What are the elements needed to create an effective visual art intervention for people with dementia? A qualitative exploration.

BACKGROUND: This article aimed to advance the understanding of 'what works' in visual art interventions from the perspective of key stakeholders, including people with dementia, their family members and visual art professionals.
METHOD: Semi-structured interviews were conducted with 22 participants, exploring their perceptions on barriers, facilitators, perceived benefits, experiences of delivering/attending a visual art intervention and any recommendations for implementation.
RESULTS: Five factors were identified within the interviews that indicated important considerations for intervention structure and implementation, including benefits of group work, a skilled facilitator, participant choice, artistic ability and activity content. While art therapists expressed a clear protection of professional boundaries, the success of all of the visual art interventions was largely attributed to the supportive facilitator who possessed certain core values such as empathy and compassion and had knowledge in both artistic practice and the impact of living with dementia. It was clear the group dynamic was valued, and it was important to provide enjoyable, failure-free activity content with a strong focus on the creative process.
CONCLUSION: These findings offer a direction for evidence-based practice when implementing visual art interventions.

Background

In recent years, arts-based psychosocial interventions have been developing a prominent role in the field of dementia research, particularly as individuals with dementia are provided with a non-verbal channel of communication (Wang & Li, 2016). They appear to make significant achievements in improving attention, quality of life and social skills (Chancellor et al., 2014). Although the evidence base requires further strengthening and is still largely under-theorised (Gray et al., 2017), it is widely accepted that arts-based approaches are important in a variety of ways for ameliorating the lives of people with dementia (Creative Health, APPG, 2017). Different forms of arts-based approaches for people with dementia have flourished, including initiatives as diverse as music, drama, dance and visual art (Zeilig et al., 2018). Visual art is an arts-based approach that can be defined as ‘drawing, painting, sculpture and other art forms’ (British Association of Art Therapists, 2014). Diverse studies have suggested a positive relationship between participation in the visual arts and improvements in well-being (Peisah et al., 2011), cognitive function and communication (Beard, 2012; De Medeiros & Basting, 2014).

Visual art interventions are complex in nature, in that they involve several independent and interacting components (Windle et al., 2018). These include variations in the facilitator skill set, content of the creative activities, participant demographics and the setting in which the intervention is delivered (Pawson et al., 2004). These variations can influence the intervention outcomes, and thus, understanding which elements lead to outcome changes is a key component of intervention research (Medical Research Council, 2006). However, within the limited visual art intervention research in dementia, it is seldom investigated why visual art activities can result in positive outcomes (Burnside et al., 2017). Systematic reviews of arts interventions in dementia care identify this lack of understanding of the processes and elements that lead to beneficial outcomes as problematic and attribute this to methodological weakness and the field still being ‘in its infancy’ (Zeilig et al., 2014, p. 9). They thus recommend further research is required (Windle et al., 2018) in order to inform appropriate future research designs (De Medeiros & Basting, 2014).

A recent systematic review (Shoesmith et al., 2020) examined components of effective visual art interventions. Despite the varying methods, sample sizes and designs, the authors identified a number of common features of successful visual art interventions, based on the description of the intervention provided within the article. These included intervention ‘dose’, session content, participant choice, artistic ability, the role of the facilitator and group work. However, the review noted that qualitative data were seldom collected from the facilitators delivering the interventions, restricting perspectives and opinions on what works and why from those who play a vital role in the implementation and delivery. Furthermore, only five of 21 studies in the review collected interview data from participants with dementia, thus limiting our understanding of the experiences, likes and dislikes of arts interventions within the target population. While this demonstrates that qualitative research has a role in the area of visual art interventions, its role appears to be underutilised. Given stakeholder perspectives are vital in developing successful interventions (Armstrong et al., 2007), it is important to also include their views within intervention design. In response to this, this article aimed to address this gap through contributing to understanding of ‘what works’ in visual art interventions from the perspective of people with dementia, their family members and visual art professionals in relation to the following:

The successful elements of visual art interventions;

The acceptability and feasibility of visual art interventions for people with dementia, including barriers and facilitators to implementation;

The benefits of visual art interventions for people with dementia.

Methods

Participants

Recruitment of visual art professionals

Visual art professionals were art therapists (ATs), creative facilitators (CFs) or artists who had experience of delivering visual art sessions to people with dementia. The visual arts practised included mediums such as drawing, painting and sculpture. The inclusion criteria were as follows: must (1) only use visual arts, as opposed to other arts-based approaches, for example music or dance, (2) have experience of delivering visual art sessions to individuals with dementia and (3) speak English sufficiently to partake in interviews.

Visual ATs were identified via a public listing on the British Association of Art Therapists (BAAT) Web site. Visual art facilitators were recruited through asking local organisations, including day-care centres and charities to act as gatekeeper organisations and distribute information packs to their contacts and networks. If visual art facilitators were interested, they were given the first authors’ contact details to discuss the study and if consented to arrange a convenient time and place for the interview. Snowball sampling (Morgan, 2008) was used to reach other visual art professionals who might be interested in taking part. The interviews were conducted at the visual art professionals’ place of work or via telephone.

Recruitment of people with dementia and family caregivers

Inclusion criteria for both groups (people with dementia and family caregivers (FCs)) included the following: must (1) have capacity to give informed consent, (2) speak English sufficiently to partake in interviews and (3) attend/have attended a visual art intervention within the last year. FCs must have attended the visual art intervention with their relative with dementia, either to participate in the activity or accompany the care recipient. Local organisations, including day-care centres and charities were approached as gatekeeper organisations and asked to distribute the information to their contacts and networks. With their consent, the gatekeeper then passed on the contact details of interested participants to the first author, so they could be contacted directly to confirm willingness to participate and to arrange a convenient time and place for an interview. The interviews were conducted at the local organisations’ offices or via telephone.

Ethical issues

Ethical approval was granted by Leeds Beckett University. Written informed consent was recorded for all participants prior to commencing the interview.

Data collection

Semi-structured interviews were conducted by the first author, using a topic guide developed by the research team prior to conducting interviews (see Supplemental Material). The topic guide was based on existing research, with themes such as the elements required to deliver a successful intervention, the incorporation of participant choice, the perceived quality of sessions and the burdens or benefits of their experiences. This ensured the same topics were discussed with each interviewee group. The topic guide for caregivers was designed to focus on their perceptions on the experiences of their relative/friend from their personal perception.

The guide was applied in a flexible manner, allowing the interviewer to follow up on other cues that arose during the interviews, which helped capture nuances and reflections expressed in participants’ own words and framed in the context of their experiences. Despite having predetermined questions, the interview was refined and guided by the participants’ responses. The interviews were audio-recorded and transcribed verbatim by the first author. Confidentiality was maintained by anonymising the data on transcription.

Data analysis

Thematic analysis was performed in a recursive manner, using guidelines outlined by Braun and Clarke (2006). This involved the following steps: (1) The first author read through the transcripts several times to gain familiarity and highlighted sections of text and coded this under initial descriptive titles; (2) Themes were constructed from codes by the first author utilising the topics asked in the interview questions as a guide for determining what interview content should be analysed and (3) The second and third authors independently reviewed the construction of themes and relevant quotations to agree to the assignment of themes. The data collection and analysis stages were undertaken simultaneously, and data collection was stopped when saturation was achieved and no new codes or themes were being identified. All coded content was included for analysis, and quotes deemed to represent the overarching themes are presented as exemplars of selected themes.

Results

Interviews were conducted with 22 participants (see Table 1 for demographics), including visual ATs (n = 5), visual artists (VAs) (n = 3), CFs (n = 3), people with dementia (n = 6) and FCs (n = 5).

Table 1.

Participant demographics.

Facilitator demographics (n = 11)		N (%)
Gender	Female	11 (100)
Ethnicity	White	9 (82)
Mean age (years)		43 (range 26–57, SD = 10.67)
Mean years in occupation		8.4 (range 1–27, SD = 12.92)

SD = standard deviation.

The facilitators delivered their sessions at a community centre (n = 7) or in a residential care home (n = 4). Table 2 provides details of the interventions delivered by each facilitator. All participants with dementia had attended a different visual art intervention within the last year (delivered by one of the facilitators included within this study, as described in Table 2). For four participants with dementia, the interview was conducted within 1 month of completing the visual art intervention. Two participants completed their interview within 3 months and 6 months of the last visual art session, respectively. The FCs had all attended the same visual art intervention as their relative, either to participate in the activity or accompany the participant with dementia. For four caregivers, the interview was conducted within 1 month of attending, whereas one interview was conducted within 3 months of the last session.

Table 2.

Intervention information delivered by facilitators interviewed.

Facilitator ID	Facilitator role	Group or individual	Group size	Intervention length	Frequency
001	AT	Group	3	No predetermined length	As required
002	AT	Group	4	No predetermined length	As required
003	AT	Group	8	No predetermined length	1 × hour/1 × week
004	VA	Group	6	4 weeks	1 × hour/1 × week
005	VA	Group	7	6 weeks	1 × 50 minutes/1 × week
006	CF	Group	6	4–6 weeks	1–2 × 1 hour/1 × week
007	CF	Group	6	4 weeks	1 × hour/1 × week
008	AT	Group	4	No predetermined length	1 × 50 minutes/1 × week
009	VA	Group	5	4–5 weeks	2 × 45 minutes/1 × week
010	VA	Group	8	6 weeks	1 × hour/1 × week
011	CF	Group	6	4–6 weeks	1 × hour/1 × week

Note: AT = art therapist; VA = Visual artist; CF = Creative facilitator.

The length of interviews varied substantially. The interviews with people with dementia and FCs were often shorter than those conducted with the facilitators, dependent largely on the interviewee’s recall of the intervention they had attended. For visual art facilitators, the interviews ranged from 16 minutes to 32 minutes, with an average length of 17 minutes. For FCs and people with dementia, the interviews ranged from 7 minutes to 15 minutes, with an average length of 8 minutes 11 seconds.

The important considerations for intervention structure and implementation fell under five themes, with a number of sub-themes (see Table 3). Quotations are presented to illustrate the themes. Participants are identified by ID codes: AT, VA, CF, person with dementia (PwD) and FC.

Table 3.

Five main themes with corresponding sub-themes.

Themes	Sub-themes
(1) The benefits of group work	Social inclusion and peer support
	Creating and enhancing relationships
(2) A skilled facilitator	Training and experience
	Core values
(3) Participant choice	Autonomy
	Tailoring to preferences
	Age-appropriate materials
(4) Artistic ability	No prior artistic ability required
	Non-judgemental attitude
(5) Activity content	Style and format
	Presence of a family caregiver
	Stimulating and enjoyable
	Main focus on the creative process

The benefits of group work

This theme reflected that participants perceived group-based visual art interventions as more beneficial than one-to-one implementation. This was for a range of reasons (sub-themes), including social inclusion, peer support, the sharing experience and creating and enhancing relationships.

Social inclusion and peer support

All VAs and CFs offered group sessions only to people with dementia. ATs offered both group and one-to-one sessions, but at the point of interviewing, they had only had experience delivering group sessions to participants with dementia. They indicated that delivering visual art interventions to groups supports social inclusiveness, allowing all participants to be involved, encouraging one another and offering peer support. All facilitators, regardless of their role, agreed that group work was advantageous over one-to-one work.

Group work provides opportunities to learn from one another, to experience that feeling of togetherness. Art is just so inclusive because there is no judgement, art has no right, or wrong answer and it opens a whole avenue for group discussion. (VA: 004)

The participants with dementia also shared this opinion. Five participants expressed they preferred a group format and felt they made more progress in a group than in a one-to-one format.

I don’t think that I would have benefitted from one-to-one arts. It was just nice being with others and it meant I had time to sit and think without the teacher forcing something out of me like I think a one-to-one kind of thing does. (PwD: 005)

I felt part of something, I had a purpose within that group that may not have been there if I was doing something individually. (PwD: 002)

Where participants with dementia were able to identify a reason for this, they attributed it to feelings of peer support and the opportunity to share their experiences with others.

It made me feel like I wasn’t alone for the first time in a long time, and just knowing others had to face it too was a comfort in itself. (PwD: 004)

It was great to hear other people complimenting my work, it spurred me on to want to do more, get better and use it as a way of relaxing. (PwD: 002)

Although the majority of participants with dementia identified they had benefitted from being with others, they also indicated it was important they did not feel ‘pushed’ to share and could do so at their own pace.

It was helpful because it wasn’t intrusive. I’ve been to things before where you have to expand on everything you say, and in this I just got to express myself through art. Even if I wanted to say something, she didn’t push me. (PwD: 002)

While there was a strong support for a group approach, there was one participant who preferred a one-to-one format. This was generally attributed to a personal wish for privacy and the nature of the problems they wanted to work on during the art session.

A one-to-one environment is of greater value to me […] I don’t want other people knowing about my diagnosis and my journey. I’d rather not divulge things like that to others. (PwD: 006)

Creating and enhancing relationships

Participants who attended the visual art interventions felt they were able to form relationships and connections with people who they could relate to, resulting in a warm and supportive environment.

It can get lonely at home, so I enjoy going. It’s a lovely place with lovely people and I really do hope I will continue meeting them. (PwD: 001)

It was of such value to me, relating to people in the same situation and sharing that time together […] and I met lovely people along the way. (PwD: 002)

A sense of belonging and feeling part of a group is of particular importance for people with dementia, given the negative impact caused by social isolation, which may occur after a diagnosis. The FCs reported that participants with dementia used the social networks the visual art groups offered to create and develop friendships.

Since they met, they meet every week. It’s something she looks forward to weekly and it’s a friendship that I don’t think she would have ever developed if she hadn’t have gone. (FC: 001)

The visual art groups also appeared to enhance the relative–caregiver relationship outside of the art sessions themselves. Participants frequently noted that the dyadic relationship had been improved because it gave the individuals something different to discuss and share together.

It’s nicer I am able to talk to my husband now. I did bottle everything up. It’s made me think about it, that using art I can talk about it more. It’s easier to put something on a piece of paper when you’re not feeling up to talking. (PwD: 002)

We’ve started drawing and painting at home, something to share together as we both enjoy it. (FC: 002)

A skilled facilitator

Participants indicated that a key contextual feature within visual art interventions was skilled facilitation. ATs require specialist training, but community-based artists believed they could also effectively deliver a therapeutic intervention with the requisite knowledge and expertise about living with dementia, knowledge about the arts as well as encompassing core values and qualities, such as empathy, respect and patience.

Training and experience

In order to practice legally as an AT in the UK, it is mandatory to complete the training validated by the Health and Care Professions Council (British Association of Art Therapists, 2014). ATs expressed a clear protection of professional boundaries during the interviews.

Those who have not received the professional training cannot deliver art therapy. We are not just arts and health but dealing with severe mental issues and severe distress. (AT: 001)

However, VAs and CFs believed they were able to engage with participants in a therapeutic manner without formal art therapy training. They did not attempt to deliver art therapy but suggested the creative process is in itself therapeutic.

The process is therapeutic. Of course, I am not delivering art therapy, but rather the art I’m delivering is acting as a therapeutic activity. Working with people with dementia for years, you become immersed in what is required […] and really connecting with that person during the creative process. (VA: 005)

Community-based artists who worked with individuals with dementia identified the need for dementia-specific training, as well as a thorough art-based knowledge, suggesting they felt it was important they were prepared to support people holistically taking into account the specific needs of a person during sessions. Dementia-specific training was not mentioned once by ATs.

Having that training and that experience of working with those with dementia is absolutely paramount. It’s a devastating diagnosis and you need to be able to work therapeutically with these individuals, for them to use art as a way of catharsis. (CF: 006)

One CF highlighted the importance of having confidence in their own artistic ability to facilitate a session, and their motivation and enthusiasm while delivering the intervention.

The person who is running the sessions needs to be confident and create excitement, they need to be good at engaging people and drawing them in, how to guide that person so they can get the best out of them. Most certainly people need to feel safe and will pick up if the facilitator isn’t confident, doesn’t believe in the session, isn’t fully present, doesn’t respect them, or isn’t enjoying or being moved themselves. (CF: 011)

Participants with dementia never referred to the training or experience of the facilitator. However, FCs did report that the facilitator(s) having experience within dementia care was important, and they felt more comfortable knowing the visual art sessions were being delivered by someone who had worked with people with dementia before.

The person doing the sessions needs to fully understand the dementia, and the effect it has on the person. (FC: 001)

Core values

When people with dementia were asked about the best element of the intervention, they would often refer to the facilitator, irrespective of their role. The encouragement and support provided by the facilitator was referred to more than other elements of the programme. For example ‘they made me feel so comfortable, she really put me at ease’, and ‘she didn’t push me, she just encouraged me’. Through the interviews, it was apparent facilitator participants perceived there to be certain qualities for an artist working within a health or social care context to have, that are central to success. For example it is vital that the facilitator shows respect, empathy, patience and is able to communicate well with the individual.

The ability to create that empathic relationship with the person is critical. I’ve worked with people who have just recently been diagnosed and we are starting with essentially, the journey of acceptance. Displaying that empathy is just absolutely necessary when someone is going through that. (CF: 011)

When participants were asked what core values were ideal, these characteristics were echoed as valuable by people with dementia and their FCs. Every participant who attended a visual art session always believed their facilitator held positive values, and not one participant held a negative attitude towards the individual delivering the sessions.

They were just so compassionate and empathic. (PwD: 001)

The non-judgemental nature was key for the apprehension to ease, they were just so patient and lovely (FC: 004).

Participant choice

The importance of having access to activities that are tailored to individual preferences is discussed within this theme. Participants indicated that it is important to achieve a balance between promoting autonomy and choice and the risks of causing potential distress via offering too many options.

Autonomy and tailoring to preferences

All facilitators emphasised the importance of preference and participant choice in order to enhance a sense of independence and autonomy. Giving the participant freedom to choose their own materials and techniques heightened their perception of control and allowed the PwD to feel empowered throughout their visual art sessions.

I don’t think art therapy works if you don’t support participant choice. The whole point of creative work and the arts is to express yourself, and you can’t do that if you’re forced to use things you don’t want to use. (AT: 003)

We ask the client what they would want to use. It’s just about giving them that bit of empowerment and control, and assuring them that it’s their time, it’s their artwork. (AT: 001)

Although participant choice was offered as much as possible by all of the facilitators, they also suggested that it is important to not display too many materials so the PwD becomes overwhelmed. This was particularly important if the participant had no prior experience with art and appeared to be anxious at the beginning of the sessions.

It’s finding that balance, so the person can have that control, but not feel scared by the multitude of different options. If the person hasn’t been to any arts-based activities before, it’s difficult for them to know what they want straightaway. (CF: 007)

Subsequently, the facilitators were asked if they used any strategies or techniques to find an optimal balance between supplying a range of materials and techniques, while also ensuring the PwD does not feel overwhelmed or distressed. Common suggestions involved getting to know the participant at the beginning and having an informal conversation with the participant to become more familiar with their needs and preferences, allowing the facilitator to work well with the individual.

An informal chat before we start any sessions, to get an idea of the client’s preference with art. I find if the client has never had any experience with art, I give them options, then the ones they say yes to, I can bring them all along, so they are able to play around with them all and choose. (CF: 007)

The majority of individuals with dementia mentioned participant choice as a beneficial element of the groups too. For one participant, whose experiences of visual art sessions included being restricted to using one creative material, having a wider range of options would have been ‘nicer’.

The woman had loads of things on the table. Everyone in the group got to pick what they wanted to use; paints, pencils, watercolours, clay, beads. (PwD: 003)

It would have been much nicer to have a wider selection of things to use than just pencils. It would have been nice to have an option. (PwD: 006)

Age-appropriate materials

Facilitators also noted they must be cautious in what materials they did offer, to ensure the materials provided would suit the individual’s needs while preserving dignity and independence. The majority of facilitators highlighted that materials and techniques must always be age-appropriate.

It’s paramount that you don’t treat someone with dementia like a child. Their capabilities can be astounding, it’s frustrating to see when creativity and dementia is just seen as giving them some crayons […] Those type of materials can be juvenile, like playdoh, instead of that you can provide some modelling clay which is equally as easy to manipulate and use but looks less childish. (VA: 005)

Artistic ability

This theme represents the perception that no prior artistic ability or experience is required for participants with dementia to engage in a visual art intervention, despite potential apprehension about the creative process. It was identified within this theme that providing a supportive and non-judgemental environment can help ease any initial trepidation.

No prior artistic ability required

Regardless of occupation, all facilitators agreed that previous artistic skills and abilities did not need to be assessed prior to sessions commencing. It was often reported that previous artistic experience is irrelevant to the creative process, and visual art should be an accessible activity that can be enjoyed by a variety of individuals.

We don’t assess individual skill, and it doesn’t matter about previous artistic talent. In fact, we have had the most amazing art made by people, where carers said their loved ones had never made art before, and they’re absolutely blown away that they’ve made art. (CF: 007)

One CF suggested it may be more beneficial for individuals if they had not had any prior artistic experience.

It’s a new language for some people who may have lost another one. I think it’s a different part of someone who has had previous experience that attends a group – feeding into their sense of self and awareness of skills, whereas someone new to it is looking forward rather than trying to re-capture a lost skill. (CF: 011)

Similarly, one AT specified that having previous artistic experience may have a negative impact.

We have found problems with people who have had previous artistic ability, because they are comparing now with what they have previously been able to do. We usually find out that they have a very traumatic response. (AT: 003)

If this occurred, the AT suggested the individual would be referred to another form of art therapy, such as music or dance, as ‘that is not a direct comparison with what they used to be able to do’.

Non-judgemental attitude

The majority of facilitator participants noted that an absence of artistic experience often comes with the fear of creativity. Facilitators highlighted that creativity can be highly personal, and many participants with dementia may feel apprehensive at the sight of a blank page prior to producing artwork. In addition, participants with dementia suggested prior to attending the visual art sessions that they were anxious about their produced artwork being judged. For example ‘I thought if I couldn’t do something good, people would laugh, and I’d be terribly embarrassed’. This fear was highlighted by all participant groups as a challenge, and thus, a non-judgemental attitude is required from the facilitator to encourage participants to begin the creative process and provide a safe and supportive environment for each person to produce artwork and express themselves.

It doesn’t matter at all if you can’t draw, it’s about using a different medium other than verbal language to express yourself. Providing that non-judgement and allowing them to use art exactly how they want is essential. (VA: 005)

There was a general consensus among the individuals with dementia that they were anxious about being creative and apprehensive about the anticipation of attending a new artistic activity. The non-judgemental and supportive environment allowed them to engage with the arts and subsequently feel proud about their achievements.

I think it was the anticipation more than anything. I had never been to anything like that before and I was nervous. Just having that support from the lady and the others in the group was enough to fade that apprehension. (PwD: 002)

Activity content

Participants discussed practical aspects of the sessions, including the session length, frequency and duration of the intervention, as well as whether FCs should attend with their relative. This theme also represents the importance of an enjoyable activity that places focus largely on the creative process, rather than the value of creating an aesthetically pleasing product.

Session format

There were a number of aspects surrounding session format that participants identified as advantageous. For example participants highlighted that the session length is an important element to consider and should allow sufficient time to meaningfully engage with the creative process, yet not be too long that the participant may lose concentration, interest or motivation.

You need to have enough time for the person to really get in the flow of things, but not too long that they just become tired and probably start to disengage. (CF: 011)

I do find it hard to concentrate for long periods of time now. With an hour you have just enough time to complete the activity, have a chat and come out feeling like you’ve achieved something. (PwD: 001)

The visual art professionals also acknowledged that the duration and frequency of the intervention should be carefully considered. The majority of facilitators identified that the session should be delivered weekly for a duration of 4–6 weeks. Facilitators often reported that this amount of time was long enough to be able to observe a positive impact for the participants.

A nice length is between 4-6 weeks. I think that range of time gives people enough time to get acquainted with myself and the group, the weekly attendance for that time builds up the familiarity and […] they will feel very comfortable within the group by about 2-3 weeks in. (CF: 011)

One facilitator suggested that a longer intervention may become tiresome for the participants, and a shorter duration of 4–6 weeks would maintain their attention.

I was seeing that two months in, the attendance was very poor. I assume it had run its course so to speak, people were getting tiresome or bored […] a shorter period with an eclectic mix of sessions would maintain interest and engagement. (VA: 010).

People with dementia echoed this and reported that a six-session duration was sufficient. The only participant who disagreed attributed the reason to wanting more sessions due to enjoying the visual art intervention and wished to continue the beneficial experience of accessing the groups.

Six sessions is good for me because I could participate in different things and get out of it what I wanted. (PwD: 004)

More than enough, I just went in wanting to try something new and I think six-weeks was enough for that. (PwD: 002)

I didn’t want them to end, I wished it could have gone on for longer. It was something I really looked forward to each week because I can get quite lonely, you know. It was just easy, easy to be there. (PwD: 005)

Presence of a FC

Given there is the possibility to deliver visual arts interventions just to people with dementia or to include family members/caregivers, facilitators were asked whether they felt family or friends should attend the sessions with people with dementia. The majority stated this should be based on the preference of the PwD; however, two facilitators stated they should not attend.

It’s an empowerment thing. I know that the family members always want the best for their loved one, but I run my art groups for the individuals living with dementia. I want them to be in control of their art […] I want them to be in a situation where nothing can influence their own creativity, and their artwork to be solely created from their creative process. (CF: 011)

Participants with dementia were also invited to discuss their opinions regarding the presence or absence of a caregiver in the sessions. There was a general consensus that while they enjoyed attending activities with a relative or friend, they also felt that ‘having time just for me’ was beneficial. This time spent with a group of peers in the absence of a caregiver appeared to be valuable for participants with dementia.

Whilst it was lovely having him there, I also treasure having time just for me, a thing just for me while I’m not dwelling on the negatives, it brings me a lot of comfort (PwD: 002)

I was anxious before I joined, and I felt I needed him there. Now I don’t and I know it’s lovely to share this with others just being me (PwD: 003)

Stimulating and enjoyable, main focus on the creative process

Every facilitator highlighted the importance of the activities being stimulating and enjoyable for the PwD. They all wished to deliver an activity that was enriching and fun. To achieve this, the facilitators commonly reported that factual questions should be avoided, so the art can be approached in a purely sensory way, and the main focus would subsequently be placed on the creative process itself.

Just have fun with it, make it worth their while, fun and enriching, interesting. Everything should be placed on their creative journey and not who can make the best piece of art or who knows the most about an artist. (CF: 007)

Facilitator participants often identified the need to enable discussion ‘in the moment’, and not to just encourage discussion at the end of the session. By doing so, participants with dementia could experience enjoyment while also recognising their own personal learning and development, alongside enjoying the socialising aspect with their peers.

Art is about ‘in the moment’ […] It’s important to have discussions as you see fit, because it will allow for the person to understand they can participate in the arts, they can learn or create something new and have opinions about it that they can share. (CF: 011)

Furthermore, all facilitators highlighted the importance of the process remaining failure-free. They reported that this lowered participant apprehension from the beginning, especially for those who believed visual art groups placed emphasise on the aesthetic value of the product.

Always needs to be completely failure-free, […], once people realise that, their barrier comes completely down because they understand no one is judging their work. (VA: 009)

That fear of creativity at the beginning is intense. That non-judgemental environment shows that failing is just not a valid concept in the world of visual art. (CF: 007)

Discussion

This article aimed to explore key components of existing visual art interventions, from the perspective of various key stakeholders. Qualitative data from semi-structured interviews were sought to identify barriers, facilitators, perceived benefits, experiences of delivering/attending a visual art intervention and any recommendations for implementation. Although art therapy and therapeutic art-making are distinguishable for multiple reasons (according to the British Association of Art Therapists (2014), art therapy can only be delivered by a qualified and registered professional, and the primary aim is to address emotional issues), this study identifies elements from both approaches. This combination was important in order to capture successful elements from a broader perspective of various existing visual art interventions, which could usefully be adopted in the development and implementation of future creative interventions. The experiences of participants were positive, and indicated there is a need for meaningful, focused creative activities in the community, such as group visual art interventions that people with dementia can attend.

Structural elements of interventions varied between those offered by the visual art professionals within this study. Participants described a variety of formats for their interventions, including different frequencies and durations of the sessions. However, all of the programmes were delivered in groups. Previous literature demonstrates the benefits of socialisation through shared art activities (e.g. Flatt et al. (2015), MacPherson et al. (2009) and Ullán et al. (2013)) and notable improvements in relationships between caregivers and people with dementia (e.g. Camic et al. (2016) and Johnson et al. (2017)). Group work is strongly supported in previous literature, as it can provide people with dementia an opportunity to meet other people in a similar situation, share their experiences and enjoy shared activities and interests (Øksnebjerg et al., 2018). Engaging in a meaningful, social interaction with others can play a vital role in terms of positively influencing well-being and quality of life in people with dementia (McDermott et al., 2018; Woods et al., 2012). Furthermore, delivering sessions to groups has been argued to be essential for realisation of the benefits of visual art interventions (Hanevik et al., 2013). The current findings indicate that the group dynamic should be considered alongside the activities and materials used. This combination may help facilitate successful uptake and implementation.

Despite these documented benefits, one participant with dementia in the current study suggested they would prefer a one-to-one format, attributed to a personal wish for privacy and the nature of their problems they wished to work on during visual art sessions. The primary aim of art therapy is to address deeper emotional issues, and some people with dementia may feel more comfortable discussing distressing emotions in a focused one-to-one interaction with the facilitator. Given all of the therapists in this study highlighted the value of group work, it would have been beneficial to include visual ATs who had experience of delivering both group-based and one-to-one sessions with people with dementia to explore their perceptions. Conversely, it was clear that art-making delivered by CFs and/or VAs exclusively offered a creative activity embedded within social and peer support. The combination of socialisation and the art activity itself may be important to achieve value for the participants, achieving positive psychosocial impacts without the overt emphasis on the uncovering and exploring of emotion as there is in art therapy.

Irrespective of the role of the facilitator, they generally agreed with each other on the facilitators and barriers they identified to implementing a visual art intervention. Despite this, the protection of professional boundaries for ATs is clearly apparent, and it was implied throughout certain interviews that art therapy training is essential to acquire the necessary qualities to implement a visual art intervention. This perception is common in previous literature, with research indicating that through art therapy training, individuals will acquire certain qualities that community-based artists do not possess. These include interpersonal sensitivity, observational skills, awareness of group dynamics and an ability to create psychological safety (Moon & Shuman, 2013). These attributes contribute towards their ability to critically analyse social issues and work well with a community (Frostig, 2011). Furthermore, ATs highlighted the importance of being able to work with difficult emotions. The ability to handle emotional situations is necessary in order to create a sense of safety for the individual (Lawthom et al., 2007) and is an advantageous skill for artists working collaboratively with communities (Finkelpearl, 2013). Lawthom et al. (2007) indicated that community-based artists may lack dementia-specific training or mental health training and knowledge, resulting in challenging situations that they will not be equipped for.

However, not all participants shared these views, as many agreed that delivery can occur by any person who has a detailed knowledge of dementia, understanding of visual art and core traits such as empathy and patience. As several participants with dementia were attending visual art sessions for the first time, successful and meaningful experiences may be attributable to the sensitive and supportive nature of the facilitator, and their knowledge of the impact of living with dementia. Previous literature has indicated that a key contextual feature of visual art programmes is the role of the artist facilitators (Windle et al., 2018). Aligning with the current results, Windle et al. (2018) identified that a skilled facilitator was not only knowledgeable about artistic practice, but they also had knowledge and expertise about living with dementia. In addition, previous research supports that successful visual art interventions can be delivered by those who are not trained ATs (e.g. Sauer et al. (2016)). In the intervention delivered by Sauer et al. (2016), facilitators were trained in ways of effectively promoting the autonomy and selfhood of the participant with dementia, incorporating person-centred core values such as compassion and empathy. The authors reported enhanced well-being for participants with dementia during the sessions, indicating that such core values are important for the facilitators to possess.

In the current study, there was a general consensus between community-based artists that the visual art process is therapeutic in itself, and specialist training is not required to deliver a therapeutic, visual art session that can provide positive impacts for the PwD. Rather, therapeutic art can be delivered by a facilitator who designs and initiates spontaneous, expressive and creative processes for participants, and their roles can largely vary from artists to counsellors to helping professionals such as non-profit workers and volunteers (Klammer, 2017). Previous literature has reported that an art-based intervention is therapeutic if it involves (1) a minimum of five sessions, (2) a therapeutic relationship between the facilitator and participant, (3) a therapeutic objective which may include communication, relationships, learning or expression, (4) individual preferences and (5) active participation from individuals with dementia (Van der Steen et al., 2018), thus differing from traditional arts and craft activities that only require active participation from the individual with dementia. Furthermore, previous research has indicated that therapeutic interventions can be successfully delivered to people with dementia by non-specialist staff, for example cognitive stimulation therapy (Spector et al., 2006), music-based therapeutic interventions (Van der Steen et al. (2018)) and therapeutic reminiscence (Thorgrimsen et al., 2002).

Although facilitators are able to successfully use person-centred therapeutic principles within visual art sessions (e.g. Sauer et al. (2016)), they should not equate this with their ability to be qualified to provide structured psychological therapies. However, it is still possible for a therapeutic relationship to develop, as the establishment of this relationship can be built on sincerity, empathy, altruism and congeniality (Gibson, 2006). It has to evolve around qualities such as respect, trust and effective communication skills with the individual (Reynolds & Austin, 2000), core values in which many community-based artists recruited in this study believed they possessed and perceived as necessary for the successful implementation of a visual art intervention. Furthermore, the requirement for specialist staffing to deliver interventions, such as ATs, does have a potential cost implication that may inhibit implementation in certain settings.

Regardless of professional background, facilitators recognised the need for participant choice. The ability to deliver an intervention that is tailored to individual preference is likely to increase engagement as opposed to a non-preferred activity (LeBlanc et al., 2006). This engagement may persist longer and with fewer staff prompts if individual preference is considered when offering choices (LeBlanc et al., 2006). In addition, previous visual art intervention studies have reported that freedom of choice enhances the individual’s sense of independence and stimulates different senses (Brownell, 2008; Sauer et al., 2016). Personally tailored activities should include an assessment of personal interests or preferences of the participants, and the choices should be based on this assessment (Mӧhler et al., 2018). In line with previous research, it is likely that participants will be more engaged with the particular activity depending on their past and present preferences (Cohen-Mansfield et al., 2017). The meaning of stimuli to participants with dementia, and the extent to which they prefer such stimuli, was found to impact the levels of engagement with those stimuli (Cohen-Mansfield et al., 2010). By completing an assessment prior to the sessions commencing, this would also reduce potential distress by displaying too many materials to the participant at the beginning of the intervention. Last, the data collected from the interviews strongly support that the content should be enjoyable, failure-free and stimulating. These findings align with a previous visual art study, indicating that when sessions were designed to be failure-free, enjoyable and focused on the strengths of those with dementia, participants experienced higher intensities of well-being, engagement and pleasure (Sauer et al., 2016).

Incorporating all of these elements appeared to bring about enjoyment and satisfaction with the visual art intervention. This article yields valuable insight into individual perceptions of ‘what works’ in visual art interventions and adds to a small but growing body of research exploring the use of visual art within dementia care.

Limitations

A key limitation of this study is the use of retrospective design, as there was a delay between intervention attendance and the interviews conducted. For those experiencing cognitive impairments, it may be particularly challenging to accurately recall information about their past experiences. Additionally, if a significant amount of time had passed since attendance, this could decrease the accuracy of recall for the participants. Thus, it is likely this may have resulted in recall bias due to potential inaccuracies in the reported recollections. This limitation is important in guiding future research, whereby the delay between attendance and recall should be shortened to ensure better accuracy in results.

Despite efforts to include similar numbers of participant groups, more facilitators (n = 11) were recruited than people with dementia (n = 6) or their FCs (n = 5). Therefore, their views may be disproportionately represented in the themes. Additionally, all of the facilitators were female. However, it was apparent there was a clear gender imbalance when searching for therapists on the BAAT Web site. Of 193 therapists found across 23 regions, only 21 (11%) were male. It would be beneficial to incorporate the perspectives of male visual art facilitators in future research to ascertain whether their views differ. The sample only included people with dementia who were able to consent and take part in an interview, so perspectives and experiences of people with more moderate to severe dementia, who may still gain benefit from visual art interventions that were not included. Despite this, the interviews did rely on participants with dementia retrospectively recalling their experience of a visual art intervention and, thus, may have been more problematic for those with more severe cognitive impairment.

Lastly, all participants had experienced a positive visual art intervention and believed they were beneficial and could result in positive outcomes. This meant that the views of those who had indifferent or negative opinions on visual art were not explored. In addition, there is a possibility that facilitator participants may have attempted to come across as more positive about their work due to a social desirability bias. As a result, the data presented in this article may offer a biased view of visual art interventions. Nevertheless, data from this study add to the current theorising around how visual art programmes may be effectively implemented.

Conclusion

This study aimed to identify key components of successful visual art interventions, key stakeholders’ opinions regarding acceptability and feasibility of visual art interventions for people with dementia, including barriers and facilitators to implementation, and their perceptions of benefits of visual art interventions for people with dementia. Although initially apprehensive, the participants with dementia experienced many positive feelings creating visual art, and the sessions provided opportunities for socialisation and engagement in a meaningful activity. The success of the experiences was largely attributed to the group dynamic and the strong focus on enjoyable, tailored, failure-free activity content. In addition, it was apparent that people with dementia and FCs valued the supportive, collaborative assistance of a skilled facilitator, who was knowledgeable about the impact of living with dementia and possessed core values such as empathy and compassion. Although quantitative data provide evidence on intervention efficacy/effectiveness, personal perspectives of key stakeholders provide important evidence when understanding the potential acceptability and feasibility of interventions. Qualitative studies are thus vital to our understanding of how interventions are experienced by participants and those involved in their delivery and contribute to understanding of their motivation to participate and potential reasons for intervention efficacy/effectiveness or lack thereof. Thus, these findings strengthen the evidence base for the arts in dementia care and subsequently offer a direction for evidence-based practice when implementing visual art interventions.

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Supplemental Material, DEMA_10.1177_1471301220938481_1 for What are the elements needed to create an effective visual art intervention for people with dementia? A qualitative exploration by Emily K Shoesmith, Divine Charura and Claire Surr in Dementia

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Supplemental Material, DEMA_10.1177_1471301220938481_3 for What are the elements needed to create an effective visual art intervention for people with dementia? A qualitative exploration by Emily K Shoesmith, Divine Charura and Claire Surr in Dementia