Towards a Purposeful Ending: A study exploring the impact of Dramatherapy on the quality of life of people living with dementia.

By Rasha Mechaeil - University of Sussex Alex Graybow & Peter Cobham - Baobab (Creative Arts Therapies)

Abstract The aim of this study was to explore the effects of Dramatherapy on people living with dementia. The work was a small scale quantitative study carried out over 12 weeks comparing the experience of a Dramatherapy group with an activity group. The subjects lived in the same care home and were randomly assigned to the groups. Audits assessing quality of life measures were carried out at regular intervals. The study found that the clients receiving Dramatherapy showed significant improvements in quantitative measures of attentiveness and engagement compared with those taking part in the activity group. The results identified a cumulative benefit which suggests increasingly positive outcomes for longer term Dramatherapy.

Background In his 1930 article The Stages of Life, Carl Jung wrote A human being would certainly not grow to be seventy or eighty years old if this longevity had no meaning for the species. The afternoon of human life must also have a significance of its own and cannot be merely a pitiful appendage to lifes morning. The need for a purposeful ending is no different for older people who are living with dementia. It may be that there is a greater need to support and nurture a sense of acceptance and reconciliation for this group because dementia not only causes the loss of cognitive functioning, frequently individuals also experience the loss of their independence and relationships.

Dramatherapy works with subjective experience. It provides tools for emotional expression, an opportunity for social interaction and a place for independence and choice. It can give purpose and meaning in an environment where this may be lacking. Dramatherapy also focuses on the importance of contact and connection. It is not based on cognitive ability and so is particularly appropriate for people living with dementia. Alex Graybow and Peter Cobham, Dramatherapists working for Baobab (Creative Arts Therapies) had been subjectively evaluating the benefits of Dramatherapy at Quantum Care. Quantum Care is an organisation providing residential homes and services for older people across Hertfordshire. Quantum Care requested that the Dramatherapy work be more formally evaluated, which led to this project.

Method To evaluate the efficacy of Dramatherapy with a group of individuals living with dementia, we posed the following question: Can Dramatherapy positively affect mood and social contact for older people with dementia thus improving quality of life? We set out to measure eight factors we felt pertained to an individuals quality of life, namely; anxiety, happiness, social contact, body posture, levels of confidence, energy, attention and engagement. We set out to show the immediate effects of Dramatherapy and whether any of these could be sustained. Following conversations with Jenny Rusted, an Experimental Psychologist at the University of Sussex, we agreed that a method similar to a Randomised Control Trial (RCT) would be used as a tool for the evaluation. The study differed from a RCT in that although the clients were randomly assigned to the group, the assessors were not blind to the membership of the groups and therefore the data collected may have been influenced by preconceptions and expectations.

Ethical Considerations Consent was obtained from both the clients and their families. The option to withdraw consent at any time was also given. The consent process was carried out by the management at the care home.

Participants The Dramatherapists spoke with all the residents with dementia on the chosen unit. This was to establish who would be interested in attending the Dramatherapy sessions for the purpose of an evaluation. 4 clients volunteered to attend the group. The Dramatherapists then ran a familiarisation session with the potential group members to assess their response and whether the group will be viable for the evaluation. A control group was set up, running at the same time as the Dramatherapy group. The Control Group carried out an activity. To reduce variables, a similar activity took place each week. 4 clients were randomly chosen from this group and were assessed in the same way as those attending the Dramatherapy sessions.

Data Gathering The assessments were carried out by five assessors, the two Dramatherapists and three members of staff who facilitated the activity group. The Dramatherapists ran workshops for the staff carrying out the assessment to pilot a suitable questionnaire. This allowed for changes to be made to the questionnaire, facilitating the process and ensuring that the aims of the evaluation were understood and supported by the lay assessors. Each assessor completed a questionnaire pre and post each session, rating each client on the eight factors (anxiety, happiness, social contact, body posture, levels of confidence, energy, attention and engagement). One assessor also completed a questionnaire at the mid-point between each of the sessions regarding all of the client subjects. The Dramatherapists kept in depth process notes after each session. These were used to create a more subjective evaluation of the project.

Data Analysis The data analysis and report was prepared by Rasha Mechaeil, Department of Psychology, Sussex University, with guidance from Jennifer Rusted, Department of Psychology, Sussex University
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Study design Eight older people living with dementia took part in a study investigating the potential benefits of Dramatherapy. Four of those eight participants were assigned to a Dramatherapy condition and four acted as control participants, not engaging in Dramatherapy but involved in normal day centre activities in a regular time slot of similar duration to the Dramatherapy session each week. There were 12 sessions in total, over a 13 week period. The effects of therapy were assessed on the basis of eight individual factors, namely, anxiety, happiness, social contact, body posture, levels of confidence, energy, attention, and engagement. Assessments were conducted by five assessors, who each rated each participant on each of the factors pre-session and postsession. Three of the assessors facilitated the control activity and two of the assessors ran the Dramatherapy sessions. (assessors 1 and 2). In addition to the session assessments, one assessor provided an assessment of all participants on all factors at the mid-point between each of the sessions. The data were collated and analysed by researchers at the Department of Psychology, University of Sussex.

Data description As is conventional, an alpha level of .05 was employed for all analyses unless otherwise stated. Volunteer characteristics Mean age for volunteers assigned to the control and Dramatherapy conditions is presented in table 1 below. Group Control Dramatherapy N 4 4 Mean Age 89.5 1.3 85 8.8

Table 1: mean (SD) age of participants

An independent measures t-test revealed no significant difference in age between volunteers in the control group and dramatherapy group [p>.05]. Any treatment effects cannot, therefore, be attributed to age differences between participants.

Pre-session evaluations

Session 6 is excluded from all analyses due to missing data.

For each of the factors of anxiety, happiness, social contact, confidence, body posture, energy, attention, and level of engagement, a mixed 2 x 13 (group x session) analysis of variance (ANOVA) was conducted on pre-sessions to check for group differences prior to engaging in the sessions. No significant differences were evident between volunteers assigned to Dramatherapy or control sessions on any of the measures [all, p>.05]. This was true when the measures recorded by the two assessors who were running the Dramatherapy sessions were included as well as excluded. Figures 1 - 8 below present mean pre session scores assigned by assessors 3 - 5 to the control and Dramatherapy groups for each of the 8 factors under assessment, across the sessions.

Anxiety
4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 7 8 Session 9 10 11 12 13 Control Dramatherapy

Figure 1. Mean (SEM) pre session anxiety over the course of the study

Happiness
4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 7 Session 8 9 10 11 12 13 Control Dramatherapy

Figure 1. Mean (SEM) pre session happiness over the course of the study

Social contact
4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 7 8 Session 9 10 11 12 13 Control Dramatherapy

Figure 1. Mean (SEM) pre session social contact over the course of the study

Confidence
4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 7 Session 8 9 10 11 12 13 Control Dramatherapy

Figure 1. Mean (SEM) pre session confidence over the course of the study

Body posture
4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 7 Session 8 9 10 11 12 13 Control Dramatherapy

Figure 1. Mean pre (SEM) session scores for body posture over the course of the study

Energy level
4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 7 Session 8 9 10 11 12 13

Control Dramatherapy

Figure 1. Mean (SEM) pre session energy levels over the course f the study

Attention
4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 7 Session 8 9 10 11 12 13 Control Dramatherapy

Figure 1. Mean (SEM) pre session attention level over the course of the study

Engagement
4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 7 Session 8 9 10 11 12 13 Control Dramatherapy

Figure 1. Mean (SEM) pre session level of engagement over the course of the study

Cumulative Change The absence of significant differences between participants in pre-session analyses makes it appropriate to analyze the pre-to-post difference scores for each factor to identify change associated with participation in the therapy session. For these analyses, sessions were grouped into three phases of four sessions each with the rationale of identifying cumulative change that is potentially dissociated by stage of therapy. Sessions were grouped into three stages comprising sessions 1 4, sessions 5 9, and sessions 10 13 respectively. Each of the factors under assessment, therefore, was subjected to a 2 x 3 (group x session stage) mixed ANOVA (excluding data provided by assessors 1 and 2)1. Statistically significant changes were revealed for the factors of attention and engagement as demonstrated below.

The same analyses were conducted on the data inclusive of assessments made by assessors 1 and 2 but yielded no significant findings. It was evident from the raw data that assessors 1 and 2 tended to provide higher scores in comparison to assessors 3, 4 and 5, possibly due to greater familiarity of the first two assessors.

Attention Figure 9 presents differences in attention between volunteers assigned to the control group and those assigned to the Dramatherapy group across the three phases of therapy.
0.6 0.4 Pre-to-post attention difference 0.2

0 stage 1 -0.2 -0.4 -0.6 -0.8 -1 stage 2 stage 3 Control Dramatherapy

Figure 9. Mean (SEM) pre-to-post differences in attention levels. Stage 1= sessions 1-4, Stage 2 = sessions 5-9, stage 3 = sessions 10-13.

Results revealed a significant main effect of group [F(1,6)=7.906, p=.03]. This effect is reflected in the positive pre-to-post therapy difference in volunteers assigned to dramatherapy (figure 9). Moreover, the difference was not the same through all stages of the programme, as indicated by a significant group*session stage interaction [F(2,12)=4.620, p=.03]. Multiple independent-measures t-tests (Bonferroni adjusted statistic = .016) exploring the group*session stage interaction indicated that at stage three of therapy (sessions 10 13) volunteers who have undergone Dramatherapy were displaying greater levels of attention relative to volunteers in the control group [t(6)=-3.703, p=.01].

Engagement Figure 10 presents differences in levels of engagement between volunteers assigned to the control group and those assigned to the Dramatherapy group across the three phases of therapy.
0.8 0.6 mean pre-to-post engagement difference 0.4 0.2 0 stage 1 -0.2 -0.4 -0.6 -0.8 -1 stage 2 stage 3

Control Dramatherapy

Figure 10. Mean (SEM) pre-to-post differences in engagement levels. Stage 1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.

Results revealed a significant main effect of group [F(1,6)=8.691, p=.03]. This effect again reflects a positive pre-to-post therapy difference in volunteers assigned to Dramatherapy, with the difference score being higher in that group relative to the control group across all stages (figure 10). Furthermore, there was a near significant group*session phase interaction [F(2,12)=3.583, p=.06]. Multiple independent-measures t-tests (Bonferroni adjusted statistic = .016 denoted the largest difference in engagement levels between the two groups to be seen at stage 3 [t(6)= -2.744, p=.03].

Anxiety, Happiness, Social Contact, Confidence, Body Posture, Energy Figures 11 16 below present the changes occurring on each stage of therapy for the remaining factors. In all cases, when improvements were observed, it was the Dramatherapy group showing improvements across stages of therapy. For these remaining factors, however, observed differences were not statistically significant between the two groups.

Anxiety
0.5 0.4 0.3 0.2 0.1 0 stage 1 -0.1 -0.2 -0.3 -0.4 stage 2 stage 3

Mean pre-to-post anxiety difference

Control Dramatherapy

Figure 11. Mean (SEM) pre-to-post differences in anxiety levels. Stage 1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.

Happiness
0.6 0.5 Mean pre-to-post happiness difference 0.4 0.3 0.2 0.1 0 stage 1 -0.1 -0.2 -0.3 -0.4 stage 2 stage 3 Control Dramatherapy

Figure 12. Mean (SEM) pre-to-post differences in levels of happiness. Stage 1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.

Social Contact
1 0.8 Mean pre-to-post social contact difference 0.6 0.4 0.2 0 stage 1 -0.2 -0.4 -0.6 -0.8 stage 2 stage 3

Control Dramatherapy

Figure 13. Mean (SEM) pre-to-post differences in social contact. Stage 1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.

Confidence
1 0.8 Mean pre-to-post confidence difference 0.6 0.4 0.2 0 stage 1 -0.2 -0.4 -0.6 -0.8 -1 stage 2 stage 3 Control Dramatherapy

Figure 14. Mean (SEM) pre-to-post differences in confidence levels. Stage 1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.

Body Posture
1 0.8 0.6 Mean pre-to-post posture difference 0.4 0.2 0 stage 1 -0.2 -0.4 -0.6 -0.8 -1 stage 2 stage 3 Control Dramatherapy

Figure 15. Mean (SEM) pre-to-post differences in body posture. Stage 1= sessions 1-4, phase 2 = sessions 5-9, phase 3 = sessions 10-13.

Energy
1 0.8 0.6 Mean pre-to-post energy difference 0.4 0.2 0 stage 1 -0.2 -0.4 -0.6 -0.8 -1 stage 2 stage 3 Control Dramatherapy

Figure 16. Mean (SEM) pre-to-post differences in energy levels. Stage 1= sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10-13.

Summary of session effects From the significant changes occurring on levels of attention, it is apparent that the effects of Dramatherapy are cumulative and therefore, are most pronounced towards the final sessions of therapy (stage 3). More specifically, Dramatherapy sustains the positive increase that occurs in phase 2. In contrast, there was a significant drop in levels of attention in the control group relative to the Dramatherapy group at the final phase of therapy (figure 9). Although no significant changes emerged on any of the other factors, the means suggest a positive effect of therapy. In most measures, assessors recorded a non-significant drop in levels of these factors in the control group in stage 3. In contrast, no such drop was seen for volunteers assigned to Dramatherapy. Such pattern is strongest for the factor of engagement (figure 10). The inverse pattern was true for the factor of anxiety, in which volunteers assigned to Dramatherapy experiences a decrease in anxiety levels in phase 3 compared to control participants (figure 11). Energy levels on the other hand were paralleled in the two groups, in which the decrease in energy was equally present in volunteers assigned to Dramatherapy (figure 16).

Maintenance of therapeutic effects (Mid session) The mid session data scored by assessor 3 were used as a measure of how long the effects of sessions were sustained in participants. As before, sessions were split into three stages, with stage three only comprising sessions 10 11, due to absent mid-session data for sessions 12-13. For these analyses, post-to-mid session differences were calculated for each factor and subjected to a 2 x 3 ANOVA (group x session stage). Such analysis reflected the maintenance of effects over time in relation to the previously attended therapy session (post therapy). Statistically significant group*session stage interactions emerged for factors of happiness, social contact, attention, and levels of engagement. These interactions were further explored using multiple independent-measures ttests (Bonferroni adjusted statistic = .02). Figures 17-20 below represent the achieved effects on those factors. Happiness Figure 17 presents maintenance of happiness levels in the post-session intervals for the control and Dramatherapy groups.
0.8

0.6 Mean happiness maintenance

0.4

0.2 Control Dramatherapy

0 stage 1 -0.2 stage 2 stage 3

-0.4

-0.6

-0.8

Figure 17. Mean (SEM) post-to-mid session differences on happiness levels. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.
Results revealed a significant group*session stage interaction [F(2,12)=6.006, p=.02]. Participants assigned to the control group sustained their happiness levels at stage 2 of therapy, during which participants engaging in therapy experienced a lapse in levels of happiness ([t(1,6)=6.728, p=.04]. see figure 17).

Social contact Figure 18 presents maintenance of social contact in the post-session intervals for the control and Dramatherapy groups.
1 0.8 Mean social contact maintenance 0.6 0.4 0.2 0 stage 1 -0.2 -0.4 -0.6 -0.8 -1 stgae 2 stage 3 Control Dramatherapy

Figure 17. Mean (SEM) post-to-mid session differences on social contact. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.

There was a significant group*session stage interaction [F(2,12)=4.568, p=.03], with the largest difference to be seen in social contact at stage 2 of the sessions, [t(1,6)=10.971,p=.02]. This difference was in favour of control participants.

Attention Figure 19 presents maintenance of attention in the post-session intervals for the control and Dramatherapy groups.

1.4

Mean attention maintenance

0.9

0.4 Control Dramatherapy

-0.1

stage 1

stgae 2

stage 3

-0.6

-1.1

-1.6

Figure 19. Mean (SEM) post-to-mid session differences on levels of attention. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.

Results again, demonstrated a group* stage interaction for attention levels, [F(2,12)=13.631, p=.001]. This reflects a significant difference at stage 1 of therapy, during which the maintenance of attention was greater for participants engaging in therapy sessions, [t(1,6)=9.846, p=.02].

Engagement Figure 20 presents maintenance of engagement level in the post-session intervals for the control and Dramatherapy groups.

1.2 1 Mean engagement maintenance 0.8 0.6 0.4 0.2 0 stage 1 -0.2 -0.4 -0.6 -0.8 stgae 2 stage 3 Control Dramatherapy

Figure 20. Mean (SEM) post-to-mid session differences on levels of engagement. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.
A group*stage interaction [F(2,12)=4.345, p=.04] was revealed. The difference was greatest at stage 3 of therapy, in favour of participants assigned to Dramatherapy [t(1,6)=24.000, p=.003].

Anxiety, Confidence, Body Posture, Energy Figures 21-24 below demonstrate the effects of therapeutic sessions on the maintenance of the remaining factors, namely anxiety, confidence, body posture, and energy. For these factors, the post-to-mid session differences were not significantly different between the control and Dramatherapy group. Nonetheless, for the majority of cases, a positive pattern was observed in favour of those assigned to Dramatherapy. Non-significant positive effects of therapy were sustained for confidence (figure 22) and energy levels (figure 24) at stages 1 and 3 of the sessions. Lower levels of anxiety were also sustained as a result of therapy, throughout the study period (figure 21). On the contrary, the post-to-mid session difference on body posture was lower

for participants engaging in therapy relative to control participants at stages 1 and 2. The reverse was apparent at stage 3, however, during which Dramatherapy participants sustained improvements in body posture more than control participants did (figure 23). Anxiety
0.8

0.6 Mean anxiety maintenance

0.4

0.2

Control Dramatherapy

0 stage 1 -0.2 stgae 2 stage 3

-0.4

Figure 21. Mean (SEM) post-to-mid session differences on levels of anxiety. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.
Confidence
1 0.8 0.6 0.4 0.2 0 stage 1 -0.2 -0.4 -0.6 -0.8 -1 stgae 2 stage 3 Control Dramatherapy

Figure 22. Mean (SEM) post-to-mid session differences on confidence levels. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.

Mean confidence maintenance

Body posture
1.4 1.2 1 Mean posture maintenance 0.8 0.6 0.4 0.2 0 stage 1 -0.2 -0.4 -0.6 stgae 2 stage 3 Control Dramatherapy

Figure 23. Mean (SEM) post-to-mid session differences on body posture. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.

Energy
0.3 0.2 0.1 Mean energy maintenance 0 stage 1 -0.1 -0.2 -0.3 -0.4 -0.5 -0.6 stgae 2 stage 3 Control Dramatherapy

Figure 24. Mean (SEM) post-to-mid session differences on energy levels. Stage 1 = sessions 1-4, stage 2 = sessions 5-9, stage 3 = sessions 10 11.

Research Conclusions: Effects of Dramatherapy on people with Dementia Findings from this trial suggest that the experience of Dramatherapy has positive effects on older people living with dementia. The effects were both cumulative across therapy sessions as well as sustainable between sessions on some factors. Positive therapeutic effects are first observed in the evaluations examining the pre-to-post therapy differences. In that set of analyses, Dramatherapy influence was greatest on levels of attention and engagement. Additionally, it was more pronounced in the last stage of therapy, comprising sessions 9-13. A similar pattern was evident on all other factors, in which scores on the final stages of therapy reflected better performance in individuals assigned to Dramatherapy. The final set of data evaluations provided some support for the sustainability of beneficial therapeutic effects. Findings demonstrated that the positive effects of therapy are sustainable between sessions on factors of attention and engagement. This strengthens the initial findings pointing towards positive therapeutic influences specific to those two factors. Moreover, maintenance of positive therapeutic influence on levels of engagement was pronounced towards the final stages of the programme of sessions. This demonstrates that the experience of Dramatherapy enhances levels of engagement as the programme progresses, as well as sustaining this enhancement over time. Implications for the timeframe for such therapeutic interventions are clear: 12 week programmes can produce positive outcomes that are cumulative and still increasing; longer term programmes may produce even larger benefits. Although for factors of happiness and social contact, the sustained effects were in favour of the control group, in the middle stage of therapy, they were followed by a (non-significant) rise in performance to Dramatherapy individuals in the final stages of therapy. This again supports the positive influence of therapeutic effects and sustainability towards the final sessions of therapy. Means on other factors (confidence, body posture, and energy levels) also reflect such pattern. It is thus reasonable to conclude that engagement in Dramatherapy induces positive effects on attention and engagement levels, factors that are considered critical to older people living with dementia. Furthermore, such positive therapeutic effects are sustained between therapeutic sessions. In all cases, effects are more apparent when therapy is treated as a continuous process, during which effect size varies across sessions, but cumulatively leads to positive effects following a 12-week experience of Dramatherapy. Considering the small sample size and the relatively short time frame of the intervention implemented for this study, these results are remarkably positive

and offer a very strong argument for the value of Dramatherapy in this client group.