Pop music played as a group of teenagers danced in the gymnasium. It was a quintessential scene of American youth that could be witnessed throughout the country. Except this school was high atop Crotched Mountain and most of these students were in wheelchairs.
But as 18-year-old Kaitlin extended her hand and her father grabbed it and twirled her wheelchair across the floor, she was no longer limited by cerebral palsy but was instead a girl dancing with her dad.
It was an image that challenged the conventional notion of who is allowed to dance. And it was a reminder that the arts are not highbrow or elitist. They belong to everyone.
The arts can be a distraction but they can also heal and soothe. The arts can light shadows in a mind otherwise darkened by dementia. They can remind us that yes, while cancer and autism do not discriminate neither does the joy of dancing or the warmth of a familiar song.
The power of art is strong and it is being harnessed to not only inspire but heal. Artists are emerging from their studios, theaters and concert halls and are entering the arena of public health. It is a national movement in its infancy and New Hampshire is very much in the lead.
The idea of using art to enhance the human condition is nothing new. Native American medicine has long used song and dance to help heal, as this culture looks at the physical and spiritual connection as paramount to recovery, according to Dr. Laurance Johnston.
And that is but one example. History has many more. But what does “arts in health care” mean today?
For the most part, the arts are administered in health care in three main areas, primarily in, but not limited to, hospitals, nursing homes, and hospices.
The first, according to Catherine O’Brian, Arts and Health Care coordinator for the State Council on the Arts, is to change the environment itself.
“Hospitals and hospices are working at changing the environment,” O’Brian said. “Adding more glass windows, bringing in more plants and having nature trails for both patients and caregivers. Other hospitals are including art galleries.”
The second is when an artist enters a health care facility and either performs in a public space or at bedside. For example, if a child has a sitting blood transfusion that lasts from morning to evening, doctors have found the process is easier if the child and his family are engaged or distracted by an artist.
The final and most scientific avenue is through a board-certified arts therapist. In this situation, a music therapist may use music to help improve an autistic child’s motor skills.
How we got here
This new marriage between the arts and health care is a byproduct of changes in the way we administer care.
The process of using art to heal was codified following World War II, when music was used to soothe soldiers suffering from what is now referred to as post-traumatic stress.
While primitive musical therapy was being used and degrees in arts therapies were being offered, it took many years for the research to catch up with popular opinion. It wasn’t until 1993 and the release of journalist Bill Moyers’ book Healing and the Mind that the practice crossed into public awareness, according to Alice Kinsler, director of Therapeutic Arts and Activity Services at Concord Hospital. Moyers’ book and the entire arts-in-health-care movement look at a patient as a whole human being, which includes mind, body, spirit and emotions.
In the past, surgeons and anesthesiologists might have listened to music they enjoyed as they performed surgery. Now, they play music the patient enjoys, according to Kinsler. As the patient listens, the music often calms him, which makes the anesthesia work more quickly. The more quickly it works, the less is needed. This is an immediate cost-saver, but even better, when the patient wakes up, he is less groggy, which means he can respond better to post-surgery treatment.
“Using art is not just for fun and games,” said Lynn Graton, acting director of the State Council on the Arts. “It is about extending dignity to the most vulnerable chapters of our lives.”
“When you enter the hospital everything is taken away from you, even your clothes,” said O’Brian. “Participating in the arts helps humanize the experience.”
It was also at this time that national health care was changing. “In the past 30 years, health care has ballooned from 6 percent to 16 percent of the nation’s GDP — exceeding $2.5 trillion in 2008,” according to the 2009 State of the Field Report: Arts in Health Care, a collaborative report by the National Endowment for the Arts and the Society for the Arts in Healthcare.
With increasing expenses, there was a call to arms to find other ways to make a patient healthy without medication, technology or science, according to Kinsler. As a result, people began to look at the arts. Immediately, there were some economic savings. A study done by Dr. Gene Cohen, author of The Creative Age: Awakening Human Potential in the Second Half of Life, found that “just comparing medication use and doctor visits between individuals who participated in a choral group and the control group, he calculated annual savings of $172.91 per year per participant.”
Ironically, while researchers were finding benefits from a more human approach to health care, changes in technology were making such an approach more difficult.
As hospital stays began to be driven by insurance companies, according to Kinsler, they became shorter. As a result, the field of nursing changed. In the 1940s and ’50s, patients would have longer hospitals stays and nurses would often sit by their bedside. They would hold the patient’s hand, talk about life, get to know the families and often be there while the patient died.
Along the way, life-saving technology advanced but with it came a shift in nurses’ responsibilities.
“I often hear nurses say they feel like they’re ‘nursing machines’ and no longer nursing patients,” Kinsler said.
While nurses are called to perform superhuman tasks, they are still mortals. As a result, they need a life outside of work. Many work three-day shifts, Kinsler said. So if a patient comes in on the last day of a nurse’s shift, chances are the patient will be gone when the nurse returns next week. As a result the care of patients may need to be compartmentalized. At Concord Hospital, Kinsler and her staff pick up on the human relationships that the nurses would love to do if they had more time.
Arts in use
Kinsler travels the hospital’s corridors pushing Art a la Cart. The cart contains a selection of framed art prints offered to patients who may choose one to hang in their room. Many of the prints are of idyllic images like a trampled pathway leading to the ocean. At first glance, such an activity seems simple, but art is always more complex.
“When patients enter the hospital, so many of their choices are taken away,” Kinsler said. “It can be scary. Just the fact that they get to make a choice on the art can be really helpful.”
When a patient makes a choice, it instantly gives the art additional meaning. The painting wasn’t just hanging in the room; the patient chose this particular image. This creates an invitation for conversation for a caregiver.
Kinsler said some patients refuse the service because the hospital is not their home and they don’t want to be there one moment longer. But she said most enjoy it and when some transfer rooms, even to the Intensive Care Unit (ICU), they ask for the painting to come with them.
To buy 20 prints and frames (Kinsler framed the prints herself) cost $1,000.
Concord Hospital offers much more than Art a la Cart. Although it is not art-related, the program began with Pets Uplift People (P.U.P.), which brings dogs to people’s bedside. The hospital also offers Reiki, the ancient art of Japanese energy healing; TV Bingo, which is broadcast to every room, and live music by Certified Music Practitioners and by volunteers. Sometimes a piano player will tickle the ivories or a guitarist will strum some chords. Additionally, an artist may enter a room and paint a picture for a patient.
Such therapeutic visits have increased greatly over the years at Concord Hospital. In 1990, Kinsler recorded 500 services to patients. Last year the number was 6,800. Some patients have one visit during a stay, while others may hear a musician, play bingo, paint with an artist and see a dog all in the same day. With so many visits it could be assumed that Kinsler has a large staff. In fact, the entire Therapeutic Arts department consists of Kinsler, a part-time employee, and an extensive network of volunteers and interns.
Kinsler said the program has been so successful because, first and foremost, it helps patients. This occurs through the connection of mind and body. If a patient is experiencing pain but is anxious and afraid then his muscles will tense, creating more pain. If that patient is relaxed, so too is the body and then perhaps less pain medication is needed. When people are having fun, the body releases more endorphins, which are natural pain- and stress-fighters.
Even if there aren’t direct physical benefits, patients appreciate the extra effort and feel more satisfied with their stay, according to Kinsler. Since a hospital is a business that competes against other hospitals, maintaining patients for future visits is a positive.
But what is truly beneficial about the use of arts in health care, according to Kinsler, is the impact it has on others besides the patient.
It helps build trust in families as they know when they leave, their loved one will be treated as a human being. There is also a huge impact on staff, which cannot be minimized. Doctors, nurses and extended caregivers appreciate an environment that helps patients heal and helps make the medicine work.
“Now physicians call us all the time and ask us to send a musician to help calm a patient,” Kinsler said. “This never happened before. They’re beginning to see the results.”
At Concord Hospital, these therapeutic visits are being entered into a patient’s electronic file right next to surgery records and medication prescriptions.
One example: Recently a patient, an older woman, was very agitated to such a degree that it was difficult for the nurse to administer care. A hospital employee who plays the flute on her lunch hour played for the woman in her room. While the flute played, the older woman sat still and attentive. Her agitation subsided for hours afterward. The nurse now knows how to connect with that patient in the future.
When an artist engages patients with art, there can be surprising outcomes.
Artist Regina Delaney said she once brought her harp into a nursing home in the north country. She performed a concert but was then asked to go into the room of an elderly woman. The woman had not left her room for some time and was isolated and unresponsive to her treatment. Delaney started playing. Instantly, the woman’s hands and feet began tapping rhythmically. She confessed she used to be a drummer. Delaney got a drum and the woman’s smile lit up the room. The two started jamming. Delaney asked the woman if she would play the drum with her at the next concert. The woman said she would love to. Not only did she leave her room that day and perform in front of a group of her peers, she told Delaney she would try to form a music group at the home.
Inviting artists into health care facilities has been made easier by the dedication of the State Council on the Arts. The Council has created an Arts in Health Care Artist Directory, which is a listing designed to help health care and nursing home providers locate professional artists who can entertain their patients or provide training to staff. The State Council on the Arts acts as a facilitator, matching appropriate artists with health care facilities, according to O’Brian. But it also provides grant opportunities for these facilities, which allow longer-term residencies or projects. The first grant was administered in 2006.
In fact, of the 56 members of the National Assembly of State Arts Agencies, fewer than five have allocated “Arts in Health Care” as a specific category of funding. Judy Rigmont, during her time on the State Council on the Arts, first saw this as a worthwhile cause.
“Now the rest of the country looks to us for leadership in the field,” Graton said.
Arts in health care is an initiative reaching out across the state.
“We are proud of the programs we are running,” said Frumie Selchen, former director of the Arts Alliance of Northern New Hampshire.
Dartmouth Hitchcock in Hanover was one of the first facilities in the state to bring in the arts and now has a long-term poet and story-teller. The Elliot Hospital in Manchester provides artist training. The Center For Expressive Arts, Therapy and Education, also in Manchester, and Havenwood Heritage Heights in Concord are also doing amazing work, just to name a few.
As a state organization, the Council on the Arts is entitled to money from the National Endowment of the Arts. There is a stipulation: the Council must ensure that arts are available to under-served populations — those that face obstacles in getting access to the arts. Each state gets to define who is under-served. The obstacles could include geography, economics, age or health.
Different facilities have different goals, which is why the Council tries to offer broad enough grants to meet a variety of needs, O’Brian said. One example of a grant is one that was given to a group called Senior Moments.
Never too old
Senior Moments began 11 years ago and works in partnership with the Seacoast Repertory Theatre to provide educational performances for seniors by seniors. The group has 18 members, the oldest age 91, according to Joanne Dodge, a member. For those involved, the acting is a new lease on creativity.
“Few of us have any acting experience,” Dodge said. “It gives us a chance to go out and have fun.”
Besides having fun, the group addresses serious topics. They have performed skits across the state reminding seniors to take their medication and how to deal with suicide or depression. The group warms the audience up but is followed by an expert in the field they’re addressing.
Dodge said times have changed. She respected and adored her grandmother; now old people are just old. She said the group works well because they’re going through the same experiences as their audiences.
“Everyone can speak to the youth,” Dodge said. “We’ve all been young. But nobody has been old.”
Nursing homes and hospitals work hard to rehabilitate people both mentally and physically. The Furniture Masters’ Prison Outreach Program tries to rehabilitate inmates’ behavior.
A furniture master, like Terry Moore, will go into the correctional facility in Concord or Berlin and work with inmates as part of the Hobby Craft Program.
“When they’re in prison, every aspect of their lives is ordered,” Moore said. “Hobby Craft is like a different world. They get to create whatever they want. I’ve been told by inmates when they’re in there it’s like they’re not even in prison.”
The Hobby Craft Program is an incentive for prisoners with good behavior. There is a long waiting list, so it can take up to two years to get in. During that time, if a prisoner so much as peeps at a guard, he becomes ineligible. On the flip side, inmates who are in the program have spent a long time in prison most likely because they’ve committed a serious crime, like murder, according to Moore. If that is the case, shouldn’t they feel like they’re in prison? Do they deserve to have one-on-one training with a furniture master?
Moore said the reality of New Hampshire prison is that about 99 percent of inmates will get out at some point in their lives. Even people spending life sentences may get out in 60 years.
“Would you rather have some guy lifting weights for 10 years or learning to work on skills that are changing them on a personal level?” Moore asked. “With prison, there is the punishment side but there is also the rehabilitation side. I feel like if a lot of these guys had discovered wood-working when they were young, they wouldn’t have ended up in there.”
The Prison Outreach Program’s poster child is Donald Briere, who was featured on New Hampshire Chronicle. Briere is a “graduate” of the program and since being released from prison has gone on to win Best in Show at the League of NH Craftsmen’s Fair — even beating out Moore.
Serving our veterans
About 200 men and women live within the walls of the New Hampshire Veterans Home. Nearly half are losing the battle within their own minds — there are “neighborhoods” or wards designated for patients with dementia. Outside the individual rooms are glass memory boxes in which the residents keep mementos of a past that often eludes them: a photo of the ship he served on in World War II; a photo of a father dancing with his daughter at her wedding; an image of the resident as a vibrant, young man.
“They have pictures from when they were young because when they see their reflection in the mirror now, they might not recognize it as themselves,” said Jackie Bonafide, program information officer at the Veterans Home.
In many ways it contradicts all we’ve been taught. The bank can take our money, the dealership can repossess our car, we can lose all worldly possessions but the memories of our loved ones are untouchable. Until our mind betrays us.
While many veterans at the home suffer dementia, most of it is caused by old age and not by their experiences in the military. Yet, according to Bonafide, post-traumatic stress can accelerate dementia. Post-traumatic stress is commonly associated with soldiers returning from Iraq and Afghanistan.
“What we’re learning to do now will be even more important in the future,” Bonafide said.
At the Veterans Home, the arts act as an equalizer. When a resident with dementia bangs a drum next to a staff member, both are musicians.
“If you have a disability and that is all you look at, you’ll see that disability,” Bonafide said. “If instead, you look at what you can do, then it doesn’t matter.”
Last year, the Veterans Home received a grant from the State Council on the Arts and so was able to hold a six- week, once-a-week weaving class and a one-week, five-day drumming workshop. On the last day of the weaving class, a resident with dementia didn’t want to leave the room. His caregiver tried to coax him back to his neighborhood but he really didn’t want to leave the weaving he had created. She asked him why. He said it was because he was doing something important. He had a job.
Bonafide said while weaving some residents with dementia could remember back to the days they worked in a weaving mill. They would tell stories of their youth. Residents with dementia were teaching the staff. It should be noted that the residents who participate in the arts programs typically have a moderate level of dementia, while those who are more advanced usually do not participate.
But half of the residents in the home do not suffer from dementia. For the first time, many of them find time on their hands.
“A lot of people are creative,” Bonafide said. “But a family, a job, grocery shopping and a lot of other things prevent them from doing anything with it. Here our residents have time and we want them to use it.”
“I thought I was going to splash around some paint,” said David Clarke, who served in the military from 1965 to 1967. “But I liked what I saw and so I kept spending more time on it. Now I say, I can’t believe I accomplished that. It’s not a masterpiece but it is a masterpiece to me. I am going to continue expressing myself.”
Clarke is one of the Veterans Home residents who has had his work displayed in a solo show on a wall outside the dining hall. Bonafide said the Home will exhibit a resident’s work for a few months, until another artist comes along for a turn.
One such artist is Arthur Foley, who arrived at the Veterans Home in January 2007. Shortly thereafter he was confined to a wheelchair. One day, Bonafide saw him outdoors staring out into the distance. When she asked what he was doing, Foley said he was wishing he was a bird so he could fly out of his wheelchair. Such movement was familiar to Foley, who as a young Corporal in the U.S. Army participated in D-Day 6, which was part of Operation Neptune, the Allied Invasion of Normandy. Bonafide did not discourage Foley’s fantasy of flight. She told him to write about it. Thus began the adventures of Blue Boy, a bird who traveled all around the world on the wings of Foley’s imagination.
“The hardest part is getting started but you shouldn’t be afraid to express yourself,” Foley said. “It feels really good.”
“We are in the business of long-term care,” Bonafide said. “For us it is not just about quality of care. If that is all they have, they’re going to die. It is also about quality of life. If this is to be their last home, then it should be as good as it can be.”
The problem is that quality of care is often validated with anecdotal evidence, which is moving but hard to quantify. At Concord Hospital, Kinsler has been collecting data to give more concrete examples. For example, a woman was in the ICU with high blood pressure, which was being watched and medicated. Her blood pressure went down 35 points while a musician played music. On the flip side, Kinsler said some patients’ blood pressure is too low and they’re sleeping too much. Certified Music Practitioners will come in and play upbeat music to increase it.
“Hearing is the first sense to develop in utero,” Regina Delaney said. “And it is the last sense we lose.”
Delaney said humans are a musical society even if we’re not particularly musical. She noted the heart, the epicenter of our survival, beats rhythmically.
Music can heal
It is not surprising, then, that music therapy would be one of the most advanced of the disciplines. From its origins after World War II, Music Therapy as a career is celebrating its 40th year. However, in New Hampshire there are only 14 board-certified therapists, as opposed to Massachusetts, which has 200. Almost half of those 14 music therapists in the state are employed by the Manchester Community Music School.
Music therapy means more than having a regular artist go into a health care facility. In music therapy, the therapist is using music to address non-musical goals. Many times this means working with clients with special needs, the most prevalent being autism. Therapy is tailored to the individual with the goal of developing or rehabilitating motor, cognitive or social skills.
“Children respond to music like no other therapy,” said Shannon Laine, director of music therapy at the Manchester Community Music School.
During the day, the Music School’s therapists are often out in the schools, as music therapy might be part of a student’s Individualized Education Plan (I.E.P.). After school hours, they’re at the Manchester facility.
Music is processed differently in the brain than speech, according to Laine. That is why when a stroke victim loses his ability to talk because that area of the brain is damaged, nine times out of 10 he can sing back to you his favorite song. Speech and song are processed on different pathways. Many youngsters with autism are non-verbal, so music therapists try to literally retrain their brain to speak by using the singing part of the brain.
Music therapists can also use that natural rhythm to calm an autistic child down. Laine said the therapist might watch how a child is tapping his foot or rocking back and forth and will begin by playing music that matches the tempo. They can then slow the musical tempo down, which ultimately calms the child down. A calmer child is more open to further lessons.
Such expertise requires a lot of schooling. There are 70 colleges or universities in the U.S. that have Music Therapy as an undergraduate or graduate degree, according to Laine. That number is growing. To become a certified music therapist a student must be a musician first and foremost. He must be proficient in playing both the guitar and the piano and must take musical classes, including theory and history, as well as psychology, education, biology, physiology, anatomy and a language. There is also a six-month internship.
Laine said music therapy has a high success rate. The times it doesn’t work are often a result of a dearth of therapists. Laine said sometimes youngsters come to Manchester from Portsmouth or Laconia and the drive is too long. But she said she has seen progress in 80 to 90 percent of clients, some instantaneous, some taking 6 to 12 months.
Such patience and dedication requires a certain type of individual. When Laine was an early teenager, she had a cousin born with Down syndrome. She spent years babysitting him and knew she wanted to help people and be involved with music. When she learned of a career that could do both, she was hooked.
“I love the challenge and the ebb and flow,” Laine said. “I love seeing the growth in the kids.”
How to get it going
Laine epitomizes, like Kinsler and Bonafide and many others, the championing that is needed to get an arts program in health care off the ground. Starting a program can be inexpensive but takes dedication and long-term commitment. At the Veterans Hospital, Bonafide began by publishing a small literary magazine. She then added residents’ photographs. This blossomed into the art gallery. Kinsler, who has a degree in art therapy from the 1970s, had a skeletal department at the hospital; she started small as well.
“People think an arts program is going to be expensive and that it’s not worth it,” Kinsler said. “But really, it costs almost nothing. We started small and stayed around a long time. Now people love it.”
The Active Ingredients Dance Troupe is only one of many arts programs at Crotched Mountain, according to Stephanie Wells, the dance club coordinator. For an instructor, staff time, props for the final productions and wheelchair modifications it cost around $23,000 a year to operate. But it reaches 10 to 25 kids on a weekly basis.
“We help the students change the way they see themselves,” said dance instructor Ella Gantt. “Then when the community watches performances we help change the way the world sees disabilities.”
“The students use skills they learn in school and therapy but in a fun way,” said Liz LaRose, director of marketing.”
“Some hospitals haven’t supported it because they think it is like acupuncture and it gives them the heebie-jeebies,” Delaney said. “It is not the beginning or the end. But it is a complementary form of therapy.”
And it is catching on.
A 2007 survey done by the National Endowment for the Arts and the Society for the Arts in Healthcare found that of the 1,807 institutions to respond, 43 to 45 percent reported arts programming.
As arts in health care gain traction, the landscape of American care is once again changing. If universal health care continues to move forward how would that impact this emerging practice?
“I can’t predict what would happen,” Kinsler said.
But she did note, while America is the world leader, Canada, the U.K. and Australia all have arts in health care programs.
When asked how dance made her feel, Kaitlin, who is mostly non-verbal, answered through an interpreter, “Dance makes me feel good by letting me express myself. It also makes me feel pretty.”