There were neurologists from Italy, allied health professionals from France and Russia, scientists from Taiwan, researchers from Scotland, medical sales representatives from Australia, Parkinson’s patients and their caregivers from the United States, and the list goes on. This is a small example of the attendees at the Second World Parkinson Congress in Glasgow, Scotland, September 28-October 1, 2010. It was an opportunity for the world to come together and learn from each other about the diagnosis, treatment, and how to live with Parkinson’s disease (PD). The common goal was to address and enhance the quality of life for those diagnosed with Parkinson’s disease (PD) and to find a cure.
Among the many presentations was research initiated within the Hofstra University community. Deborah Elkis-Abuhoff, a faculty member in the Counseling, Research, Special Education and Rehabilitation Department’s Creative Arts Therapy program, was an invited featured speaker. She was asked to discuss her work in bringing art therapy to Parkinson’s patients. In addition to the honor of a formal presentation, she was invited to present two additional sessions that included a hands-on experiential. Clinicians, caregivers, and those diagnosed with PD engaged in a clay manipulation experience. There were attendees from Scotland, Scandinavia, Italy, France and the United States, to name a few. Even though one might think language would be an obstacle, the created clay project brought everyone together with the power of nonverbal communication. Attendees shared what they made, and everyone enjoyed the outcomes.
Figure 1: Examples of clay products created by those with Parkinson’s disease and their caregivers who attended the clay manipulation workshop at the World Parkinson Congress, Glasgow, Scotland.
One woman diagnosed with PD entered the workshop dyskinetic, having trouble managing her total body movements. Once engaged in the clay manipulations, she became more relaxed and her involuntary movements lessened. After working quietly throughout the workshop, she shared her objects: a basket, a snail and a baby in a bassinet. She told a story about when she worked at a nursery and was the caregiver for many infants. She became verbal and smiled while telling her story. In the end, she said she really enjoyed the clay experience; when she left, she demonstrated better control of her body, and her involuntary movements had noticeably subsided.
After the clay manipulation workshop, three clinicians from Slovenia approached Dr. Elkis-Abuhoff. They were interested in speaking with her about the profession of art therapy, specifically her work with PD patients. They shared that art therapy is not a profession in their country; in fact, they do not have any art therapy programs. They were excited to be introduced to art therapy, and the power of engaging in the creative process. They wanted to discuss ideas of bringing art therapy into their facility – to be the first to offer art therapy in Slovenia. After about 45 minutes of conversation, they exchanged contact information, and now they have a connection to art therapy, and an art therapist from Hofstra University, as they move forward with the development of their program.
Dr. Elkis-Abuhoff’s experience at the World Parkinson Congress gave her the opportunity not only to present her research and introduce a clay manipulation experience, but also to share with the world what has been the central focal point of her research for the past five years. Dr. Elkis-Abuhoff and her team – Dr. Robert Goldblatt, a psychologist from New York College of Osteopathic Medicine; Morgan Gaydos, licensed art therapist and activities specialist at Nassau University Medical Center; and Samantha Coratto, both Hofstra Creative Arts Therapy program alumni; and Dr. Anthony Napoli, a professor at Suffolk County Community College – have developed research that addresses PD symptomology with the use of art therapy treatment.
This research project introduced and encouraged people diagnosed with Parkinson’s disease to manipulate and be creative with modeling clay, while the researchers were interested in monitoring any changes in their emotional and symptomatic reactions. The approach utilized a medical art therapeutic method to target the negative symptoms related to the PD diagnosis. What they sought to find was if engagement in a tactile medium, such as simple modeling clay, could have beneficial effects on the somatic dysfunction and emotional distress that usually accompany a PD diagnosis.
Figure 2: Engagement in clay manipulation by an attendee with Parkinson’s disease.
Forty-one (41) participants volunteered; 22 volunteers were diagnosed with PD, and 19 did not have a PD diagnosis. The volunteers were first asked to complete a self-report assessment called the Brief Symptom Inventory (BSI) (Derogatis, 1993). This assessment consists of 53 questions used to screen the level of psychological symptoms and their intensity within a specific timeframe. The subscales of the BSI (Derogatis, 1993) assessment evaluate levels of distress in nine specific and three global areas, and include somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobia, paranoia, and psychiatric difficulty to gain a baseline of functioning in these areas.
Once the BSI (Derogatis, 1993) was completed, each volunteer was presented with four balls of clay. Each ball was approximately the size of a racquetball and varied in color (red, blue, green and yellow). Since many with PD experience hand tremors and/or a deficit in fine motor abilities, modeling clay was used as the art medium because it is easily controllable and allows individuals at all skill levels to successfully engage and create. The focus of the clay experience was to intimately engage the volunteers in the modeling clay medium. Volunteers were asked to start squeezing the ball in each hand, moving it back and forth. Once the clay was warmed up and malleable, the volunteers were asked to pull it apart into small pieces. This allowed the volunteers to become comfortable with the clay medium, while warming up both the clay and their hands. This exercise promoted the use of fine and gross motor skills.
At this point, volunteers were asked to freely create an object by reintegrating the clay pieces back into a shape. The only restriction was that the new shape could not be the original ball. This was a free creation, and there was no time limit. In a true medical art therapy approach, the simple act of creating, or the process, is healing. This activity was the crux of the study, and took anywhere from five to 45 minutes to complete. The modeling clay activity is very engaging, and the user becomes intimately involved with the medium. Although the clay is cold when the user first holds it, once handled, it quickly becomes warmed, softer, and more malleable. As the clay is manipulated by the user, a natural connection is created.
After the creative activity, a member of the research team sat with each volunteer and interviewed him/her about his/her experience with the clay. Some of the questions included why they chose the color they chose. They were asked to describe the clay manipulation experience, explain what they created, and whether they would be interested in working with clay in the future. This allowed the volunteers to freely discuss their experience while the researchers gained valuable information regarding the qualitative experience from the volunteers’ perception.
After the oral interview, a post BSI (Derogatis, 1993) was administered so the results could be compared to the results of the baseline symptomology. Once the data was collected, the BSI (Derogatis, 1993) statistics were evaluated and the outcomes were reported. The created clay product was further reviewed for trends and themes. The researchers wanted to know if the participants reintegrated the entire ball of clay, or if they just used some of the pieces. They were looking to find out if the clay was easy to manipulate so the volunteers would be able to create freely and easily. They wanted to look at each clay product to find out if the created object was recognizable, and how refined and defined it was. If the volunteer reported a positive experience, did it matter if the researchers couldn’t identify the final clay shape? Based on the interview, the researchers looked to see if the experience triggered an emotional response. If so, was it positive and healing, or negative and upsetting? Finally, the researchers reviewed how many of the volunteers were interested in working with clay in the future. This was important information, because the interest in continuing the experience bears a connection to the practicality of creating a long-term program to support patients with Parkinson’s disease.
Figure 3: Clay creations by an attendee with Parkinson’s disease.
Figure 4: Reintegration of the ball of clay into objects other than a ball.
So what did the researchers find? Based on the BSI (Derogatis, 1993), when comparing the baseline to the post-clay experience, those diagnosed with Parkinson’s disease demonstrated a greater decrease in psychological symptomology than the non-Parkinson’s volunteers. All 41 participants were able to easily manipulate the clay medium, and 36 fully integrated the clay into a shape other than a ball; the five other volunteers, while their objects were not completely reintegrated, were still able to create a shape other than a ball. Although only 30 outcomes were recognizable, every volunteer was able to identify his or her creation. All volunteers conveyed a strong emotional response to the clay manipulation experience in areas such as family, childhood experiences, a connection to nature, and personal hobbies. One of the most important pieces of information from the qualitative interview was finding out if the PD patient enjoyed the experience and would be interested in exposure to future clay manipulation. All PD volunteers reported that they enjoyed the clay experience, and the majority stated that they would be interested in becoming involved in future clay manipulation opportunities (Elkis-Abuhoff, Goldblatt, Gaydos, & Corrato, 2008).
The team continued to review the quantitative outcomes of the BSI (Derogatis, 1993) and to explore how the results of the subscales could give a more defined explanation for the reduction of negative PD symptomology. The researchers set out to understand the clinical benefits of modeling clay with patients diagnosed with PD (Goldblatt, Elkis-Abuhoff, Gaydos, & Napoli, 2010). Three specific subscales stood out: obsessive-compulsive thinking, phobia, and depression. It was exciting to find that these three scales were not only significantly decreased, but were reduced in symptomology to within normal adult range. What the researchers concluded was that these three scales were interrelated for those diagnosed with PD. Many PD patients find that after their diagnosis they become overwhelmed with their symptomology and tend to ruminate about their difficulties. This develops into obsessive-compulsive thinking. As this thinking continues, they begin to become fearful that they might not be able to control the changing world around them. This fear turns to phobia, and many times normal daily activities are avoided or become limited. The continuation of obsessive-compulsive thinking and the developed phobia lead patients to label themselves as handicapped or disabled, and they often become hopeless in their functioning, leading to an increase in levels of depression.
However, by engaging in an art therapy, clay manipulation program, PD patients were able to use their fine/gross motor skills to intimately engage in the activity, and experience a sense of control within their environment. Clay manipulation as a tool lies within the malleable nature, providing a soothing and relaxing sensation. The clay experience provides the patient with an opportunity, and a platform, to communicate, both verbally and nonverbally, through the giving nature of the media that accommodates their fine/gross motor difficulties. The clay manipulation can create a tactile “connection” to the world, thus giving them the sensation of regaining a “grip on the world” (Goldblatt, Elkis-Abuhoff, Gaydos, & Napoli, 2010).
This research project has been the focus of several national and international presentations: the American Art Therapy Association, Canadian Art Therapy Association, Society for the Arts in Healthcare, and World Parkinson Congress. The clay manipulation project has also been published nationally in Art Therapy: Journal of the American Art Therapy Association, and, in September 2010, Arts & Health: An International Journal for Research, Policy and Practice. These presentations and publications have drawn attention to the outcome of the project and have motivated Dr. Elkis-Abuhoff to continue this study in a second phase of clay manipulation research.
As part of this continuing work with the effects of clay manipulation, Dr. Elkis-Abuhoff, with the support of Hofstra University, has received an appointment as an assistant investigator at The Feinstein Institute for Medical Research, North Shore-LIJ Health System, in the Center for Neuroscience. This appointment, and a consultancy grant received through the Society for the Arts in Healthcare, has allowed Dr. Elkis-Abuhoff to develop a second round of research, and she is actively recruiting participants for a late winter/early spring 2011 start.
This research, Phase II, will look at the psychological and physiologic effects of manipulation of therapeutic art forms among patients with PD. This six-week program will explore the impact of clay manipulation using a medical art therapy approach. Developed as a group process, the goal is to explore the three specific areas of obsessive-compulsiveness, phobia, and depression, but will also assess for perceived stress levels, observable behaviors and actions of the PD patient, and their overall attention to daily living skills. This research will evaluate whether there are continued benefits over time, a six-week period, from engagement in a clay manipulation program.
The researchers are hopeful that the positive outcomes observed in the original study will be maintained over time, and even have a cumulative beneficial effect. This would support the development of a community-based art therapy clay manipulation program for PD patients to help manage their symptoms and improve their quality of life.
Derogatis, L.R. (1993). Brief Symptom Inventory: Administration, scoring, and procedures manual (4th ed.). Minneapolis, MN: National Computer Systems.
Elkis-Abuhoff, D. L., Goldblatt, R. B., Gaydos, M., Corrato, S. (2008). The Effects of Clay Manipulation on Somatic Dysfunction and Emotional Distress in Parkinson’s Patients. Art Therapy: Journal of the American Art Therapy Association, Volume 25, 2.
Goldblatt, R. B., Elkis-Abuhoff, D. L., Gaydos, M., Napoli, A. (in press, 2010). Understanding Clinical Benefits of Modeling Clay Exploration with Patients Diagnosed with Parkinson’s Disease. Arts & Health: An International Journal for Research, Policy and Practice.