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The Arts in Psychotherapy

Drama therapy with older people with dementiaDoes it improve

quality of life?
Joanna Jaaniste, PhD a, , Sheridan Linnell, PhD b , Richard L. Ollerton, PhD c ,
Shameran Slewa-Younan, PhD d
a
School of Social Sciences & Psychology, University of Western Sydney, Penrith, NSW, Australia
b
Art Therapy, School of Social Sciences & Psychology, University of Western Sydney, Penrith, NSW, Australia
c
School of Computing, Engineering & Mathematics, University of Western Sydney, Penrith, NSW, Australia
d
Mental Health, School of Medicine, University of Western Sydney, Penrith, NSW, Australia

a r t i c l e i n f o a b s t r a c t

Article history: This article describes a pilot study that aimed to evaluate the effect of drama therapy on the quality of
Available online 31 December 2014 life (QoL) of elderly people with mild to moderate dementia, using a mixed method (quantitative and
qualitative) approach.
Keywords: Study participants (N = 13; age range 6188 years; 1 female) were Australians of European descent,
Dementia principally with Alzheimers disease, living in the community in an east-coast Australian context. The
Drama therapy
drama therapy group (N = 4) was compared with a group of participants (N = 9) who watched movies
Elderly people
over a four-month period. All participants were assessed for QoL using the quantitative Quality of Life
Mixed method
Quality of life
Alzheimers Disease (QoL-AD) scale of Logsdon, Gibbons, McCurry, & Teri (1999, Journal of Mental Health
and Aging 5, 21) prior to and following 16 group meetings. Qualitative data were generated and examined
using phenomenological methods including recording and transcribing body language and dialogue, as
well as narrative, ethnography, group themes and metaphor.
Although not statistically signicantly different, the average QoL-AD score increased for the drama
therapy group while it decreased for the movie group. Qualitative ndings established an unambiguous
participant ability to express ideas and feelings through drama therapy as well as an unveiling of conscious
awareness of participants own wellbeing and QoL. The ndings also indicate the potential worth of a
future larger study along the lines exemplied here.
2014 Elsevier Ltd. All rights reserved.

Introduction accounting for 6070% of cases (World Health Organisation &

The World Health Organisation estimates that in 2010 some
35.6 million people globally were living with dementia (World
Health Organisation & Alzheimers Disease International Report,
2012, p. x). The same report gives dementia prevalence in Aus-
tralasia as 6.91% and in the USA as 6.46% of the population (p. 14).
Moreover, the report predicts a signicant global increase in both
absolute and percentage terms, so that by 2030 there will be close
to 66 million people worldwide living with dementia.
Dementia as a syndrome involves deterioration of the higher
cortical functions of the brain (Coulson, Fenner, & Almeida, 2002).
Its most common form is Alzheimers disease (AD), possibly
Corresponding author. Tel.: +61 295186519.
E-mail addresses: e.jaaniste@uws.edu.au, dramatherapy@ozemail.com.au
(J. Jaaniste).
Alzheimers Disease International report, 2012). There is abundant
evidence that amyloid production in the brain from protein is a
major indication of AD, sometimes with genetic aetiology (Masters
& Bayreuther, 1998). The amyloid protein produces neuro-brillary
tangles which are known to underlie brain degeneration (Ginsberg,
Hemby, Lee, Eberwine, & Trojanowski, 2000).
Commonly recognised features of AD include lack of recall
(Greene, Baddeley, & Hodges, 1996), language deterioration (Price
et al., 1993) and visuospatial deciencies (Esteban-Santillan,
Praditsuwan, Ueda, & Gelbmacher, 1998). This litany of decits can
be devastating to the person with dementia as well as their family
and caregivers. Drama therapist Casson (1994) calls this potential
loss of personhood in a confused elderly person . . . one of the most
devastating aspects of dementia (p. 2). Drama therapy can provide
interventions which help people with AD to access their creativity
and spontaneity in the face of loss of physical movement, their free-
doms, loved ones, partners, recognition of others and deprivation of

http://dx.doi.org/10.1016/j.aip.2014.12.010
0197-4556/ 2014 Elsevier Ltd. All rights reserved.
 J. Jaaniste et al. / The Arts in Psychotherapy 43 (2015) 4048
the self they thought they knew (Johnson, Smith, & James, 2002). In
selecting a denition of drama therapy, Jones (2007) believes that
local practitioners can offer a more rened sense of what drama
therapy aims to be in a particular context. For our purposes, a local
(Australian) denition is as follows:
Dramatherapy purposefully uses drama techniques and
theatre-based models to encourage the clients creativity and
expressive ability. It helps the clients to tell their story, express
feelings, set goals, extend inner experience and try on new and
more fullling roles, so far unexplored (Dramatherapy Centre,
2014).
This description emphasises the availability of new-found roles
for participants in drama therapy. There is a core loss of sig-
nicant life roles for people with dementia, and drama therapy
can assist people to gain condence through orientation into the
present moment (Bailey, 2006; Langley, 2006). Potential drama
therapeutic gains for people with dementia include opportunities
to nd meaning for those affected by AD dealing with coherence
of role into the present (Gorst, 2011). Drama therapy through
stories can assist with sociability (Gersie, 1997), through humour
can promote mental acuity (Jennings, 2005), through improvisa-
tion can assist with end of life issues (Johnson, 1986) and through
stimulation of the imagination can reduce stigma (Davis Basting,
2009).
A review of the literature revealed that little research has been
published on drama therapy in the specic context of dementia.
More generally, successful mixed method research into elements
of the wellbeing of elderly participants has been carried out by
nursing home care staff in Davis Bastings (2006, p. 18) Timeslips
project. Rather than relying only on drama therapy techniques, staff
members helped participants build a story on the basis of a set of
open-ended questions, accepting all responses and weaving them
into a story form. Davis Basting (2001) strongly recommends the
use of images to stimulate reection, memory and group process.
Feil and de Klerk-Rubin (2012) describe their validation method
(VM), a psychogeriatric approach that can be helpful to drama
therapists by offering solutions to communication difculties with
people who have memory loss, as one of acceptance of people with
dementia, based on practical techniques of touching and reminis-
cence. They apply sensitive, non-judgmental listening to the elderly
to enhance self-esteem and provide emotional release. Research
conducted by Feil (1990) and Kohn (1993) shows that through
the use of VM with clients, caregiver burnout decreases. How-
ever, Finnema, Droes, Ribbe, & Tilburg (2000), in their review of
psychogeriatric models, found no evidence of VM having been
empirically tested for people with dementia. Weisberg and Wilder
(2001) investigated the psychosocial change in self-expression of
their elderly participants and stress the value of adult creative play.
They showed how engaging even the most unwilling participants in
drama and movement could stimulate happy participants, shared
experiences and moments of optimism even in the bleakest envi-
ronments (2001, p. 96). In their case study of initial engagement
of ten participants, what began as total resistance by one reluctant
volunteer ended up as an opportunity for her to re-visit a detailed
40-year-old memory of a colourful scenic drive through the moun-
tains. Another group member said: Except for this hour with all
of you, Im getting dopey sitting in this place . . . no one to talk to.
Ill forget who I am (p. 97). Such comments reveal the importance
and value of a sense of identity.
Core themes emerging from the above literature include a sense
of connection with others, condence to express feelings, sponta-
neous interaction, engagement of imagination, shared memories
and motivation. These attributes are all important aspects and qual-
ities for people with dementia which can be developed through
drama therapy.
41
More specically related to the focus of our research, Lepp,
Ringsberg, & Holm (2003) conducted a study where two groups
of randomly assigned elderly people (N = 12; age range 7395
years; 10 female) with mild to moderate dementia met weekly
and were given an experience of either dance, rhythm and songs
using costumes (Group A: N = 6) or storytelling (Group B: N = 6).
Seven nursing staff were also randomly allocated to the groups and
a drama teacher and a storyteller ran the relevant group. The groups
were not compared, as the researchers were investigating improve-
ments in two categories: one for clients (interaction) and the other
for nursing staff (professional growth). Using phenomenography,
the authors found that the people with dementia in groups A and B
showed improved abilities in communication and condence. The
authors do not explain why these two treatment groups were used
or why a drama therapist was not used, but their data analysis indi-
cates that both groups improved in fellowship, communication and
reactivated memory. There is a recognition in their article that sto-
rytelling, with its associated songs and poems, is an integral part
of drama (as it is of drama therapy). Although the study was not
designed to examine relationships between clients and staff, one
conclusion was that improved interaction between clients and staff
may result from use of both methods described. Additionally, the
importance of professional development of staff was highlighted
(see also Jaaniste, 2011).
Using a mixed methods approach, an earlier pilot study assessed
the use of drama therapy over a six month period with 16 elderly
people with dementia (Wilkinson, Srikumar, Shaw, & Orrell, 1998).
This research did utilise a drama therapist. The drama therapy
group participants (N = 9; average age 79.6 years; 9 female) were
pre-selected for their higher level of communication abilities while
the control group (N = 7; average age 80.0 years; 1 female) were
mainly non-verbal and cognitively impaired. Activities under-
taken by the control group were not stated. It was reported that,
although not statistically signicantly different, members of the
drama therapy group had (perhaps unsurprisingly) better cogni-
tive function, better daily living skills and lower dependency than
the (non-randomised) control group, using six neuropsychologi-
cal measures pre- and post-intervention. The authors admit that
their methodology needs modication: in particular, they disclose
in the discussion that the drama therapist selected participants
who were more likely to do well. They conclude that the quali-
tative ndings nevertheless support the idea that drama therapy
may help people with dementia to build communal spirit, increase
self-understanding and acceptance and facilitate reminiscence.
The non-random group selection (along with other aspects of the
methodology) emphasises the need for systematic research into
the use and benets of drama therapy for people with dementia,
possibly based on the model described in the present study.
In recent years, awareness and acceptability of a range of arts
therapies in medical journals have increased, with calls for further
research to be conducted in this area. In a Lancet Neurology arti-
cle, Burton (2009) groups together studies of art therapy, drama
therapy, music therapy and dance therapy. While Burton notes
that most evidence for arts therapies is observational and anec-
dotal, there has been one multi-centre, randomised controlled trial
(RCT) of art therapy with people with dementia (Rusted, Sheppard,
& Waller, 2006). Again using mixed methods, Rusted and colleagues
conducted an art therapy intervention with people with dementia
using an RCT design. Although described as a multi-centre study,
facilities included a day resource unit in a hospital, a privately
owned nursing home as well as a nursing home and a resource
centre both funded by social services. Hence, a more useful cate-
gorisation may have been that clients were either in long term or
day care. The 45 participants had diagnoses of probable dementia
of the Alzheimer type (N = 18; 11 females), multi-infarct dementia
(N = 19; 13 females) and unspecied dementia (N = 8; 7 females).
42 J. Jaaniste et al. / The Arts in Psychotherapy 43 (2015) 4048
The average age of women was given as 84.05 years and of men
80.33 years. They were randomly assigned to art therapy or
activity (control) groups for 1 h each week for 40 weeks, with a
maximum of six in each group. Group-interactive, psychodynamic
methods were used in association with the art therapy, while the
activity groups were run by occupational therapists (OTs) who were
instructed not to use formal OT methods or art/craft work. Prior to
and following the 40 weeks, numerous neuropsychological scales
were administered. Researchers found no signicant differences
between the two groups in many of the scales; however, there was
a statistically signicant change in the within-session measure-
ment of the BondLader mood scale (BLMS) (Bond & Lader, 1974).
For the art therapy group, BLMS scores in mental acuity, physi-
cal involvement, sociability and calmness increased/improved over
time, while in the activity group they decreased over time. The
authors determined that all of the standardised measures selected
met all of the criteria for validation and reliability as reported in
their original verication studies. The BLMS was the measure that
produced the most compelling evidence for change through art
therapy. Since the BLMS attributes referred to above have distinct
resonance with quality of life (QoL), we considered the above study
to be a useful model for the present investigation.
Good QoL is recognised as one of eight essential evidence-
based practice (EBP) recommendations for people with dementia
(Karttunen et al., 2011) and is described by Banerjee (2010) as
doing the diagnosis well (quoted in the Alzheimers Disease
International report 2011, p. 10). The World Health Organisations
vision is for an improved quality of life for people with demen-
tia and their families throughout the world (Alzheimers Disease
International report, 2013, p. 33). QoL encompasses the achieve-
ment of goodness and meaning in life and well-being, satisfaction
and dissatisfaction (Farquar, 1994, quoted in Moyle, McAllister,
Venturato, & Adams, 2007, p. 176). QoL in dementia is considered
by some as having been largely ignored and worthy of much greater
examination (Moyle et al., 2007). As a partial result of seminal work
by Kitwood and the Bradford Group (Kitwood, 1997), QoL for people
with dementia in the UK is considered to encompass the following
attributes, in order of importance:
Relationships;
environment;
physical health;
sense of humour;
independence;
ability to communicate;
sense of personal identity;
ability to engage in activities;
ability to practise faith or religion;
ability to be treated fairly
(Alzheimers Society report, 2010, pp. 1722). Our study was
informed by this view of QoL.
Both the Wilkinson et al. (1998) and Rusted et al. (2006) studies
described above used a mixed method approach, dened in the
present study as research in which the investigator collects and
analyses data, integrates the ndings, and draws inferences using
both qualitative and quantitative approaches or methods in a single
study or programme of inquiry.
An important advantage of mixed method research is that one
of the approaches can balance the decits of another (Johnson
and Onweugbuzie, 2004) and therefore more effectively support
the ndings. While some researchers believe that a qualitative
approach is more relevant to the clinical practice of the arts ther-
apies (Tpker, 1990; Rogers, 1995), others point out that if a
qualitative approach is slavishly followed (Grace and Everard,
2001, p. 723) then the wider healthcare research community, who
use EBP models, may not recognise the effectiveness of these thera-
pies (Pothoulaki, MacDonald, & Flowers, 2006). EBP combined with
high practitioner standards and a exibility of approach to research
is important for many clinical practitioners who want to apply the
results of evidence-based research in the general area of health
where the biomedical model is strongly supported (Evans, 2003).
However, to date few studies have been conducted in the eld of
drama therapy using quantitative measures.
Both the incidence and prevalence of dementia are on the rise
and good QoL is clearly signicant for people with dementia them-
selves as well as their families, caregivers1 and the society in which
they live. Important research has been carried out in each of the
areas of dementia, arts therapies and QoL but there has been lit-
tle cross-over research using drama therapy. Drawing upon the
relevant literature, and in particular the evaluation of short and
long-term effects of art therapy on older people with dementia
(Rusted et al., 2006), we sought to explore the effect of drama ther-
apy on the QoL of elderly people with mild to moderate dementia,
using a mixed method (quantitative and qualitative) approach.
Study design
Two groups of elderly people with mild to moderate dementia
living in east-coast Australian communities were compared, one
of which participated in drama therapy sessions while the other
watched movies. The groups were located in Sydney and Newcas-
tle NSW, respectively. Movies were chosen by consensus and this
group was regarded as the normal activity (control) group.
Quantitative and qualitative data collection was undertaken
over a ve month period between April and August 2011. The study
programme involved an initial three-week period for pre-session
assessment (T1), two eight-week blocks of sessions with a three-
week break in between and a two-week period for nal assessment
(T2) (see Table 1).
Sessions for both groups lasted for 1.5 h and were run on a Fri-
day (drama therapy) and the following Monday (movies). Two art
therapy students assisted as members of the drama therapy group
and two Alzheimers Australia staff members attended alternately;
provision of resources for this group was shared between their
organisation and the drama therapist. The movie group was super-
vised by an art therapy student with staff support. The room at the
Newcastle facility was set up as a movie theatre and ice creams and
other refreshments were provided.
The drama therapy sessions always included the same struc-
tural elements, whichever techniques were being used. A group
contract was made in the rst session, employing suggestions
from participants on condentiality, time and place boundaries,
self-responsibility and drama therapist responsibility. All parties
1
After careful consideration and vigorous debate, we have chosen the word care-
giver as a generic descriptor for the people, all of them family members and most
of them spouses, who supported the involvement of the research participants in
this study and accompanied them to the drama therapy workshops, as well as car-
ing for them in their daily lives. We are aware of the critique of such terms as
carer and caregiver in the work of Molyneaux and her colleagues (Molyneaux,
Butchard, Simpson, & Murray, 2011, p. 422). We agree that such terms have become
bureaucratised and can render invisible the specicity and mutuality of diverse rela-
tionships that can and do exist between people living with dementia and others
in their families and networks. In day-to-day situations, we support the recom-
mendation to carefully negotiate specic, relational ways of naming each unique
connection between a carer/caregiver and a person living with dementia. Here
however, we needed a generic description for the purposes of our research. In choos-
ing caregiver, our intention was to honour the etymology carian [Old English]:
to feel concern, and carity [17th Century English]: dearness from Latin cari-
tas, (Onions, 1950, pp. 265266). We also aimed thereby to honour nuances of
the words care and giving in relation to the mutually enriching and demanding
commitment of caring for and about someone living with dementia.
 J. Jaaniste et al. / The Arts in Psychotherapy 43 (2015) 4048
Table 1
Quantitative and qualitative investigations.
agreed on safety of performance space and participants rights
to absent themselves from performance at any time. It was also
agreed that any aggressive behaviour necessary to the drama would
be improvised, so that no one would actually be harmed. Each
weekly session was based loosely on an overall theme, such as
seasons, favourite animals or families. Issues which would nor-
mally occur in a group of people with dementia tend to be different
from other targeted groups, and the prominence of socialisation
(Langley, 2006) and end of life issues (Johnson, 1986) inuenced
the choice of session topics. Sessions began with warm-up exer-
cises and games using balls and coloured cloths to get to know one
another, energise and prepare the body for activity and encourage
spontaneity and awaken creative imagination in the participants
(Langley, 2006). Opportunities for physical contact are valuable,
since loss of identity and sense of self can occur when people do not
receive human touch (Ehrenfeld, 2003). There was a further warm-
up period to facilitate connection between group members, some
pair work, some group improvisation and then reection, de-roling
and closure. De-roling was of particular signicance for this group.
Jones (1996) suggests that to leave a client in role or suddenly to
close the dramatic activity can be highly problematic (p. 27) and
drama therapists have several means at their disposal to assist with
disengagement from a role. Over-stimulation of participants imag-
inations was sometimes challenging for them if cognitive strengths
and boundaries were weakened through the unwelcome persis-
tence of a role which should have been left behind in the group
space after a session. A period of reection at the end of each group
session assisted in the de-roling process and each meeting ended
with a song relevant to the topic as a form of closure. A ritualised
ending such as a song can provide the nal boundary between the
therapeutic space and the outside world (Langley, 2006, p. 101)
and allows completion, the closing of the emotional space and a
sensitive end to creative engagement.
Developmental Transformations (DvT) techniques were among
those used in the drama therapy that is the focus of this research.
43
Johnson (2009) describes DvT as a form of drama psychotherapy
that is based on an understanding of the process and dynamics
of free play. The essence of Developmental Transformations is the
transformation of embodied encounters in the playspace (p. 8).
DvT methods, including transformation, embodiment, encounter and
playspace (Johnson, 2009), enable participants to develop some
of the Alzheimers Society (2010) QoL attributes listed above. For
example, relationships became more exible when participants
transformed scenes from a scenario where an action was stuck
and their spontaneity loosened it. They were able to engage using
humour in encounters, as well as achieve purposeful communi-
cation. Embodiment through movement within the safety of a
specied playspace assisted their physical health and gave them
a sense of independence and personal identity through their non-
directed choice of activity in the engagement.
Other techniques used throughout the 16 session weeks were
story making (Gersie, 1990), where a story was told and then
offered to participants to improvise, as well as role playing and
improvisation of personal stories. A large number of reminiscence
objects and photographs were provided by the drama therapist
and sensory material, painting and drawing resources were also
available to group members during sessions. As Davis Basting
(2001) points out in describing her Timeslips project, pictures
and images can assist participants to engage in hitherto unexplored
roles, as they stretch the boundaries of traditional reminiscence
activities . . . as storytelling groups make up new stories (p. 80).
A mixed method (quantitative and qualitative) analysis of the
data obtained during the study was undertaken. The University of
Western Sydney Ethics Committee gave ethical approval for the
study.
Participants
Alzheimers Australia, Sydney and Newcastle, supplied con-
tact details of 80 people, most of whom had dementia and had
44 J. Jaaniste et al. / The Arts in Psychotherapy 43 (2015) 4048
been involved in the organisations Living with Memory Loss pro-
gramme. Of the people contacted, 17 agreed to participate and
were included in the study (see Table 1). The inclusion criterion
was a prior diagnosis by a medical doctor or geriatrician of demen-
tia (mixed origin). There was no age criterion. Exclusion criteria
were other diagnosed co-morbid psychiatric conditions. All partic-
ipants were volunteers, gave informed written consent and signed
releases to allow withdrawal from the study at any time. Informed
consent was also obtained from their agents with power of attor-
ney.
The diagnostic prole of the entire group was dementia of the
Alzheimer type (N = 14; 2 females) and unspecied dementia (N = 3;
2 females). The average age of the group was 74.8 (range 6188)
years. All participants were of Australians of European descent liv-
ing in east-coast Australian communities.
Of the 17 people with dementia originally invited to take part
in the research project a total of 13 (drama therapy: N = 4; movie:
N = 9) completed the study. Two drama therapy participants absent
from the quantitative assessment were included in the qualitative
aspect of the study. One participant died, one discontinued after
the rst assessment, one became depressed and entered a nurs-
ing home and one found it too uncomfortable to concentrate on
movies but completed both assessments. Another participant had
an accident after the thirteenth drama therapy session and was hos-
pitalised. The remaining participants completed both assessments
and attendance in both groups was regular.
Quantitative investigation
Baseline demographic data were recorded at time T1. QoL was
measured at times T1 and T2 using the Quality of Life Alzheimers
Disease (QoL-AD) tool Logsdon, Gibbons, McCurry, & Teri (1999)
which assesses QoL from the perspectives of family and friends,
socialisation, life as a whole and self as a whole. QoL-AD is a 13-
item self and caregiver measure rated on a 4-point scale (1 being
poor and 4 being excellent) with a total score between 13 and 52.
QoL-AD provides a composite score of the person with dementia
and caregiver responses. The psychometric properties of this scale
are considered to be reliable and valid for older adults (Logsdon,
Gibbons, McCurry & Teri, 2002, p. 510) and the testretest reliabil-
ity of this scale for patients with cognitive impairment and their
caregivers was 83% and 90% respectively (p. 510).
Statistical analysis
Demographic and study quantitative data were analysed using
an independent samples t-test and Fishers exact test as appropri-
ate to provide comparisons between the drama therapy and movie
groups.
To examine changes in average QoL-AD scores over time and
between groups, a (paired) QoL-AD change score was rst calcu-
lated by subtracting each participants score at T1 (baseline) from
that at T2 (completion of the intervention).
Statistical comparisons were two-tailed and a p-value of less
than 0.05 was taken to indicate statistical signicance. Data were
analysed using SPSS Version 20.0 (SPSS, 2012) and Excel 2007
(Microsoft).
Quantitative results
Table 2 presents the study characteristics of the drama therapy
and movie groups.
The study groups were not statistically signicantly different in
terms of age (t(11) = 0.79, p = 0.46), gender (p = 0.31), educational
Table 2
Participant characteristics and QoL scores pre and post intervention.
Variables Level Drama therapy Movies
(N = 4) (N = 9)
Age, average (SD) 70.5 (7.1) 74.0 (7.7)
Gender (N) Male 3 9
Female 1 0
Education (N) High school only 1 6
Tertiary degree 3 3
Diagnosis (N) Alzheimers disease 3 9
Other dementias 1 0
QoL score (scale Time 1 (baseline) 47.0 (4.4) 48.3 (6.4)
1352), average (SD) Time 2 48.0 (4.7) 47.0 (6.1)
attainment (p = 0.27), type of dementia (p = 0.31) or baseline QoL-
AD score (t(9) = 0.44, p = 0.67).
On average, over the study period the drama therapy group QoL-
AD scores increased by 1.0 (SD 3.9) points (with 3 of 4 participant
scores increasing) whereas those of the movie group decreased
by 1.8 (SD 5.5) points (with 7 of 9 participant scores decreasing).
However, this difference was not statistically signicantly different
(t(8) = 1.03, p = 0.33).
Qualitative investigation
Qualitative data were obtained and examined using pheno-
menological methods including recording and transcribing body
language and dialogue, as well as narrative, ethnography, group
themes and metaphor. However, qualitative research can be seen
as complementary rather than incompatible with its quanti-
tative counterpart (Malterud, 2001, p. 483). Qualitative enquiry
investigates the reasons behind how things happen (Grainger,
1999, p. 74) while quantitative inquiry is generally concerned with
assessing change statistically. Drama therapy in the context of this
study aimed to improve QoL (quantied by QoL-AD) as well as heal
aspects of self and relationship of the participants, and our paral-
lel qualitative investigation was a means of exploring and richly
describing if and how any improvement occurred through drama
therapy.
Themes emerge within any therapeutic process, including
drama therapy, and part of the professional training of the therapist
is to identify and work further with these themes. Thematic anal-
ysis is also a primary technique of qualitative research where the
investigator needs to show through choice of themes something
important about the data set in relation to the research question
(Braun & Clarke, 2006, p. 82). In the present case, the chosen themes
were all loosely indicative of the QoL attributes listed earlier. This
convergence might best be understood by regarding the qualita-
tive aspect of the present project as a cooperative enquiry (Heron,
1996), wherein the research participants are simultaneously clients
and co-producers of knowledge. Moreover, producing knowledge
about ones condition, individually and/or collectively, can itself
be therapeutic. The fact that the therapist/researcher is engaged
in both therapy and research at once also requires sensitivity and
is not without its pitfalls (Human, 2010). However, conducting an
on-going, reexive meta-analysis of the phenomenological data
can provide a balance as well as enhancing the therapeutic pro-
cess and contributing to research outcomes. (Inter-) subjectivity
is a strength and a limitation of such practitioner-led qualitative
research, and in this study is also balanced by a quantitative dimen-
sion.
 J. Jaaniste et al. / The Arts in Psychotherapy 43 (2015) 4048 45

Themes emerging in the drama therapy away thinking about shaving off his beard for her. He never actu-
ally removed his beard, but in the session he transferred his own
Themes of anger and frustration, family members, demen- opportunity for life improvement to his wife, perhaps because he
tia/memory loss and grief arose during the drama therapy sessions. felt he owed her a lot, or perhaps because magic did not t with the
Participants names have been changed for de-identication pur- religious beliefs he had shared with us.
poses. There had been hard times early in the lives of more than one of
the middle class, well-educated participants. In Leannes case, her
parents had been poor and she had led a hand to mouth existence.
Anger and frustration
Leannes mother had not been able to persuade an abusive school
principal to change her behaviour towards Leanne. Leannes mem-
Very early in the life of the group, Tanya, an 88 year old woman
ories were inspired by the selection of projective material. Objects
with moderate dementia who often spoke for other participants,
and toys, which use the metaphorical distance provided by drama
voiced frustration that she had lost her brain and that she had no
(Langley, 2006, p. 136), are often used in drama therapy interven-
idea who had brought her to the facility. Johnson (1994) writes of
tions. Used as a distancing technique, the objects assist clients to
the shame that clients can suffer when they feel constantly humil-
access memories rather than constrain them with open questions
iated, as Tanya surely did. She demonstrated her shame by hiding
which can be difcult for people with dementia. For the purposes of
her face and saying she wished not to be there. At other times she
this group, objects relevant for the average age of the participants
would adopt an air of wanting to control the group, nding fault
were chosen by the drama therapist.
with others, and in so doing failed to make interpersonal contact.
Leanne chose a silver serviette ring, a type of item which had
These defences increased her frustration and contributed to her
been of no use to the family and stayed in the drawer; in other
repeated shame-prone incidents during the programme (p. 176).
words, they lived simply and such items were irrelevant to their
In the rst session, photographs were offered to and chosen by
lives. Ben, a 73 year old man with moderate dementia and whose
participants. The selections made spoke volumes about anger and
verbal abilities deteriorated over the study period, had improvised
frustration. In Tanyas chosen picture, the farmer is pouring grain
the role of a stove in a kitchen where people had left notes for each
out of his bag onto a drought-stricken, grassless eld for his sheep,
other when he was a teenager. His father was rarely at home. That
surrounded by heat haze. It looked like a hard and thankless task;
was a shameful kitchen, he said. He could not say why this was so
getting up in the mornings may have been like that for most partic-
(participants were often questioned about their memories, but fre-
ipants. Tanya was not sure why she chose the picture but noticed
quently declined to or could not reply); however, his mood changed
that the sheep were being fed. Neil, a 62 year old man with early
and he seemed sad. Drama gave Paul, an 85 year old retired architect
onset dementia, said he was heavier in mood than he had been
with moderate dementia, the opportunity to celebrate his parents,
recently and chose a light hang-gliding photo. Neil had not ini-
children and wife, while the projective qualities of a babushka doll
tially wanted to come to the group, as he felt he was often singled
stirred Tanyas memories of her brave father who had made sure
out for programmes. Somewhere in his frustration may have been
they left their Nazi-occupied country. David took on the role of a
this hope of lightness of being.
glass window, behind which he remembered snuggling up with
As the sessions progressed, participants embodied their frustra-
his beloved family dog and his lost twin brother, mentally diving
tions. David, a 74 year old man with unspecied dementia who had
through the glass between them and their grandfather - to get the
introduced himself on the rst day with sts at the ready, impro-
attention he never was given as a child at a boarding school he
vised a bull-ght. He was lonely at home by himself and craved
hated. The story of Ulu and the Breadfruit Tree (Gersie and King,
attention. He was encouraged to talk in sessions about his anger
1990) was role played by Neil and David, together with two art
(as recommended in the talking therapies, see Daldrup, Engle, &
therapy students. Once again, David was able to get attention in
Greenberg [1988]). However, for some clients the promotion of
the role of the invalided young son. Neil played the dying father
action methods appears to promote signicant clinical change
which assisted him to grieve and resolve his paternal relationship.
(Wiener, 1999, p. xiii). Two spontaneous dramas involving all par-
Situations involving family members and others emerged
ticipants occurred during the programme. It is signicant that both
through use of DvT techniques, in the story-making and in the
were concerned with strong feelings of anger and frustration: a
improvisations, and allowed others to witness loving, joyful,
march to Parliament House was dramatised, waving banners and
uncomfortable, burdensome and sad family times without empha-
protesting to a politician, and the gurative expulsion from the
sizing or stereotyping anyone as elderly or having dementia. The
drama space of an abusive teacher in the early life of Leanne, a
movement of the sessions from warm-ups to play, to main event,
70 year old woman with moderate dementia, was also enacted.
to reection and closure allowed previously blocked memories to
Difculty in articulating thoughts, painful feelings of shame, of
ow and participants to be free for a while from the expectations
being a disappointment to a caregiver and fear of abandonment
of their caregivers.
can all be factors in bringing these frustrations and anger to group
sessions. Unarticulated and irrational feelings that are usually held
within often come to the surface through drama therapy (Emunah,
Grief and loss
1994) and were prevalent during these drama therapy sessions.
In her article dealing with death anxiety in older adults, Grun-
Family berg Smith uses case examples to highlight how DvT techniques
can show
There were times during the sessions when participants accom-
how, even though we are all born alone and die alone, we can be
panying family members were actually or guratively present
together in our aloneness. Coming up against the bony truths of
within the space. This was not surprising, as each participant had
the existential givens of life, the older adults in this nursing home
a relative as their caregiver. Occasionally, a family member was
found a soft resting place within the Developmental Transforma-
focused on instead of the participant. For example, in one session
tions group (Grunberg Smith, 2000, p. 331).
Neil was offered a new life opportunity or gift from an improvised
Magic Shop (Emunah, 1994). He did not choose one for himself The contract made initially with the group ensured a safe place
but instead wanted to give his wife something special. He went to grieve, as did warm-up trust exercises in the two grief and loss
46 J. Jaaniste et al. / The Arts in Psychotherapy 43 (2015) 4048
sessions. Safety boundaries of condentiality and time manage-
ment helped to establish trust and enabled participants to feel
comfortable about expressing their losses. One of the art therapy
students taking part in the sessions lost her mother during the
course of the programme and her sharing of her own grief assisted
others to express instances of loss and mourning.
Examples of loss were manifold, partly because the participants
themselves realised the sessions were a forum for memories. For
example, it was a natural progression for Neil to re-cognise a
scent in one smelling game and go on to celebrate memories of
his mother, feeling the yearning that came when he realised she
could not live forever.
Early in the rst grief and loss session, Leanne criticised the lack
of consideration of those who advise the grieving person to get
over it. The bereavement story of Ulu and the Breadfruit Tree was
told and then dramatised by participants and students in the reec-
tion time after a trust exercise. Emotionally affected by the story,
even though he had objected to its appropriation from a different
culture, Paul told us of some German immigrants who were not
allowed to stay in Australia after being incarcerated during World
War II and who experienced environmental dislocation and stigma
as a result. The symptoms of loss of a sense of place and loss of social
status apply to people with dementia as well. Dislocation can also
be experienced by those who are placed in care. These forms of loss
affect the QoL of people with dementia (Alzheimers Society report,
2010).
Two male participants regretted wartime deaths (all those killed
in war and a father who fought in World War II), as well as a twins
death in an aerobatic ight. Such regrets can add to a persons
burden of lack of recall, language deprivation and loss of friends.
Bowlby (1998) considers that such losses, if not grieved at the time,
may be associated with the onset of depression, a condition which
frequently accompanies dementia. Johnson (2010), in an article on
war veterans losses, explains how national and patriotic narra-
tives can be used to give meaning to returned soldiers. People with
dementia also need such narratives to make sense of their lives in
the absence of comprehension. In Johnsons (2010, p. 62) words: To
perform incomprehensibility, rather than trying to be comprehen-
sible; to show absence through mime, gesture, tone and stillness,
rather than only to tell the story through word can assist people
to cope with trauma; as was the case for Leanne, described below.
In the second last session, after the dramatised group projec-
tion of her abusive teachers power over her, Leanne said that she
didnt want to be one of those people whos always looking down
and feeling miserable. Her choice of photograph in the very rst
session, had depicted a small boy, unhappy because (he was) look-
ing down. Her later statement seemed to link her catharsis of grief
and shame to the picture. The comments of Leanne and her co-
participants at the end of the later session brought it to a warm and
cohesive close:
Neil: Leannes the Queen of the Castle.
Ben: It was certainly times coming to clear [sic] all those things
that mattered and do something about it.
Leanne: Im so relieved thats over. Its been good. Its been very
thera-patic [sic] (also see Jaaniste, 2013a).
Leannes caregiver, having called the memory of the emo-
tional abuse an obsessional memory as it was so often repeated,
reported one year after the closure of the drama therapy group
that Leanne had never mentioned the issue again (Jaaniste, 2013b,
p. 123).
Leannes embodied experience in the drama therapy space
assisted her to deal with the bleak memories and enhanced her
feelings for group members. Grunberg Smith (2000) writes about
isolation in aging nursing home residents, quoting Yalom, No rela-
tionship can eliminate isolation, but existential aloneness can be
shared in such a way that love compensates for its pain (Yalom,
1980, p. 363). In contrast, the study participants lived in the com-
munity; but the drama therapy work with shared grief and loss also
contributed to improving their QoL, bringing joy and support of one
another rather than further sadness.
Memory and loss
In the rst memory session, entitled The Joys and Woes of Mem-
ory, some poignant moments in participants professional lives
were elucidated. David remembered being articled as a solicitors
clerk for 2 a week and Paul picked up an architects pen and fondly
remembered his lifes work designing buildings. It became obvious
that, for the men especially, working life was important and not
working was associated with a loss of status.
For Leanne, the only female participant of this session, there
was a more homely memory. She rarely spoke of her teaching
career except to say that she was a very different kind of teacher
from the one who had abused her as a child. The act of choosing
a cotton reel from a large group of objects helped her to remem-
ber how she had made her own clothes as an adolescent as there
had been very little money in the home to spend on them. Early in
the session entitled In the Land of Dementia there was conversation
about dementia and memory. The following discourse occurred,
delivered with humour about forgetfulness and the unforgiving and
slippery power of words to hide and vanish.
Paul: I discovered a lot of things about memory, or lack of mem-
ory.
Joanna (drama therapist): What have you discovered?
Paul: Well, I forget things left, right and centre. Forgotten. (broad
smile)
Leanne: Gone, gone, gone!
Neil (laughing): Very good. Ah, good one! (general laughter)
Ben, whose word retrieval ability seemed to be diminishing
quickly, was confused by playing a Fruit Bowl game. Each time he
was it in the centre of the circle and called out apples, bananas
or oranges, he completely forgot to nd himself a chair after
everyone swapped places and so found himself back in the middle.
Later in the same session, Neil spoke about his experience of
picking up the sticks of anger, stones of fear, petals of tears and
bowls of emptiness (see Macy and Young Brown, 1998 for sym-
bolic designation) and related a conversation with staff member
Delyse, his partner in the activity dyad:
We talked about I suppose the bigger picture, our part in the
bigger picture, what we can do and what we cant do. Do you
have any thoughts? Can you remember?
He cried as he remembered family members and his conversa-
tion assisted Delyse to talk about the loss of her mother, which in
turn allowed the participants to empathise with her and remem-
ber their own bereavements. Leanne practised a tune on the piano
as we sang Hey, Ho, Nobody Home? (Simon, 1981, p. 194). When
Leanne heard us sing, she said the song pressed [her] buttons. She
remembered how her mother had worked, because they needed
the money, and that Leanne had returned from school to an empty
house.
In summary, the choice of thematic description had three impor-
tant functions. First, it enabled the researcher to track the progress
of the expression of feelings such as anger, frustration, grief and loss
over the 16 sessions. Second, the life situations of the participants
and their relationships with family members past and present were
highlighted, allowing expression of their feelings about those rela-
tionships. Third, participants attitudes to their own diagnoses of
dementia and associated memory loss became more evident.
There are many reasons for improvements in the social, psy-
chosocial, condence, decision-making and grieving areas of QoL.
 J. Jaaniste et al. / The Arts in Psychotherapy 43 (2015) 4048
Socialisation was a signicant factor in the improvement of QoL
observed qualitatively in the drama therapy group, and this can
be perceived in the mounting ease with which the participants
interacted and spoke together.
QoL improvements which align with those advocated by people
with dementia for themselves (Alzheimers Society report, 2010,
pp. 1722) were observed over time as drama therapy participants
got to know and trust one another. Their abilities to communicate
their anger and grief and to be treated fairly became obvious as
they shared information about their relationships and the asso-
ciated joys and losses. They had a condential space in which to
share information about their caregivers and to express their anger
about childhood issues. The two main highlights of the sessions
were the protest march and Leannes unpleasant experience with
her teacher. Several participants sense of humour was apparent,
especially when dementia and memory loss were discussed. Ability
to engage in activities was never called into question, since the only
occasions when participants refused to engage were when physical
abilities were poor (Tanya) or there was objection to appropriat-
ing a story from a different culture (Paul). Even so, Paul showed
independence in that particular judgement. Relationships were dealt
with by Neil, Leanne and David and a sense of personal identity was
displayed by all members of the group.
Discussion
The aim of this pilot study was to examine the effect of drama
therapy upon the QoL of elderly people with mild to moderate
dementia. There was a suggestion of improvement for participants
in the drama therapy groups average QoL-AD score when com-
pared with that of the movie group, although the difference was
not statistically signicant. It is interesting to note that this trend
towards improvement was demonstrated in the context of the fact
that the drama therapy group started with a lower QoL-AD score
at baseline than the movie group, but by the end of the study this
had reversed and the movie group was at a lower level.
There are a number of postulated reasons that may account
for the lack of statistical signicance of the QoL-AD score com-
parison. First, of the 80 candidates initially identied from the
Alzheimers Australia (NSW) database, only 13 participants went on
to complete all 16 sessions and the nal QoL-AD assessment. Con-
sequently, the power of the study to detect a difference in average
QoL scores was compromised by the small sample size. Second, the
small sample size limited the ability to match on all related factors
(baseline QoL, age, gender, education, location) which meant that
both groups were not necessarily starting at an equivalent point.
Further, both groups began with relatively high baseline QoL-AD
scores which may also have limited the studys ability to show any
additional positive effect of drama therapy. Another source of vari-
ation was introduced by the pragmatic decision to hold groups in
two separate cities when the number of volunteers in Sydney was
inadequate for the project. Future randomised studies with larger
numbers of participants of both genders are needed to examine
further the effect of drama therapy on QoL while controlling for fac-
tors such as QoL starting point, date and type of diagnosis, gender,
education level and location.
It is important to note that the themes which emerged
through phenomenological investigation support the suggestion of
improved QoL-AD scores in the drama therapy group. The qualita-
tive data reveal that powerful aspects of QoL such as relationships,
ability to communicate and personal identity were involved which
are in accord with the QoL-AD questionnaire as well as with the
recognised QoL attributes listed previously (Alzheimers Society
report, 2010). No behavioural disturbances of an aggressive or inap-
propriate nature occurred during the sessions and it is clear that
47
drama therapy can help in this area, as anger, frustration and grief
may be expressed responsibly within a safe space. The trend in the
QoL-AD scale, which involves assessment of family and friends,
socialisation, life as a whole and self as a whole, is congruent in
many of its aspects with the qualitative ndings. The study in its
entirety can potentially serve as a resource and stimulus for further
research.
Conclusion
As detailed earlier, Lepp et al. (2003), Wilkinson et al. (1998)
and others have shown some improvements in the wellbeing of
people with dementia when therapeutic drama and drama therapy
are used. Although Rusted et al. (2006) were offering art therapy,
the similarities between the foundations of these two arts therapies
are signicant and the ndings of this earlier research project have
been instructive. Given this contingency, it was hypothesised that
the use of drama therapy could also show an improvement in the
QoL of elderly people with mild to moderate dementia. Our ndings
provide support for this hypothesis.
QoL is a growing concern of caregivers and organisations for
aging populations worldwide. Future mixed method research with
a randomised component that includes recruiting a larger sam-
ple of participants to better represent the wider community would
be instructive. The qualitative research not only supports the sug-
gested improvement in QoL, it demonstrates the ability of people
with dementia to express feeling and show their wealth of expe-
rience brought to bear on the present moment. Further work
conducting drama therapy sessions with people with dementia is
recommended across a greater number of groups, as the outcomes
of this study indicate a promising improvement of quality of life
using drama therapy for people with dementia.
Acknowledgements
Dr Janice Ollerton, who proof read and edited this paper; Kerry
Blake, Sally Dooner and Seiko Furuse, Art Therapists, who made
valuable contributions to the group work and the anonymous
reviewers who assisted us in positioning our work in the wider
research context. Most of all our thanks go to the study participants
for generously sharing their thoughts and feelings.
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