is perhaps one final perspective that social planners, politicians and elder care facility directors should bear in mind. By the year 2020 Japan will be the ‘world’s oldest country’ with almost one third(31%) of the population over age 65 (as compared to an estimated 24% for Europe and 23% for the United States). These people will be very different from their counterparts today. They will be more affluent, more well-informed and internationally aware, more healthy, more consumer-conscious and demanding, more critical and selective in choosing facilities, and will possess far more economic, social and political power. In such circumstances, there will be no more room for poorly-run, staff (as opposed to client) centered, patronizing and unimaginative, uncreative institutions. The elder care facility of the future will have to compete with the best and satisfy the increasing expectations of a far more demanding clientele determined that their remaining years be spent in environments that stimulate the brain, the senses and stir the spirit to new levels of imagination and expansion. Let there be no mistake, changes are vital now to prepare for a very different future and a very different kind of elderly population.