Contributions of art therapy to promoting the health and quality of life of older adults

Abstract

Objective

to analyze the contributions of art therapy in promoting the health and quality of life of older adults.

Method

an integrative review was carried out using the health descriptors: “health promotion”, “art therapy”, “quality of life” and “aged”. Complete original articles were selected, in Portuguese, English and Spanish, and the period of publication of the articles was not defined to obtain a greater number of articles published. The search and selection of the articles included were carried out by two reviewers from November 2019 to April 2020.

Results

of the four articles selected to compose the sample, two were written in English and two in Portuguese. The articles included were published between 2007 and 2014, with two indexed in Scopus, one in the Scopus / PubMed / BVS databases and one in the CINAHL database. The expressive resources used in the art therapy process were varied: painting, drawing, modeling, body expression, among others.

Conclusion

the use of art therapy for health promotion in older adults demonstrated benefits in reducing negative factors of an affective, emotional and social nature. The articles analyzed suggest the positive effect of art therapy on quality of life in older adults.

Keywords
Health Promotion; Art Therapy; Quality of life; Health of the Elderly

Resumo

Objetivo

Analisar as contribuições da arteterapia na promoção da saúde e na qualidade de vida dos idosos.

Método

Trata-se de uma revisão integrativa utilizando os descritores em saúde: “health promotion”, “art therapy”, “quality of life” e “aged”. Foram selecionados artigos originais completos, nos idiomas português, inglês e espanhol. Não foi estabelecido período de publicação dos artigos para obter um maior quantitativo de artigos publicados no decorrer do tempo. A busca e a seleção dos artigos incluídos foram realizadas por dois revisores no período de novembro de 2019 a abril de 2020.

Resultados

Dos quatros artigos selecionados para compor a amostra, dois artigos estavam escritos em inglês e dois em português. Os artigos incluídos foram publicados no período entre 2007 e 2014. Quanto às bases de dados, dois artigos estavam indexados na Scopus, um nas bases Scopus/Pubmed/BVS e um na base CINAHL. Os recursos expressivos utilizados no processo arteterapêutico foram os mais variados: pintura, desenho, modelagem, expressão corporal entre outros

Conclusão

A utilização da arteterapia para promoção da saúde em idosos mostrou benefícios na redução dos fatores negativos de ordem afetiva, emocional social. Os artigos analisados sugerem o efeito positivo da arteterapia na qualidade de vida em idosos.

Palavras-Chave:
Promoção da Saúde; Terapia pela Arte; Qualidade de Vida; Saúde do Idoso

INTRODUCTION

In recent years, the global growth of the older population has highlighted the importance of guaranteeing a better quality of life for this group. To do so, it is important to consider the various changes that arise from the aging process, such as physical, psychological and social alterations. These changes may directly affect cognitive and motor functions and, thus, interfere with the quality of life of this population¹.

The quality of life of the older population is associated with the preservation of their functional capacity and autonomy. Therefore, the decline of such capacities is a risk for dependency, morbidity and mortality in this population².

In order to improve the quality of life of the older population, the World Health Organization (WHO) suggests that policies and programs for active aging are implemented, aimed at improving the health, participation and safety of older citizens³.

Thus, health promotion initiatives are important for controlling common health problems in this age group. Such actions allow older adults to live with the limitations or diseases they may experience, as they enable a more positive perspective on one’s personal and social life⁴.

Activities that stimulate the sensory, cognitive and motor functions of older adults are important to protect the intellect and reduce its deterioration. These activities enable the maintenance of the individual’s cognitive abilities, ensuring a better quality of life in old age⁵.

In this context, art therapy is a tool that can be used to promote the health of older adults, since its potential for stimulation contributes to improving social relationships and the self-esteem of this population⁶.

Art therapy is defined as a therapeutic process that uses art as an expressive process for self-knowledge and the expression of conflicts and internal emotions. It is a therapeutic resource that absorbs knowledge from different areas, and is therefore a transdisciplinary practice, which seeks to recuperate the individual in their entirety through processes of self-knowledge and transformation⁷.

The images produced through the expressive processes in art therapy are internal projections and personal representations. They allow the individual to express themselves in their own way, giving new meaning to their existence. It can be said that art therapy, when combined with expressive processes, represents a revealing and inspiring pathway. Such a therapeutic pathway helps individuals to believe, challenge, reconstruct, create and express emotions and feelings, which are often repressed in older adults⁸.

Given the above, the important role that art therapy can play in the quality of life of older adults is clear. Understanding the scientific production on the benefits and contributions of art therapy in aging will allow the identification of possible gaps in knowledge and guide new research that contributes to the subject. Thus, this literature review aimed to analyze the contribution of art therapy to promoting health and quality of life for older adults.

METHOD

An integrative literature review was performed, with the purpose of systematizing knowledge about the contributions of art therapy to the quality of life of older adults. This study followed the recommendations of Galvão⁹, which establish six stages: 1) Identification of the theme and selection of the hypothesis or guiding question; 2) Construction of inclusion/exclusion criteria for studies and sampling and literature search; 3) Categorization of studies defining the information to be extracted from those selected; 4) Full reading of the selected studies; 5) Interpretation of results; 6) Presentation of the review.

The guiding question of this review was: what contribution does art therapy make to promoting the health and quality of life of older adults?

The inclusion criteria established were: complete original articles that responded to the research question, published in Portuguese, English and Spanish. The period of publication of the articles was not defined, with the goal of identifying a greater quantity of articles and, thus, verifying the number of publications over time. The exclusion criteria were: theses, dissertations, books or book chapters, editorials, newspaper articles, integrative or systematic reviews of literature, reflective studies, reports of experiences and reviews.

The research was carried out in the following databases: VHL (Virtual Health Library); SciELO; CINAHL (Cumulative Index to Nursing and Allied Health Literature); LILACS (Latin American and Caribbean Literature in Health Sciences); BDENF (Nursing Database); MEDLINE/PUBMED (Medical Literature Analysis and Retrieval System Online); IBECS (Spanish Bibliographic Index of Health Sciences); SCOPUS; CUIDEN (Bibliographic Database of the Fundación Index); COCHRANE (Cochrane Library).

The search and selection of articles included in this review was carried out by two reviewers and was performed independently, from November 2019 to April 2020. Descriptors indexed in Health Sciences Descriptors (DeCS) and Medical Subject Headings (MESH) were used, with the following descriptors selected: in Portuguese, promoção da saúde, terapia pela arte, qualidade de vida, idoso; in English, health promotion, art therapy, quality of life, aged; and in Spanish, promoción de la salud, terapia con arte, calidad de vida, anciano.

Table 1 shows the search strategy applied with the descriptors, using the Boolean operator “AND”. Using the four descriptors “health promotion” AND “art therapy” AND “quality of life” AND “older adults”, 28 articles were found.

Chart 1
Search strategy for articles in data bases. Recife, Pernambuco, Brazil, 2020.

Descriptors	Health promotion AND Art therapy	Health promotion AND Art therapy AND Quality of life	Health promotion AND Art therapy AND Quality of life AND Older Adult
Database
SciELO	5	1	1
CINAHL	49	2	1
LILACS	2	0	0
BDENF	1	0	0
MEDLINE/PUBMED	240	23	8
IBECS	1	0	0
SCOPUS	270	45	13
CUIDEN	53	8	0
COCHRANE	1	1	1
TOTAL	669	87	28

• Source: the author.

After reading the titles and respective abstracts of the 28 articles found, ten were selected and responded to the research question. Of these ten articles, five were duplicated in the databases and were excluded, resulting in a final sample of five articles, which were read in full.

Figure 1
Flowchart of article selection. Recife, Pernambuco, Brazil, 2020.

The articles were evaluated for methodological rigor, using the standardized form of the Critical Appraisal Skills Program (CASP)¹⁰. This instrument was chosen due to its effectiveness in assessing the quality of articles with both a quantitative and qualitative approach. The form has a checklist with ten questions, each of which can be assigned a score (1 point), giving a total score of between zero to ten. A score equal to or greater than six (classification A) indicates that the study should be included in the review, while a score equal to or less than five (classification B) represents low methodological rigor, and recommends that the study should be excluded. At this stage, one study was excluded, since it did not meet all the criteria established for level A, giving a final sample of four articles.

To gather and synthesize information regarding the contribution of art therapy to promoting the health and quality of life of older adults, the instrument constructed and validated by Ursi¹¹ was used, in which the following information was recorded: name of study; authorship; institution; year of publication; study objectives; methodological design, sample characteristics; level of evidence, results and conclusions.

The selected articles were evaluated for level of evidence, according to the hierarchical classification adopted by Stillwell et al¹², as follows: Level I (systematic review or meta-analysis); Level II (randomized clinical trial); Level III (clinical trial without randomization); Level IV (cohort or case-control study); Level V (systematic review of descriptive and qualitative studies); Level VI (descriptive or qualitative studies) and Level VII (opinions of authorities and/or reports from specialist committees).

RESULTS

Table 2 shows the selected studies, categorized as follows: Author/Year, Objective, Method/Level of Evidence, Art Therapy Used and Results.

Chart 2
Synthesis of publications on “Contribution of Art Therapy to the Promotion of Health and Quality of Life of Older Adults”. Recife, Pernambuco, Brazil, 2020.

Author/Year	Objective	Method/Evidence	Art Therapy Used	Results
Oepen R, Gruber H13. 2014	Analyze the contribution of Art Therapy to the well-being of self-help groups with Burnout syndrome.	Qualitative quantitative exploratory study. 26 older adults (2 men and 24 women) VI	Painting, drawing, collage, modelling and weaving.	Quantitative analysis: 83% increase in current and habitual well-being. Qualitative analysis: better acceptance of environment, increased self-esteem and greater motivation for work.
Kim SK14. 2013	Analyze the effects of Art Therapy on healthy aging.	Randomized controlled study. 50 older adults (3 men and 47 women) II	Painting, drawing, collage, modelling, weaving and body expression.	Intervention using Art Therapy positively promotes healthy aging, with a reduction in negative emotions, improved self-esteem and decreased anxiety.
Aguiar AP, Macri R15. 2010	Describe the contribution of Art Therapy to the quality of life of older adults.	Qualitative Intervention study. 14 older adults (women) VI	Painting, drawing, collage, modelling, weaving, active imagination, tales, myths, body awareness, dramatization and creative writing.	The interventions carried out allowed the reduction of the frequency or intensity of depressive symptoms, contributing to self-knowledge, the recovery of self-esteem and confidence in older adults, as well as increasing their familial and social integration.
Castro PC, Tahara N, Rebelatto JR, Driusso P, Aveiro MC, Oishi J16. 2007	To evaluate the influence of the arts programs of the Open University of the Third Age and the Geriatric Revitalization Project (or REVT) on the quality of life of older adults.	Quantitative Intervention study. 70 older adults (4 men and 67 women) VI	Body expression, music and performing arts.	Statistically significant improvement (p= 0.004) in the level of quality of life, according to the WHOQoL-Bref. Statistically significant improvement in the psychological (p= 0.003) and environment (p= 0.0001) domains. Significant increase (p= 0.013) in the score for the domain of general health.

Of the four articles analyzed in the final sample, two were in English¹³,¹⁴ and two in Portuguese¹⁵,¹⁶. One article was published in each of the following years: 2014¹³, 2013¹⁴, 2010¹⁵ and 2007¹⁶. In relation to the databases, two were indexed in Scopus¹⁴,¹⁶, one in Scopus/PubMed/BVS¹³ and one in CINAHL¹⁵. No articles were found in the LILACS, BDENF, IBECS, SCIELO, CHOCHRANE or CUIDEN databases.

In terms of methodological design, two articles used a quantitative approach¹⁴,¹⁶, one a quantitative-qualitative approach¹³ and one a qualitative approach¹⁵. In relation to level of evidence, three articles were classified as level VI¹³,¹⁵,¹⁶ and one as level II¹⁴.

In relation to the expressive resources used in the art therapy, three articles described the use of painting, drawing, collage, modelling and weaving¹³-¹⁵. Body expression was used in two articles¹⁴,¹⁶. The resources of active imagination, tales, myths, body awareness, dramatization and creative writing were reported in one article¹⁵ and music and the performing arts appeared in another¹⁶. The results are shown in Table 2.

DISCUSSION

The expressive languages used in the art therapy interventions, described in the articles of this review¹³-¹⁶, were diverse and involved as resources: painting, drawing, collage, modelling, weaving, body expression, active imagination, tales, myths, body awareness, creative writing, music and performing arts. Thus, there is a wealth of resources that can be used in the art therapy process so that older adults are able to express feelings and emotions that interfere with their physical, mental, social and spiritual well-being.

The expressive resources of painting, drawing, collage, modelling and weaving were used in different interventions to assist in the well-being of self-help groups with Burnout syndrome¹³, the effects of art therapy on healthy aging¹⁴ and to analyze the contribution of art therapy to the quality of life of older adults¹⁵. The results suggest positive effects from the use of these therapeutic resources in three studies in this review.

According to Silva¹⁷, painting has a liberating and cathartic function, due to the fluidity of the paint and its subtlety, through which emotions and feelings are addressed therapeutically, as it is in the energetic movement of painting that the unblocking, freeing and expansion of consciousness occurs. This expressive resource allows older adults to work on motor coordination, awakening sensitivity, intuition and the creative and imaginative spirit, providing greater knowledge of themselves and the world. This favors the development of a greater perception of the limits and potentialities that are present in the aging process.

In the art-therapeutic process, collage is an expressive organizing, structuring and integrating resource, as it allows cutting, breaking down and assembling, favoring the act of recreating. This resource makes it possible to work on transformation, death and rebirth; the end of one stage and the beginning of a new stage, issues present in the life of the older adult. Loiola and Andriola¹⁸ describe how collage is a technique that favors starting from already familiar things that then open up to new possibilities, resulting in the creation of a new scenario – the portrait of an existential moment of possibilities – that can be accessed and brought into the reality of each older adult. This possibility of openness allows older adults to resignify emotions that improve their quality of life.

Moraes et al.¹⁹ state that modelling is an activity that stimulates sensory function, which is often impaired in old age, and works with three-dimensional organization. When older adults touch clay, they establish an intimate contact with the material and stimulate their creativity, which allow them to create forms and enlarge the imaginary world. The materials used in this expressive modality can be: clay, papier-mâché, plaster, plasticine, colored modeling clay, craft dough. These resources enable the individual to get in touch with their emotions and feelings, promoting self-knowledge.

The study by Araujo²⁰ describes how weaving is another resource used in art therapy that helps to re-signify life situations, as when mistakes are made with fabric, the older adult must redo his or her movements. The recognition of error and the desire to correct it makes one reflect on life and leads to the awareness that there is always time to start over in an attempt to get something right. It is another possible manner of finding the thread in the tangles of the internal contents of life²⁰. This resource can allow the older adults to recognize themselves in the aging process as the integral beings that they are.

Body expression, as a therapeutic resource, was used in a study¹⁴ that analyzed the effect of art therapy on healthy aging and in a study¹⁶ which evaluated the influence of the arts programs of the Open University to the Third Age and the geriatric revitalization project on the quality of life of older adults. The authors concluded that body expression and the influence of art programs were resources that improved the quality of life of older adults, reducing negative emotions, improving self-esteem and decreasing anxiety.

When working with the body, the older adult directly connects with their affective memories, bringing remembrances of sensations and forgotten content. Body expression is one of the expressive channels of art therapy, as it favors experiences that lead to body awareness and seeks the organization and reorganization of movement through creativity²¹.

In addition to the use of resources such as: painting, drawing, collage, modelling, weaving and body expression, activities such as active imagining, tales, myths, body awareness, dramatization and creative writing were used as contributions of art therapy to the quality of life of the older adult¹⁵. Music and the performing arts were also used to assess the influence of arts programs on the quality of life of such adults¹⁶. In both studies¹⁵,¹⁶, the benefits of these resources for promoting the health of older adults were observed.

The use of music and performing arts allows older adults to experience verbal, non-verbal and bodily experiences that permit them to recover affective memories and express emotions²². The relationship between music and therapeutic goals is sustained by making older adults relive their memories, giving them the opportunity to experience a catharsis. In this process of awareness, there will be an opportunity to remake themselves, promoting their quality of life.²³.

All the studies¹³-¹⁶ pointed out the satisfactory effects of the use of art therapy, regardless of the types of expressive resource employed. These results corroborate the findings of the study by Assunção et al.²⁴, showing that this form of therapy can be developed through different expressive modalities such as: theater, dance, poetry, music, literature and visual arts. Through these resources, it is possible to work with non-verbal languages – such as sound, body and materials – in older adults.

The multiple expressive modalities that art therapy uses facilitate the search for self-knowledge that helps to awaken sensoriality and perception in older adults²⁵. It is important to stimulate cognitive, sensory and motor functions, aiming to preserve, in older adults, a degree of autonomy and independence, promoting a better quality of life.

In relation to the positive contributions of art therapy in promoting the quality of life of older adults, two of the studies analyzed¹⁴,¹⁶ concluded that there was a statistically significant improvement in the psychological domains and those related to the environment, according to the WHOQoL-Bref.

Among the benefits of using art therapy, a study¹³ revealed a significant increase in current and habitual well-being among older adults, reported from the participants’ narratives about improved acceptance of the environment, increased self-esteem and motivation to work. In two studies¹⁴,¹⁵, a reduction in the frequency and/or intensity of depressive symptoms and anxiety, improvement of self-knowledge and the recovery of self-esteem and self-confidence in was noted.

Thus, the benefits of art therapy to promote the well-being of older adults was observed, since it results in changes in the affective, interpersonal and relational fields; demonstrating improvement in emotional balance²⁶.

Art therapy contributes to the improvement of the understanding of emotions and feelings experienced in the face of life’s challenges. This statement was evidenced in the results of the studies¹³-¹⁶ through the narratives of the participants, who highlighted an improvement in their self-esteem, their interpersonal relationships and their way of seeing life, thus resulting in a feeling of general well-being.

The studies¹³-¹⁶ revealed that, through the use of art therapy, participants experienced their difficulties, conflicts, fears and anxieties with less suffering, influencing the improvement of their quality of life.

Through artistic expression, the power of the self-knowledge that art therapy provides to older adults was demonstrated¹³,¹⁵,¹⁶. Valladares²⁷ emphasizes that art therapy is a therapeutic process that aims to salvage the integrality of older adults, through self-knowledge and transformation processes. It is through the process of creation that older adults can expand knowledge of themselves and others, increase their self-esteem and deal better with the changes of the aging process²⁸.

Thus, the creative processes constitute a revealing and inspiring pathway that allow older adults to get in touch with their possibilities of believing, challenging, reconstructing, creating and expressing emotions, feelings and life stories.

The results of the studies¹⁵,¹⁶ revealed an improvement in the interpersonal and family relationships of older adults, preventing social isolation. In old age, it is common to lose one’s social role, which leads to feelings of incapacity and isolation for older adults. Group experiences, through artistic expression, help such adults with a sense of belonging and acceptance of their own history

Art therapy enhances the individual’s uniqueness, as it allows older adults to follow a path of expression, communication and synthesis of their personal experience. By representing both conscious and unconscious content, artistic expression contributes to integrating the affective and cognitive aspects of health and disease, and is therefore beneficial in expanding the understanding of the self and, in the same way, improving the quality of life of older adults²⁹.

A limitation of this study is that few studies published in indexed journals investigating the theme of the effects of art therapy on the quality of life of older adults were found, resulting in a small final sample. Thus, it is suggested that further investigations on the benefits of art therapy for promoting the quality of life of older adults are carried out.

CONCLUSION

A small number of publications with the subject of the use of art therapy to promote the quality of life of older adults were found on the databases searched, demonstrating the need to explore the theme further, as the benefits of art therapy for the older population were evidenced.

The interventions involving art therapy revealed the unfolding of the intrapsychic processes present in older adults and demonstrated how their use favored the acceptance of the changes that occur during the aging process, contributing to well-being and quality of life.

It was found that the expressive resources employed: painting, drawing, collage, modelling, weaving, active imagining, tales, myths, body awareness, dramatization, creative writing, body expression, music and performing arts, constituted an approach in which older people were able to express themselves and talk about their feelings and how they experience and perceive the world in imagery. This results in moments of profound reflection that will often only be noticed when a therapist requests that the individual talks about the image created. At that moment, the conscious level is reached and the transformation begins, as the older adult appropriates their own internal contents, coming to know themselves and become an active subject in the art therapy process.

Therefore, it is important to expand studies on the subject, as such ludic, recreational interventions can lead to moments of catharsis, resulting in the recreating of the subject and a better quality of life.

• No funding was received in relation to the present study.

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Edited by

Edited by: Ana Carolina Lima Cavaletti

Publication Dates

• Publication in this collection
  15 Feb 2020
• Date of issue
  2020

History

• Received
  03 June 2020
• Accepted
  11 Jan 2021