Art Therapy with an Alzheimer Patient: Wet-on-Wet Watercolor Painting

By: Liz Baring

Journal of Anthroposophic Medicine, 1997

Abstract 
The purpose of this paper is to introduce art therapists to a concept of using wet-on-wet watercolor painting as a healing modality for an older adult with Alzheimer's, emphasizing the process, medium and colors rather than the result. It will describe thirteen individual art therapy sessions using wet-on- wet watercolor painting. It will discuss the choice of medium and colors prescribed by the patient's physician and the results of these interventions. The author wishes to emphasize a different focus of art therapy to meet the patient's needs rather than use art therapy as a psychological approach to help elicit fragments of the person's life. In this case, the intervention addresses the direct therapeutic needs and the social aspects of a dependent adult. 

Introduction 
The Fellowship Community, located in Rockland County, New York, is a residential care facility for dependent adults. Surrounded by 20 acres of biodynamic gardens, fruit trees, chickens and sheep, the young and the elderly share their lives. The community includes a pottery studio, a weav- ery, candle shop and a store for the sale of these items. Mercury Press addresses the Community's printing needs and undertakes outside contract work. Three physicians form the medical practice. 

The Fellowship comprises three distinct, non-hierarchical groups: members, co-workers, and volunteers. The members are the elderly, in- cluding both independent, active ones and those needing total care. The latter live under one roof at Hilltop House. The co-workers provide the support structure and care for the members. "Central to life at the Fellowship Community is the idea that the dynamic exchange of all age groups is an integral ingredient in a person's physical, emotional, and spiritual wellness."(1) 

This community is an extension and application of the work of Austrian philosopher, scientist, and spiritualist, Rudolf Steiner. Steiner is father to Anthroposophy, a way of life and thought that synthesizes spirituality and science.(2) 

Methodology and Procedures 
The model of artistic therapy described in this paper is based on Anthroposophy in association with the ideals of this community. "Artistic therapy does not use artistic elements for psychological purposes." Mees-Christeller states that the therapy is purposeful, the product is not emphasized but, rather, "of importance is that [the patient] goes through a certain process."(3) 

D'Herbois explains that wet-on-wet painting "often runs into a soul- experience... the ego comes in, associates itself and plays in a rhythmic way on the blood. Then a rhythmic, movable connection is established between the astral and the etheric body. The life forces are called upon, become active and restore themselves. The etheric forces are mobilized, and that brings about the healing."(4) 

The Members Art Group, the name for the art therapy sessions, meets weekly in the spacious, large-windowed dining room at Hilltop House. The sessions last 60 minutes, and the chosen modality is always wet-on-wet watercolor painting. All members are invited to participate. The group con- sists of an average of 4 to 8 members, ranging in age from 77 to 90. This group had been meeting regularly for over a year at the time that Mary was invited to join. (This person's name has been changed for purposes of confidentiality.) 

Each member is given a Masonite painting board, 20" x 16," two jars of water, a sponge, a sheet of watercolor paper, a 1" flat, long-handled water- color paint brush and paints already diluted in small containers. 

As D'Herbois posits, the intention of these sessions is to use this modality of wet-on-wet painting "as a possibility of recreation or as a kind of social activity in groups." In Mary's case, these intentions applied, and I wanted to include her in the group, engage her interest, increase her concentration and attention span and reduce her inner agitation within a social setting, and "[her] soul is nursed by the colors."(5) 

Controversy exists among art therapists about when it is applicable to use wet-on-wet watercolor painting. Liebmann posits that working with colored washes on wet paper can be undertaken as a meditation or relaxation.(6) In contrast, Robbins cautions art therapists to be aware of the implications of using watercolor painting with people "with loose ego boundaries or fear of fusion."(7) Wadeson alerts the art therapist to consider the ability of the client to control the chosen media.(8 D'Herbois points out that "painting on wet paper makes one more fluid, and that is necessary for many people."(9) In the elderly, this medium works on the fluid processes in the body, in contrast to the hardening sclerotic tendencies in old age. Mees-Christeller indicates that "working on wet paper has a favorable effect on excretion" and that painting in this medium "brings joy and courage."(10) 

Emotional and physiological responses to color take place whether we are conscious of them or not.(9,10) Each color has a particular movement.(11) Blue belongs to the cool or passive side of the spectrum and red to the warm or active side. As quoted by D'Herbois: RudolfSteiner once spoke about the working of the colors blue and red on the blood (Dornach Feb. 21, 1923). He said that when one looks at red the working of it is such that it "destroys" the blood in the eye and thereby also the nerve that, for its sustenance, is dependent on the blood. To counteract the destruction, the organism mobilizes its oxygen and sends it up to the eye in order to restore the life-process there. This activity affects the whole organism in a wholesome way because all of its revitalizing and restoring processes are stimulated when the oxygen is used in this way. On the other hand, when one looks at blue nothing of the kind happens. Blue does not affect the blood or the nerve. The oxygen is not called upon and, being left to itself in tire organism, it combines with the carbon. The result is carbon dioxide which has the opposite working: it is not a bringer of life, but an instrument of the process of consciousness which to the body is a process of destruction. The working of red on the blood gives us good health; to the working of the blue on the blood we owe our consciousness.(12) 

Case Study 
Mary is a 77-year old, married, white female with a diagnosis of Dementia of the Alzheimer's Type as defined in the DSM-IV.(13) Mary was an accomplished viola player prior to the onset of her illness. 

Mary's first session took place on February 27,1996. At this time, she was a new, prospective member. I invited her to attend the art therapy group. She had been noted pacing the house, with her head down and hands behind her back. When I made eye contact with her she looked very scared. She came with me to the group session, and I placed her between an art therapy student/co-worker and myself. I chose this configuration to reduce external stimuli and to help Mary feel safe and protected. The directive for the group was to paint a 'Shining moon' a color exercise mentioned in Koch and Wagner using Prussian blue, cadmium yellow light and very light carmine red.(14) 

The members were instructed to paint the whole surface of the paper with a pale wash of this cool Prussian blue. Next, they painted the cool pale yellow to form the moon. A discussion of the choice of colors and the inner dynamic they offer to the painter are beyond the scope of this article. 

In observing Mary's response to the directive, I noticed that as I led the members through the various steps of the exercise she demonstrated her ability to imitate gesture. She started by painting the perimeter of the paper forming a border with the blue. She then made a rectangle in the center of the page with the yellow, and, of course, the painting turned green. As she continued to paint, I noticed that she had become aware that a student had painted a moon. Mary was able to make a circle in the center of her painting. Mary made scrubbing motions with the brush like a young child does and at other times showed good control of her movements. She remained for about 20 minutes of the session and then got up and left. Based on my observations of her response to the painting session, I contacted her physician, and he prescribed a therapeutic painting exercise to address her needs. He indicated that she would benefit from working with the polarity of blue and red. 

March 5,1996. The Members Art Group met again. At this time, Mary was ill with a digestive disorder. I still approached her and mentioned that we would be painting today and that she would be welcome to join the group as soon as she felt better. My intention was to try to gain her trust and to keep her connected to the painting group. Mary made minimal eye contact with me at this time; it was not clear whether she understood what I had said to her. 

March 12,1996. Mary joined the group session. Again, I sat her next to the student, and I sat opposite her, the idea being that if Mary chose to look in front of her or to her side, we were both modeling the same painting exercise for her to imitate. The doctor recommended that I use a minimum of verbal instruction but, rather, engage her ability to imitate. I gave Mary a small piece of paper approximately 8" x 10". We both showed her how to use the sponge to wet the paper handle. We used short, rhythmic strokes from left to right across the paper. This can be a centering, meditative experience. I offered her a short-handled brush to see whether it was easier for her to handle and then gave her a small amount of dilute Ultramarine blue. The student and I both started to paint the blue at the bottom of the page. Mary was tapping her brush as she waited for us to start and said several times: “I don't know nothing." We offered her support. She scrubbed a little with her brush, but less so than the previous session. I then gave her the red and showed her how to rinse her brush and apply the red all the way up the rest of the page. She completed the painting. I asked her to write her name on it. She was unable to do so. She then left the group and started her characteristic pacing around the residence. 

March 19,1996. I repeated the painting exercise with Mary. I worked with her before the members started their session. She made an unusual clicking sound with her mouth at the end of the session. This time when asked to write her name, she wrote her husband's name. She made good eye contact with me and gave a deep smile at the end of the session. I invited her to stay and observe the group; she tolerated it for about 5 minutes and then left. 

March 26,1996. Mary came and painted. We repeated the same exercise; however, I gave her a slightly larger piece of paper. I always placed the paper in a vertical position. Mary started with the blue as I did but did not rinse the brush before applying the red so her painting turned purple. Again, she gave me a beaming smile when she finished painting and stayed with the group approximately 15 minutes. 

April 9,1996. Mary refused to come and paint, stating a firm "no." I took this as a positive sign that she was able to express her needs. We had communicated tacitly to date. 

April 16, 1996. I brought Mary to the dining room first and painted with her before I started the members' session. We painted together; this time, I rinsed her brush with her to ensure that she did not end up with a purple painting. Once she finished, I placed a chair for her to observe the group. Mary had wheeled one of the members down to the dining room to the art group. This was a definite change in behavior for her. Mary watched for a while and then wandered off. She returned later and placed herself opposite one of the members and started to paint spontaneously in blue and red stripes. 

April 23, 1996. On this occasion, Mary was unexpectedly brought down to the group before I had been able to engage the members in their session. I was unable to give Mary the attention and keep the rhythm we had estab- lished. Mary sat next to a co-worker who had joined the group for this session. With a little encouragement by this person, Mary started her own painting. She chose to use two of the three colors the other members were using and painted a vertical page of stripes of blue and yellow. She left the group after completing this. 

April 30, 1996. The group was canceled because the art therapist was absent. 

May 7.1996. Mary did not attend this session. 

May 14,1996. Once the members had engaged in their painting exercise, I brought Mary into the group. We sat with the group and repeated her indi- vidual exercise. As Mary had not painted for a few weeks, I offered a small piece of paper to maintain her attention and not to overwhelm her. She was able to write her name at the end of the session, only inverting one letter. She did not stay and observe the rest of the group. 

May 21, 1996. The painting exercise remained the same. However, this time Mary was able to tolerate the full group time. She was able to write her name yet made a scribble when asked to include the date. This was more information for me to work with; it served as a reality check. While the members painted, I engaged her by doing a small sketch of their art therapy exercise. It was an underwater scene with goldfish. I incorporated two fish in my small sketch and made up a story about Mary and myself as we watched the group paint. Mary smiled continually as I talked with her. At the end of the group, she was able to help with the clean up, emptying the water jars. By the end of the session Mary was yawning; she was tired. 

May 29, 1996. This time when I went to invite Mary to her session, she gave me her emphatic "no." I left her and thought I would approach her one more time. When I returned for her she had put herself to bed. Again, I noticed this very frightened look in her eyes. I reassured her that she was safe and sang the Brahms Lullaby to her as she relaxed and closed her eyes. This was how I terminated my work with her as this day was my last art therapy session at the Community. 

Discussion 
Mary's increased tolerance of the group time, the quality of her eye contact and the depth of her smile where changes noted from her initial art therapy session. Mary's ability to retain and reproduce the use of two colors every time she painted, regardless of whether the therapist was directing her, points to her having internalized this painting motif and gesture. The patient's ability to assert herself and refuse the session confirms to a predictable pattern of regression at stressful times in the patient's life. A more accurate measure of Mary's response would have been to measure respiration rate or monitor her pulse before and after the sessions. Building a trusting therapeutic alliance outweighed the benefits of trying to quantify this lady's physiological response to the painting sessions. 

This limited case study may inspire others to do future research on the use of watercolor painting to complement the therapeutic goals of the medical treatment of an Alzheimer's patient. This is a very different focus from what is offered by other facilities. Sandarac states: "The tragedy of Alzheimer's disease is that it takes away the full mosaic of a person's past. The focus programs [Genesis Health Ventures] use art therapy to help people with Alzheimer's uncover and share some of the fragments of their lives."(15) Hofland draws attention to the lack of development of client-centered residential care settings. He reflects: "The quality of the care provided to persons with dementia marks the quality of our society."(16) The emphasis of care in Mary's case is to embrace her as a member of the community rather than focus on her deficits. 

References:

1. Schiff, K. Blueprint for a new culture: Spring Valley's Fellowship Community. New York Naturally 1-8.1990. 

2. Ibid. p.2. 

3. Mees-Christeller, E. The Practice of artistic therapy. Spring Valley: Mercury Press 1985; 2-3,8-9. 

4. D'Herbois, LC. Light, darkness and colour in painting therapy. Domach: The Goetheanum Press 1993; 58-59. 

5. Ibid. 

6. Liebmann, M. Art therapy for groups. Cambridge: Brookline Books 1986. 

8. Wadeson, H. Art psychotherapy. New York: John Wiley & Son 1980. 

9. D'Herbois, LC. Light, darkness and colour in painting therapy. Dornach: The Goetheanum Press 1993; 

10. Birren, F. Color and human response. New York: Litton Educational Publishing, Inc. 1978. 

11. Lüscher, M. The Lüscher color test. (Tr. & Ed: I.A. Scott) New York: Random House 1969. 

12. D'Herbois, LC. Light, darkness and colour in painting therapy. Domach: The Goetheanum Press 1993;201. 

13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed.) 1994. 

14. Koch, E & Wagner, G. The individuality of color (Tr. P. Stebbing). London: Rudolf Steiner Press 1980. 

15. Sandrick, KH. Art therapy passage into their pasts. Hospitals Sf Health Networks 1995; 69: 55. 

16. Hofland, BF. When capacity fades and autonomy is constricted: A client-centered approach to residential care. Generations 1994; 18 (4) 31-36.

Citation: Baring, L. (1997). Art Therapy with an Alzheimer Patient: Wet-on-Wet Watercolor Painting. Journal of Anthroposophic Medicine, 14(3), 24–30.