In Context

784 www.thelancet.com/neurology Vol 8 September 2009

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The observational and anecdotal evidence that diff erent types of arts-based therapy can improve the quality of life for, and even cognitive function of, patients with dementia is huge: large enough to support the existence of associations of registered therapists all over the world; large enough for the UK National Health Service (NHS) to be the country’s number one purchaser of such services. But there is little hard scientifi c evidence to show whether or not these therapies truly help. A new institute—the International Centre for Research in Arts Therapies at Imperial College, London, UK—has set itself the goal to help collect such evidence.

“We now have over 60 years of case-study research and other qualitative data that suggest arts therapies are useful in the care of patients with dementia”, explains Diane Waller (Goldsmiths, University of London, UK), chair of the management group for the new institute. “The fact that art, music, and drama therapy are statutorily regulated in the UK, and that dance movement therapy shortly will be, demonstrates that they have met rigorous criteria in terms of there being a body of knowledge.” However, there is not yet enough systematic evidence to show convincingly that the arts and arts therapies are eff ective in people with mental health problems. “Despite the enthusiasm among practitioners to carry out research, there has been virtually no coordination or high-level lead to ensure that sound projects are designed. Projects do not have to always be randomised studies or use quantitative methodology, but they do need to be very rigorous. Bringing more rigour into this area is what this new institute is about.”

A search of the literature will turn up scores of papers off ering observational

evidence that arts-based therapies are of benefi t to patients with dementia but will uncover only a few controlled, quantitative trials. For example, several randomised controlled trials of music therapy report diff erent cognitive or behavioural benefi ts in patients with

dementia, although a Cochrane review stated that none of these was of suff -icient methodological quality for any fi nal conclusions to be drawn. Further, a multicentre, randomised, controlled group study investigating the use of art therapy in people with dementia found it had positive eff ects on mental acuity, physical involvement, calmness, and sociability. Moreover, the MATISSE trial (Multicentre study of Art Therapy In Schizophrenia: Systematic Evaluation), designed to test the benefi ts of art therapy, is now underway—although in patients with schizophrenia. But the list is not much longer. If it were, and if arts-based therapies were shown to be of benefi t, the types of interventions provided might become more eff ective and better tailored to individual needs.

The activities of the new institute could be of great value to professional arts therapists (ie, those who practise a form of psychotherapy that uses an art form as its medium of communication).

“The launch of the arts therapies research institute at Imperial College is greatly welcomed by the British Association of Arts Therapies (BAAT)”, says Val Huet, chief executive offi cer of the BAAT (London, UK). “Within art therapy, the attitude towards

research has greatly changed over the past 10 years: the BAAT’s Art Therapy Practice Research Network [which is involved in practice-led research and evaluation ventures] has been active since 2000 and now has a third of BAAT membership [on its books]. However, art therapists are often ‘lone practitioners’ in their organisations and this makes it hard to gather research-worthy data. There is a vibrant interest in developing the kind of research that will help us [better found] our practice, and this new institute promises to do just that.”

This institute might also be of interest to other groups that are already systematically assessing the eff ects of their own “arts in health” work with the aim of improving the eff ect of these therapies. For example, Artists for Alzheimer’s, an initiative of the Hearthstone Alzheimer’s Foundation, has been trying for several years to unlock memories in—and thereby stimulate—patients with Alzheimer’s disease in diff erent parts of the USA, France, Germany, and Australia by taking patients on research-based

Can interactive drama clinically benefi t patients with dementia?

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For more on the review on music therapy see

Cochrane Database Syst Rev 2009; 1: CD003477

For more on the multicentre, randomised, controlled art

therapy trial see Group Analysis 2006; 39: 517–36

“The arts can be a powerful intervention, [but as] with any potent ‘medicine’ we need to understand and harness the benefi ts while being mindful of the risks.”

Bringing arts-based therapies in from the scientifi c coldArt therapy, drama therapy, music therapy, dance therapy... To many people these are valid tools that can and should be used in the care of patients with dementia—but do they really work? Adrian Burton reports.

The printed journal includes an image merely for illustration

In Context

www.thelancet.com/neurology Vol 8 September 2009 785

structured visits to art museums. “We have developed a methodology that allows us to select paintings that elicit engagement by patients”, explains John Zeisel, co-founder of the foundation. The reactions elicited in Parisian patients with Alzheimer’s disease when viewing artwork at the Louvre Museum (Paris, France) have been fi lmed in a new programme. “We recorded these interactions as we did in programmes in Australia and in fi ve US museums, and are analysing them to determine what best elicits patients’ engagement and improves their focus of attention and language use”, says Zeisel. A questionnaire is also used to quantitatively measure shifts in stigmatised attitudes among care personnel and families. “We are cooperating with experts in the UK, France, and the USA to develop a consensus regarding how to measure these responses, which would allow us to generate a critical mass of comparative data necessary to generalise beyond individual cases, [and] are now expanding our work with a project in London, so this type of initiative by Imperial could be very interesting to us.”

In the southwest of the UK, the Cascade Theatre Company has been involved in health and education projects for over a decade. In their Arts and Minds project, which ran from March, 2007, to August, 2008, in conjunction with the Cornwall Partnership Trust at Bodmin Hospital (UK), they provided inter active performances for patients with dementia. Their four plays (School Days, Wedding, VE Day, and Upstairs Downstairs) all sought to stimulate memory and facilitate commun ication through patients’ participation. Although not a scientifi c study, the project did assess the outcome, and the patients who took part were later said to be calmer, showed feelings of greater security and relaxation, and had improvements in communication capacity far beyond expectations. “It’s very important that groups like this

monitor the outcomes of their work”, explains Emma Williams, coordinator of Arts & Health South West in Bristol (UK). “The anecdotal evidence that engaging in arts activity is generally experienced as helpful is huge [and] the eff ectiveness of art psychotherapy as a means of alleviating psychological distress and disturbance is increasingly recognised in many NHS Trusts. Arts & Health South West hope that this [new institute] will be the beginning of more considered and rigorous evaluation of the impact of participating in arts activities across the whole arts and health spectrum. The arts can be a powerful intervention, [but as] with any potent ‘medicine’ we need to understand and harness the benefi ts while being mindful of the risks.”

These risks might include elicit-ing counterproductive reactions in patients who feel uncomfortable being involved in interactive drama or similar activities. “As with any treatment, the response could vary, depending upon a person’s past experience and personality”, explains Peter Coleman (University of Southampton, UK). “The type of patients that might or might not benefi t from this kind of intervention has to be well established. Further, we need to be aware that such interventions could cause memories of past traumas to resurface, thereby worsening quality of life.”

Similarly, Live Music Now, the largest provider of live music to the UK’s health sector, off ers interactive music performances by young, specially trained musicians for people who have limited access to live music—including people with dementia. In its recent Meaningful Moments project, in association with the Nightingale House Care Home in London, UK, violinist Kokila Gillett and pianist Pavel Timofejevsky played for residents in interactive music sessions once a month for 10 months. Their idea was that the right kind of music might stimulate listeners with dementia, favouring their communication with those around them. These sessions

were all followed by an evaluator to record the changes in the patients over time. “Measuring the eff ects of what we do in these projects is very important”, explains Trudy White, the London director of Live Music Now. “We welcome the formation of the International Centre for Research in Arts Therapies as it could signifi cantly improve the provision of live music as a way of enhancing well-being.”

Plans for the centre, which formally opens on Sept 21, 2009, are still being developed but the intention is to provide information, advice, and support to those wanting to undertake high-quality studies, and hopefully help them attract funding. “While there is a widespread belief that involvement in art, music, and other creative activities is of inherent value, there remain major gaps in our understanding of how such activities can be delivered in a form which is acceptable to people with dementia and other health-related problems”, explains Mike Crawford (Imperial College, London, UK), who has a founding role in the institute. “[Certainly] data on the relationship between process and outcomes of interventions is sparse and [their] costs and cost-eff ectiveness have not been explored.” With an epidemic of dementia looming on the horizon, the time might have come for these questions to be answered.

Adrian Burtonburtona@wanadoo.es

At the Louvre: art might unlock memories and stimulate verbal capacity

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The printed journal includes an image merely for illustration