ART THERAPY AND LONG-TERM CARE RESIDENTS

Group Art Therapy Curriculum for Residents of Long-Term Care Facilities

Jacey Eikenbary
COUN 7550-401: Introduction to Art Therapy Research
Pennsylvania Western University- Edinboro
Dr. Carolyn Brown Treadon
April 28, 2025

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Abstract
As the older population of the United States continues to get older, the nation’s need to provide
comprehensive, individual care also grows. The rise in the number of nursing homes, assisted
living, and other long-term care facilities around the country is a testament to the desire to honor
and care for these individuals in their late life. However, it is often that physical ailments and
disease within this population are addressed more frequently than mental health issues. This
research seeks to explore the many physical, emotional, and social challenges older adults face in
long-term care settings and the intricate connection of these three aspects of health. It will then
propose a group art therapy curriculum that endeavors to foster creativity and social connection
among residents as they pursue a high quality of life in this late stage.
Keywords: older population, nursing homes, assisted living, long-term care facility,
physical mental social challenges, art therapy,

ART THERAPY AND LONG-TERM CARE RESIDENTS
Table of Contents
Abstract.................................................................................................................................2
Section I: Introduction.........................................................................................................4
Problem Investigated..................................................................................................5
Purpose Statement......................................................................................................5
Justification............................................................................................................................6
Terms Related to Study..............................................................................................7
Conclusion.................................................................................................................8
Section II: Literature Review.............................................................................................9
Person Centered and Relational Centered Theory.................................................................9
Positive Psychology..............................................................................................................11
Developmental Theory.........................................................................................................12
Physical Development..........................................................................................................12
Emotional Development.......................................................................................................14
Social Development..............................................................................................................15
Issues Faced by Older Adults...................................................................................16
Physical Decline.......................................................................................................17
Social Changes.........................................................................................................17
Mental Health Issues................................................................................................18
Services for Older Adults.........................................................................................18
Creativity and Overall Wellness...............................................................................20
Art Therapy and Older Adults..................................................................................21

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Group Art Therapy Curriculum for Residents of Long-Term Care Facilities
According to the 2020 United States Census, the older adult population has “grown
nearly five times faster than the total population over the 100 years from 1920 to 2020” (Caplan,
2023). The life expectancy of Americans is continuing to increase with “1 in 6 people being 65
and over in 2020” (Caplan, 2023). This population of older adults is requiring more care services
including long term care, medical and living assistance, mental health services, and social
support. Additionally, there are often complex cases of age-related conditions that require
comprehensive understanding and tailored care. This type of care may not always be available to
older individuals living in their own homes; therefore, moving into nursing homes, assisted
living, and other long-term care facilities provides one option for older individuals and their
families to ensure their needs are being met.
The National Library of Medicine (2022) estimated that there are over 1.3 million people
in the United States living in nursing homes. While nursing homes, assisted living, and other
long-term adult care facilities provide essential support and medical care, these settings can also
often contribute to residents’ feelings of isolation and depression, a loss of independence and
social connections, as well as a loss of motor abilities and seemingly more rapid cognitive
decline. Moving into these types of facilities can often be bittersweet for older individuals.
While there may be a sense of loss, there can also be room for opportunity. Research has shown
that there are many positive benefits to offering creative, communal activities to nursing home
residents. However, further understanding and development of the most ethical and valuable
creative interventions must still be pursued.

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Problem to be Investigated
With the rising numbers of older adults living in the United States and the subsequent
need for more comprehensive care, it is important that this demographic receives the respect and
attention they deserve to support holistic health, especially in their later life. The overall
literature on this particular population reveals that with older age, mental and physical health,
cognitive abilities, and social connection typically decline (Urry & Gross, 2010, p. 352).
According to Cohen (2006), “significant decline with advancing years was seen as inevitableour destiny” (Cohen, 2006, p. 7).
There is mounting evidence that physical movement, cognitive tasks, and social support
can have a positive impact on the aging process (Bishop, et al., 2016, p. 339) Creative activities,
especially art therapy interventions, have the ability to encompass these three aspects of physical
movement, cognitive challenges, and social support, making it an incredibly beneficial activity
for older individuals (Cohen, 2006, p.9) This research seeks to investigate the efficacy of
implementing group art therapy services within nursing home populations for mental health and
community building among residents. The curriculum developed addresses the specific mental
health and motor abilities of older adults in the hopes that art therapy can provide a safe space for
peer support and connection, a sense of personal purpose, and provide individuals an outlet to
process their long-lived life.
Purpose Statement
The purpose of this research is to develop a group art therapy curriculum to promote
creativity, foster personal reflection, and build social connection among older adults in
residential settings.

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Justification
The number of Americans aged 65 years or older is “projected to increase from 58
million in 2022 to 82 million by 2050 (a 47% increase)” and according to the Public Reference
Bureau, the U.S. population is “older now than it has ever been” (Mather & Scommenga, 2024).
Over 1.3 million individuals who are living longer require comprehensive, individual care, often
found in the form of long-term care facilities (National Library of Medicine, 2022). While
nursing homes, assisted living, and other facilities do their best to provide the utmost quality of
care to their residents, the effects of aging can negatively impact the way people experience their
stage of late life. Residents in these long-term care facilities face a variety of physical, emotional,
and social challenges.
The prevalence of depression among nursing home residents across the country has been
“estimated to be as high as 51.8%” in 2007, with reports of anxiety up as well. Additionally, it is
estimated that around 80% of residents experience pain in their day-to-day lives (Ulbricht, et al.,
2019). The treatment of physical pain is more frequent than the treatment of emotional pain in
long-term care settings, but because the mind and the body are so intricately connected, one
cannot hope to live a high quality of life in this late stage if both physical and mental ailments
are not addressed (Ulbricht, et. al, 2019). Disruptions in social relationships take a toll on older
individuals as well, as the move to a long-term care facility can impact connections with family
and friends. Feelings of social isolation can play a role in this increase in depression along with
feelings of loss, including the loss of mobility, of independence, and of loved ones.
It is also important to consider the growing rate of dementia and Alzheimer’s disease
within long-term care facilities. Around 14% of adults older than 70 experience signs of
dementia and about half of adults with dementia are residents of nursing homes or assisted living
settings (Cadigan, et al., 2012, p. 856). The symptoms of dementia often make it even more

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difficult to provide ethical, client-centered care and can be extremely tough for older adults, their
loved ones, and caregivers.
Older adults cannot be reduced to a list of statistics. Everyone has, or had, a loved one
who is in their late stage of life. Everyone has encountered older individuals, if not on a daily
basis. And, if we are lucky, one day, maybe we will have the honor of “being old.” This phase of
later life comes with many challenges, but these challenges can also provide opportunities for
deeper connection, exploration, and self-expression. It is increasingly important, now more than
ever, that every avenue is explored in ensuring the utmost mental, physical, and social care of
long-term care residents. One proven means of fostering positive mental and physical health is
by incorporating creative group activities, specifically art therapy interventions, into the
everyday lives of older individuals. The groundbreaking Creative Aging Study demonstrated that
by implementing arts programs, specifically Chorale groups and visual arts groups, older
participants reported having “better health one year after baseline starting points,” fewer reported
falls, improvements in depression, loneliness, and morale, and an increase in activities as
compared to the control group (Cohen, 2006). This study, along with a plethora of other
research, provides a strong case for the implementation of ethical and valuable creative
interventions within nursing homes, assisted living, and long-term care facilities.
Terms Related to the Study
For this research, the following terms are used:
Art Therapy
Art therapy uses art media, the creative process, and the resulting artwork as a therapeutic
and healing process. (ATCB, 2024).

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Alzheimer’s Disease
A disease of the brain that gradually destroys memory and thinking skills that, over time,
impairs and diminishes daily tasks and functioning. Late onset symptoms of Alzheimer’s can be
seen around mid-60s with more rare early onset symptoms being recognized in a person’s 30s to
mid-60s (National Institute on Aging, 2021).
Assisted Living
Facilities for residents who need help with daily care including housekeeping, help with
medications, personal upkeep, and daily meals. These residents typically require less care and
supervision than those in a nursing home. Assisted living residents also typically live in their
own apartment style rooms (National Institute on Aging, 2023).
Blue Zones
Geographic regions around the world with the highest rates of long-life expectancy and
lower rates of chronic illness than the rest of the world. These regions include: the Ogliastra
region of Sardinia, Italy; the Greek island of Icaria; Okinawa, Japan; the Nicoyan Peninsula in
Costa Rica; and Loma Linda, California. (Robertson, 2023)
Creative Aging Study
This study was conducted at George Washington University Center on Health, Aging,
and Humanities by Gene Cohen. It “examined the influence of professionally conducted,
participatory art programs on the general health, mental health, and social activities of older
adults” (Cohen, 2006). The study took place in Washington D.C with a Chorale, then in New
York City with an art group, then in San Fransisco with another art group, with control groups at
each site as well. Intervention groups reported better health one year after baseline starting point
(D.C) and greater improvement in general health over the past year (S.F) (Cohen, 2006).

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Dementia
A loss of cognitive functioning- including the ability to think, remember, and reason- that
is so prevalent, it impacts a person’s daily life and activities (National Institute on Aging, 2022).
Nursing Homes
Facilities that provide a wide range of services and focus more on medical care than
assisted living settings. Services include 24hr a day supervision and daily meals, with physical,
occupational, and speech rehabilitation offered as well (National Institute on Aging, 2023).
Conclusion
It is evident that the older population in the United States is increasing due to a variety of
factors, which has subsequently led to an increase in a strong need for nursing homes, assisted
living, and other long-term care facilities. While there are incredible options available all over
the country for different types of residential care, this big transition in later-life has the potential
to negatively impact older individuals both mentally and physically. The literature on this topic
has provided a wide array of evidence on the impacts this transition can have, while also offering
creativity and social engagement as potential avenues for mitigating some of those negative
impacts. The following section presents literature to support the development of the curriculum.
Section II: Review of Literature
To understand how creative activities, such as group art therapy, can positively impact
residents in nursing home, assisted living, and long-term care facilities, this review of the
literature first offers two theoretical lenses for this work and discusses the physical, emotional,
and social developmental expectations of this population. The review then explores the various
services and issues that long-term care residents typically face, and the impact creative pursuits
can have on health and quality of life among these residents. Finally, the review shares the many

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positive impacts group art therapy can offer to long-term care residents in their pursuit of a high
quality of life.
Person Centered and Relational Centered Theory
As the narrative and understanding of aging develops, so has the level of care and respect
for the individual. “At the core, older adults and their families want compassionate, respectful,
high-quality care, and expect clear and appropriate communication as they navigate the system
and their health” (Young & Siegel, 2016, p. 48). Client centered, or person centered, theory was
founded on the belief that people are often motivated to achieve their own positive psychological
functioning and each client is the expert of their life; therefore, they are able to lead the general
direction of therapy with the clinician taking a non-directive approach (Yao & Kabir, 2023).
Through a person-centered lens, the client is encouraged to partake in unrestricted selfexploration to help gain better insight into themselves, as well as the world around them. It is
important for the clinician to provide a safe, non-judgmental environment that promotes this type
of self-discovery and meaning-making from a person’s own experience.
Some of the prominent tenants of person-centered psychology include unconditional
positive regard, supporting clients without conditions or judgement, empathy for the client’s
perspective, and authenticity and genuineness from the therapist. Incorporating these tenants into
practice can foster a collaborative and empowering environment for a client’s personal growth.
Within nursing homes, assisted living, and other long-term care facilities the necessity for a
person-centered approach is paramount. These residents are truly the experts of their lives, and
many have lived long, productive lives with purpose. Discounting these experiences and wisdom
to only treat the disease or aliment would be disregarding the person themselves. However,
roughly half of all nursing home residents have dementia (Maslow, 2013, p. 9). Knowing this,

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how do caregivers and health providers maintain a level of person-centered respect for each
individual, while also dealing with residents showing signs of cognitive decline?
Relational-centered care takes a step further to consider the relationships in a patient’s
life and their impact on healing and wellbeing. This approach focuses on the mutual, dynamic
connections between people- such as family members, caregivers, or healthcare providers- and
how each of these can affect the health of the client or patient. A main tenant of relationalcentered care is the understanding that the client is a whole person with emotional, social, and
cultural contexts that play a major role. Trust and collaboration are important, as well as shared
decision making to help best care for the client. This approach strives to create a partnership
between all involved in a client’s wellbeing and prioritizes relational depth, self-respect, and
awareness for all involved.
It is a unique challenge for caregivers and health professionals to navigate what personcentered care may look like considering these additional obstacles of possible dementia and
cognitive and physical decline. According to Morhardt and Spira (2013) the “dynamic and
relational view of the individual’s life needs to be considered in order to understand the whole
experience of dementia” and a family centered, or relational-focused, approach may offer the key
to deeper understanding (Morhardt & Spira, 2013, p. 37). With a relational-centered approach to
care, those who are closest to the resident-their friends, family, and other caregivers-have the
responsibility of ensuring that the individual’s social identity is continued, especially if the
individual has dementia. Therefore, it is believed that person-centered care should be inclusive of
the caregivers, closest family and friends, as well. (Morhardt & Spira, 2013, p. 39).
Regarding individuals with dementia, the main difference between a person-centered and
relational-centered approach is the understanding that the experience of dementia includes the
caregivers and should focus on the dynamics of those relationships over the course of the illness

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(Morhardt & Spira, 2013, p. 40). While the relationship dynamics may look a little different for
individuals whose caregivers are trained nursing home professionals, close friends and family are
still sources of knowledge and should be included in the relational-centered care of the
individual. This could be said for long-term care residents without dementia as well. A personcentered approach may look different for these individuals, but their social relationships are just
as important and can offer sources of care just as well.
Positive Psychology
As person-centered theory has shown us, the individual is the expert in their own life and,
given a conducive environment, they are encouraged to explore themselves to gain deeper
perspective. There is often an emphasis placed on mental health problems, disorders, and the
fragility of humans within the field of mental health. This emphasis can be appropriate in many
cases and has led to great understanding and treatment of the human mind, but with this heavy
focus on lack, there has been little focus on abundance. Positive psychology is the answer to this
focus on lack as it “calls for as much focus on strengths as on weakness, as much interest in
building the best things in life as in repairing the worst, and as much attention to fulfilling the
lives of healthy people as to healing the wounds of the distressed” (Peterson & Park, 2003, p.
143). Positive psychology is about changing assumptions of the human experience and human
potential. It doesn’t overlook distress and disease and the need for solutions.; it simply proposes
that the psychology that has been practiced in the past 60 years is incomplete. This particular
lens emphasizes “the scientific study of optimal human functioning” and “he qualities and
conditions that permit humans to live a life worthwhile” (Park, 2014, p. 1645).
When considering nursing homes, assisted living, and other long-term care facilities,
there is often overwhelming evidence of disease and distress among residents. Therefore, a
positive psychology approach to care, one that allows room for both the treatment of disease and

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the celebration of strengths, can help residents in their pursuit of a high quality of life. Seligman,
one of the originators of positive psychology, outlined five pillars to pursue for a flourishing life
including: “Positive emotions, Engagement, Relationships, Meaning, and Achievement” (Park,
2014, p. 1645). This PERMA model, according to Seligman, can determine an individuals’ sense
of flourishing or their pursuit of a high quality of life. As this review of the literature will show,
group art therapy can offer opportunities for residents in long-term care facilities to experience
the five pillars of this PERMA model and can offer an avenue to achieve a high quality of life,
even in old age.
Developmental Theory
This particular lens of understanding the human experience incorporates a range of
perspectives that examine how individuals grow, change, and develop across their lives.
Development evolves in stages that each provide their own set of challenges and opportunities
for the individual. Some of the main tenants of developmental theory are the important roles
biological, psychological, environmental, familial, social, and cultural factors play in shaping
development, as well as the sequential nature of experiences and learning that influence later life.
Developmental theory is comprised of different types of human development including
1.) psychosocial development, founded by Erikson, 2.) cognitive development, founded by
Piaget, 3.) psychosexual stages, founded by Freud, and 4.) graphic development, founded by
Lowenfeld. These various views of development and their subsequent stages throughout a
lifespan offer a look into different aspects of human growth and provide mental health, medical,
and other professionals a deeper understanding of what an individual may be facing or grappling
with in any particular time in their life.
The physical, emotional, and social development of older adults represents a unique and
dynamic phase of life marked by both challenges and opportunities. There is a belief that with

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increasing age comes increasing mental, physical, and interpersonal issues. While this may be
true for many people as they experience a loss of mobility, motor skills, cognitive functioning,
and/or loved ones, this phase of life does not have to represent death and decline.
Erikson termed the late stage of a person’s psychosocial life as the stage of Integrity vs.
Despair (McLeod, 2024). This is the eighth stage of development for individuals who are
typically 65 years and older and is defined by having either a sense of integrity as one looks back
on and contemplates their life and accomplishments. or developing a sense of despair due to
regrets, failures, or poor decisions they remain conscious of (McLeod, 2024). With the many
physical, emotional, and social challenges that can come with age, this stage in life can also offer
an opportunity for deep self-reflection and acceptance of a life well lived.
The review of literature will share some of the developmental challenges older
individuals face and will offer ways to combat these challenges. It will then provide evidence of
the opportunity art therapy offers “to draw from life’s riches and find meaning” in the last stage
of life (Stephenson, 2006, p. 24).
Physical Development
With age comes change. A lot of age-related change can come from physical decline in
the body and the mind. Many people often use the expression “I’m getting older” to make sense
of these changes and, while they may seem inevitable, there are strategies for maintaining strong
physical bodies and healthy cognition, even into older age. “Cognitive aging encompasses a very
wide range of processes, including speed, working memory, executive functions, memory,
linguistic abilities, and knowledge” (Zelinski, Dalton, & Hindin, 2011, p. 13). From 2000 to
2050, the percentage of adults aged 65 or older with low cognitive function is projected to more
than double from current estimates, as is the number of adults aged 65 and older experiencing
some sort of physical limitation (Bishop et. al, 2016, p. 338). Some of these physical limitations

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may include chronic disease or disability, a loss of motor skills, or a change in internal and
external bodily functions or appearance. These can occur from a wide variety of lifestyle choices
across the life span, genetics, or environmental factors.
While many older adults may face these physical changes as they age, especially
residents in long-term care facilities, there are a few practices that could positively impact
individuals. A wide range of research has shown that regular physical activity can decrease the
risk of chronic diseases and promote longevity, mitigate the physiological changes of aging
common in a sedentary society, and prevent disability and help maintain independence into late
life (Paterson, Jones, & Rice, 2007, p. 70).
It has been reported that individuals who are active, defined by participating in regular,
moderate-intensity walking, at age 70-75 had half the risk of dying from a disability compared to
their inactive peers (Paterson, Jones, & Rice, 2007, p. 80). While this activity level may be
possible for “more well” older individuals, many people in long-term care facilities may not be
mobile enough to maintain “regular moderate-intensity walking.” Therefore, this may be
information that is more preventative, in that individuals can start prioritizing cardiorespiratory
fitness and strength training earlier in life to be better prepared for age-related physical changes.
Physical health and aerobic exercise can also correlate to better cognitive, or mental, fitness
(Zelinski, Dalton, & Hindin, 2011, p. 13). Cognitive training exercises in basic processes like
speed or executive control functioning have also shown to be beneficial as well (Zelinski,
Dalton, & Hindin, 2011, p. 13).
Emotional Development
The literature on emotional development in older adults and the prevalence of depression
in this population seems almost contradictory. Studies have shown that, despite experiencing a
wide variety of loss, ailments, and disease, older adults have often reported higher levels of

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emotional well-being than younger adults (Urry & Gross, 2010, p. 352). In a cross-sectional
study by Urry & Gross (2010), older adults were shown to experience lower levels of negative
affect and higher levels of positive affect than the younger adults who were studied (p. 352).
Additionally, “emotional processing, social behavior, and emotion regulation remain intact and
may even improve across adulthood” (Blanchard-Fields, 2007, p. 26).
The same is true when considering emotional regulation skills and everyday problem
solving from an older individual. Because of an accumulation of life experience, “older adults
are more likely than young adults to combine (a) actions directly targeted to the source of their
problems with (b) emotion-regulation strategies that buffer psychological stress” (BlanchardFields, 2007, p. 30). It is evident that older adults are more effective at emotion regulation,
perhaps due to “changes in functional organization of the brain, accumulating different strategies
for emotional regulation throughout a lifetime, and motivational shifts” (Isaacowitz &
Blanchard-Fields, 2012, p. 3).
These findings seem to contrast with the evidence of geriatric depression, which will be
discussed later in this review, along with other mental health issues, and declines in reasoning
that are often associated with increasing age. How is it possible, then, for older adults to both
report high levels of well-being, but also experience high rates of depression? Perhaps the older
individuals who reported high levels of well-being could also be considered “more well”
individuals, potentially not living in long-term care facilities. Perhaps physical disease or
traumatic physical events, like heart attacks and strokes, and the possible comorbidity of
depression plays an important role. It is important to consider the evidence of these reported
higher levels of well-being, along with the reported wider ranges of emotional regulation skills,
and transfer this understanding into long-term care facilities in order to “advance a more
productive conversation on aging” (Partridge, 2019, p. 17)

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Social Development
Looking at the broader view of aging and what it could look like to age “successfully,”
one might think of the “blue zones” around the world, where the highest concentrations of
centenarians live. Extensive research has been conducted on these pockets of small populations
that seem to have higher life expectancies than the rest of the world. While there are four key
categories identified among these groups of people, the one that particularly relates to this
literature review is “connection” (Buettner, 2024). Within the concept of connection, blue zone
researchers have identified “belonging,” “loved ones first,” and “right tribe” as necessary
elements for maintaining social attachment and engagement (Buettner, 2024). “Belonging”
refers to the involvement in a faith-based community, specifically, however there are a variety of
communities or supportive groups one can be involved in that would promote connection.
“Loved ones first” refers the nourishing of one’s relationships with their “tribe of people.” This
could be keeping aging parents nearby or in the same household, if possible, a commitment to a
life partner, and social relationships, which can all help to support healthy behaviors. These
important aspects, along with other lifestyle factors, have a tremendously positive impact on
longevity and quality of life.
The positive impact social engagement has on older populations is seen in other areas of
literature as well. One study’s findings “suggest that maintaining high or increasing levels of
social attachments through social engagement has potentially protective effects on cognitive and
physical limitations” (Thomas, 2011, p. 430). Findings from the study also show that there are
“greater health benefits for those who were more attached to the social structure through high
levels of social engagement across time and greater health problems for those who had fewer
attachments to the social structure.” The study also revealed that “those who are more socially

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integrated likely experience more motivation, pressure, and information to take better care of
their health” (Thomas, 2011, p. 430).
Additional research has found that “older adults typically report better marriages, more
supportive friendships, less conflict with children and siblings, and closer ties with socialnetwork members than do younger adults” (Fingerman & Charles, 2010, p. 172). These positive
social interactions have been attributed to improved relationships among older adults, a shift of
perspective away from negative aspects of interpersonal relationships, and less reactivity when
social conflict occurs (Fingerman & Charles, 2010, p. 172). With all these findings, it is
important to note that, with increasing age, there can be an increase in the experience of loss. As
this review will discuss in the following sections, loss of loved ones, close friends, independence,
and abilities can negatively impact an older adult and their social connections. It is important that
connection and community, especially in long-term care facilities, are fostered for the mental and
physical wellbeing of all older adults.
Issues Faced by Older Adults
The research presents the potential for individuals to age well and maintain their physical,
emotional, and social health long into their life through a variety of practices. However, due to a
wide array of genetic, environmental, educational, and socio-economic factors, many adults
cannot maintain their independence and require comprehensive care in nursing homes, assisted
living, or other facilities. These aspects of an individual’s health are intricately linked and can
affect one another in positive and negative ways. For example, an individual may experience a
decline in their physical abilities causing them to suffer bad falls or accidents, which may require
them to move into an assisted living setting and leave their homes. This can lead to depression
and a loss of social connections they once had. On the positive side, this individual may develop
social connections within their new assisted living setting that positively impacts their depressive

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feelings by getting them involved in activities, finding commonalities among residents, and
getting the proper assistance so they no longer hurt themselves physically. The perspective on
this stage of late life can change to reflect opportunity with the accurate knowledge of the health
issues that older adults face and how these issues impact one another.
Physical Decline
Physical decline may be the most prevalent and obvious health decline that older adults
face. When looking at common types of physical decline in the older adult population, heart
disease, cancer, stroke, and diabetes are the four major chronic conditions that cause almost twothirds of all the deaths of individuals 65 years or older (APA, 2001). It is reported that almost 92
percent of older individuals live with at least one chronic condition (APA, 2001). Additional
physical issues include hearing impairments, which affect 50 percent of individuals who are 75
years or older, speech and visibility issues, and other impairments of daily functioning (APA,
2001). These types of functioning declines can be isolating for individuals as it becomes more
and more difficult to move around and for others to understand and connect with them.
There is a great possibility of accompanied “comorbid psychosocial conditions” that can
occur. For instance, patients who have experienced heart attacks or strokes also have a high
prevalence of depression and anxiety post-event (Kropf, 2018, p. 23). In fact, in a meta-analysis
on research about depression and stroke, it was reported that “55 percent of post-stroke patients
experienced depression during recovery” (Kropf, 2018, p. 23). This population requires special
consideration when it comes to depression because “they show higher prevalence rates than
younger adults, high levels of re-occurrence, and a different presentation of symptoms” (Fielden,
1992, p. 291). Often physical disease or ailments may overshadow depressive symptoms as
somatic symptoms get more focus due to their more concrete nature.

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Along with physical functioning decline, it is important to also discuss the physical
decline of the brain, or cognitive decline. For most older adults, cognitive changes are mild
throughout this late stage of life, older individuals can continue to learn new skills and express
creativity, and long-term memory often declines less than short-term memory (APA, 2001).
However, dementia, a cognitive disease often associated with age, but not considered a normal
part of aging, affects around 14 percent of the population aged 70 and older (Cadigan, et al.,
2012, p. 856). For those living with dementia, about half of these individuals reside in nursing
homes and assisted living facilities.
Dementia negatively impacts a variety of brain functions including behavior, memory,
and cognition, along with some physical functioning, and manifests on a spectrum with a variety
of symptoms. Nursing home residents living with dementia, as well as their families, experience
an array of changes and, in the later stages, patients may become fully dependent and bedbound
with extreme memory loss, limited verbal abilities, and potential incontinence (Cadigan, et al,
2012, p. 856).
Alzheimer’s disease is the most common form of dementia and is currently the seventh
leading cause of death in the United States (National Institute on Aging, 2023). Some warning
signs of early Alzheimer’s development include problems with memory and word finding, as
well as visual, spatial, or reasoning impairments (National Institute on Aging, 2023).
Alzheimer’s research and awareness is constantly evolving as technologies and studies advance,
but what is understood about the disease is that a combination of cognitive age-related changes,
environmental factors, genetics, and lifestyle factors can all contribute to the development of this
disease (National Institute on Aging, 2023). Whether older individuals face mild cognitive
changes that don’t negatively impact their daily functioning, or they experience the most extreme

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form of cognitive decline that negatively impacts their whole being, their social and familial
connections can also be affected, resulting in a subsequent loss of relationships and support.
Social Changes
Along with physical and functional changes, older adults often deal with a wide variety
of loss in their lives as well. Loss can include the deaths or disconnection from important
individuals, it can include the loss of mobility and functionality in their mind and body, also the
loss of independence and a life in their home. In adults 65 years or older, about 25 percent are
socially isolated due to the loss of loved ones, physical illnesses or impairments, or the move to a
long-term care facility (Garcia, 2022, p. 2). This type of social isolation, or loneliness,
experienced by the older adult population has been shown to increase the likelihood of
developing a variety of diseases including Alzheimer’s (by 50%), heart disease (by 29%), and
stroke (by 32%), while also having the ability to increase anxiety, depression, and cognitive
decline (Garcia, 2022, p. 3).
When living through these various types of loss and isolation, sometimes very suddenly,
older adults may experience “complicated grief, a prolonged and acute experience that extends
for a significant amount of time” (Kropf, 2018, p. 25). There are estimates that “4.7 percent of
the older population suffers from complicated grief,” which can involve intense emotional
responses revolving around death and the circumstances of dying (Kropf, 2018, p. 25). This
shows the intricate link between social and emotional wellbeing and how they affect each other.
Mental Health Issues
Approximately 85 percent of aging adults with severe mental illness are living in nursing
homes, assisted living, and other long-term care facilities (Kropf, 2018, p. 26). Examples of
severe mental illnesses include, but are not limited to, bipolar disorder, major recurrent
depressive disorder, personality disorders, and schizophrenia. Possible symptoms can include

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behaviors that are erratic and unpredictable, poor judgment, loss of interest in activities they once
enjoyed, and possible hallucinations. This can make caregiving more complicated and difficult
for professionals and families.
As previously discussed, physical functioning and cognitive declines along with social
changes can negatively impact the mental health of older individuals. Where these changes and
losses occur, so too can geriatric depression and complicated grief manifest. Depressive
symptoms may be overshadowed by physical ailments and may even mask as symptoms of
dementia, resulting in undiagnosed or unrecognized depression (Fielden, 1992, p. 294).
Psychotherapy may offer healing, but could be hindered by visual, speech, hearing, or reasoning
impairments. This shows the importance of a safe space to express these depressive feelings,
through non-verbal methods, in lower pressure environments, to connect with others who may be
feeling the same.
It is evident that increased age can lead to increased mental and physical disease or
decline, greater experiences of loss in a variety of capacities, changes in social connections, and
activity reduction. It is of the utmost importance, then, that caretakers and professionals working
with older adults remain cognizant of warning signs and the systematic connection of all aspects
of health, and to find ways to promote social connection in safe and respectful environments to
foster emotional expression.
Services for Older Adults
With the rising population of older adults and the subsequent need for more long-term
care options, it is important to differentiate what these options look like for specific individual
needs. Assisted living facilities typically offer older adults assistance with day-to-day activities
including cooking, chores, and grooming, while nursing homes typically offer a more
comprehensive level of care and supervision of its residents (Sy, 2024). There is a mix of care

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levels within this setting “from short-term post-hospital stays to long-term custodial care and
skilled nursing needs” (Sy, 2024). Additionally, it has been documented that in the past 20 years,
nursing homes have grown in size, amount, and complexity, with a majority of them being forprofit facilities (Harrington, Ross, and Kang, 2015, p. 779).
For-profit settings come with their own challenges as a major focus on profits drives the
business to further the best interests of the corporation and investors while still providing quality
of care to residents (Harrington, Ross, and Kang, 2015, p. 781). With the demanding work of
caring for older individuals facing complex issues and a potentially challenging management
structure, it can sometimes be difficult to ensure proper ethical care of all residents as well as
help residents maintain a high quality of life, especially related to social connection.
One way residents’ wellness and social connection is taken into account is by
implementing group psychotherapy in nursing home settings. Brenda Boatswain (2016), a mental
health clinician working with therapy groups in nursing homes, reflects on the potential group
therapy can offer:
Group psychotherapy in a nursing home facility offers patients a safe space to be
themselves, learn about the process of healthy and unhealthy aging, build memory skills,
learn coping skills for this part of the life journey, learn to regulate emotions to improve
quality of life, build a social support network, build compassion for themselves and
others, socialize, find joy, add more meaning and purpose to life, develop an end-of-life
identity, and face aging and death with dignity (Boatswain, 2016, p. 142).

The combination of having highly skilled, ethical care providers and opportunities for
group psychotherapy while residing in a care facility can have incredibly positive impacts on the
lives of older adults. Within a group therapy setting, all three of the developmental factors

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discussed previously- physical, emotional, and social- could be addressed and improved with the
help of fellow group members. Nursing home, assisted living, and other long/short term care
facilities do not have to be places of death and despair. With these types of services provided,
residents can rejoice in their long-lived lives, find meaning in their accomplishments, and
continue to develop their own identity with a sense of purpose, especially as it relates to their
social connections.
Creativity and Overall Wellness
Another powerful tool for assisting older adults in their pursuit of a high quality of life is
the implementation of creativity. Deeper insight on psychological growth and development in
later life has fostered an understanding of the possibility for positive change and creative
expression in older individuals (Cohen, 2006, p. 8). There are several reasons why the pursuit of
creativity and art making promote health in aging. As this literature review has discussed, social
connection and engagement “have a positive influence on general health and reduced mortality”
and many forms of creativity and art making provide social connection including painting
groups, bands, poetry, dance, or drama groups (Cohen, 2006, p. 10).
Another aspect of creative pursuits and their positive impact on health is the sense-ofcontrol mechanism. There is a body of research on aging that has linked engagement with
positive health outcomes for older individuals when they pursue activities that can provide a
sense of mastery. In other words, older individuals learn and practice creative skills that can lead
to this sense of mastery, which, in turn, can lead to “increased feelings of empowerment.” With
increased feelings of empowerment comes an “increase in the level of comfort with exploring
new challenges in general” (Cohen, 2006, p. 9).
Creativity and art making also enhance the human brain’s ability to be flexible and
adaptive. Ancestrally, human beings have had to sharpen their improvisation and invention skills

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to survive and thrive in this world. The creative process has been shown to “engage multiple
cognitive skills and strategies and in doing so engage multiple parts of the brain” (Patterson &
Perlstein, 2011, p. 35). The concept of cognitive training was introduced at the beginning of this
literature review when discussing physical development of older adults and it seems that
creativity may offer a way to stretch those cognitive muscles and exercise the brain’s flexibility.
Pursuing creativity and artmaking could also offer an opportunity for older adults to express
themselves in a way that is applicable to them. Therefore, the combination of creativity and
group therapy in a nursing home setting could be one of the best ways to cultivate a high quality
of life for every older individual, no matter their cognitive, physical, or emotional abilities.
Art Therapy and Older Adults
One proven means of bringing all of this important information together to foster a high
quality of life for older individuals is the incorporation of group art therapy into their lives. Art
therapists working with this population have found that this modality can offer a variety of
benefits including: “providing a visual link by which the individual may explore past and present
experiences, fostering exploration and emotional growth through creative expression, and, for
adults with physical impairments, it can help them relate to their environments in new ways”
(Stephenson, 2006, p. 24). These benefits could have a tremendously positive impact on the
prevalence of geriatric depression among long-term care facilities by providing an outlet for safe,
non-judgmental expression.
Erikson’s insight into this particular stage in life shows us that older adults, around 65
years and older, are faced with taking inventory of their lives and reflecting on their
accomplishments in the Ego Integrity vs. Despair stage (McLeod, 2024). Stephenson (2006), a
practicing art therapist working with the older adult population, stated that this late stage of life
is not necessarily the time to start fixing problems as a therapeutic goal. It may be more

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beneficial to this population to help older individuals recognize their own strengths and how
these have guided their life stories and brought them to where they are today (Stephenson, 2006,
p. 24). Art therapy can provide an avenue for self-reflection and can offer a way to make
meaning of one’s well-lived life while celebrating strengths and experiences.
Group art therapy may also provide residents with a different way of viewing their fellow
residents, and maybe themselves. Partridge (2019) shares that “the images and conversations
created in art therapy were often building blocks for increasing community cohesion” (Partridge,
2019, p. 58). The creative process can often have a bonding effect among participants in that one
gets to see how others problem solve, use materials, and express themselves. This is a
perspective on another individual that many people do not normally get. Group art therapy, then,
can provide a way for residents to reintroduce themselves to their fellow residents. They can
focus on showing and celebrating certain parts of themselves and not letting a disease or ailment
be the only thing that defines them. This celebration of strengths and commonalities can foster
deeper and more profound social connections among residents and therefore impact the social,
emotional, and physical wellbeing of these older adults.
Group art therapy may also help develop a sense of purpose in an older adult’s life.
Beyond individual self-reflection and meaning making, group art therapy provides an
opportunity to lean into the community and create art that is bigger than one individual. This can
be in the form of facility murals with a message, creating art together in response to social
justice, or providing something creative for the outer community that would benefit others.
Having a sense of purpose in life, especially at an older age, has a profound impact on physical
and psychological wellbeing and it is imperative that a sense of purpose is celebrated among
older adults.

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Conclusion
As individuals age, they are often faced with physical, emotional, and social issues as
their mind, body, and relationships change. A developmentally focused, person-centered,
positive psychology approach has been demonstrated as an effective modality for working with
this population. Creativity, specifically art therapy, has provided an avenue for combating some
of the challenges older adults can face. Research has shown that group art therapy can offer a
beneficial outlet for individuals in this population as they pursue a high quality of life. The
following section presents the methodology used for the curricular development.

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Section III: Methodology
This section will present an overview of a group art therapy curriculum designed for
residents of nursing homes, assisted living, and other long-term care facilities found in Appendix
A. The curriculum focuses on building social connections within this setting and fostering selfexpression through a variety of art therapy interventions. These interventions will center on
major themes that are common in the late stage of life and will work to support older individuals
as they pursue a high quality of late life.
Target Audience
This curriculum was developed to benefit residents of nursing homes, assisted living, and
other long-term care facilities. The art interventions presented in the curriculum take into
consideration the wide variety of physical, cognitive, and emotional needs and abilities common
in this population. The curriculum can aid professional art therapists, or other mental health
professionals, working in these specific settings, and enlists multiple theoretic lenses to help
foster multifaceted mental and social well-being.
Curricular Structure
The theoretical approaches driving this curriculum are Person-Centered/ Relational
Centered therapy, in which the individual is considered the expert in their lives and is
encouraged to partake in self-exploration for deeper awareness and insight into themselves (Yao
& Kabir, 2023). A Relational-Centered approach considers individuals with cognitive decline,
dementia, Alzheimer’s, etc. and gathers insight from the close relationships and caretakers in
their lives as a means of developing proper treatment plans and ensuring the utmost care
(Morhardt & Spira, 2013, p. 39). Additionally, this curriculum utilizes a Positive Psychology
approach that focuses on personal strengths, meaning making, and a focus on life fulfillment,
which is important in this late stage of life (Peterson & Park, 2003, p. 143).

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The curriculum is modeled after a variety of studies and approaches being utilized in the
field of art therapy and art education among the older adult population. One such study is the
Creative Aging Study conducted by Dr. Gene Cohen working with intervention groups that met
weekly for intensive community-based art programs meeting for about nine months of the year
and sought to investigate the influence of art programs on general health, mental health, and
social connection (Cohen, 2006, p. 11).
Additionally, the curriculum will draw from practicing art therapists and mental health
professionals working with older adult populations. Intervention ideas and resource material are
inspired by a variety of sources including Art Therapy with Older Adults: Connected and
Empowered (Partridge, 2019), Promoting Self-Expression Through Art Therapy (Stephenson,
2006), and The Creative Age: Awakening Human Potential in the Second Half of Life (Cohen,
2001).
The curriculum will allow for an open group setting in which individuals are able to
participate in one-hour sessions when they are able, new members can join for any session, and
the interventions are accommodating to anyone who wishes to engage. Because a major focus of
the curriculum is to foster community and social connection among residents, it is important that
individuals feel they have a space in the group but are not forced to attend every session.
Therefore, the facilitator must ensure new members are integrated smoothly and group
discussions foster connections within the group.
Participants in the art therapy groups can expect to partake in quick, simple creative
check-ins that will informally assess where individuals are emotionally and cognitively before
the start of the interventions. Additionally, participants will be presented with various discussion
topics and prompts to help facilitate group communication and connection. These topics include,
but are not limited to, grief and loss, making meaning of one’s life, legacy, personal strengths

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and resilience, and building supportive connections. The art interventions will also incorporate
these themes to help aid deeper self-expression and exploration into some of these more common
questions related to the late stage of life.
Curricular Outline
This curriculum offers 12 weeks of art therapy interventions that are run for one hour per
session. Each group session includes a theoretical basis, opening check-in, intervention outline
and goals, discussion prompts, and a closing check-out or assessment measures. The
interventions presented are flexible and adaptable to the group’s specific needs and expectations.
Sessions can be run once per week, twice a month, or once a month for a year depending on
availabilities and scheduling of the facility. The interventions presented are also interchangeable
and do not require a specific order to be successful. Also included in each session's outline are
ways to differentiate interventions and discussions so that the curriculum can be repeated and
adaptable to specific facilities.
The following is a brief list of interventions for the 12-week curriculum:
•

Intervention 1: Material Exploration: “Creative Introductions” (Clay)

•

Intervention 2: Abstract Emotions: “Intuitive Painting” (Paint)

•

Intervention 3: Visual Journal: “A Space to Reflect” (Drawing, Writing)

•

Intervention 4: Personal Strengths Shield: “What Makes Me, Me?” (Paint)

•

Intervention 5: Life Story Collage: “Telling My Story” (Collage)

•

Intervention 6: Legacy Boxes: “My Life’s Treasures” (Mixed Media)

•

Intervention 7: Tree of Life: “Roots and Branches” (Watercolor)

•

Intervention 8: Water Marbling: “Embracing Uncertainty” (Water marbling)

•

Intervention 9: Adapting to Changing: “Living with Loss” (Clay)

•

Intervention 10: Art for Others: “Building Connection” (Clay)

ART THERAPY AND LONG-TERM CARE RESIDENTS
•

Intervention 11: Joyscape Mosaic: “Pieces of Peace” (Paper, Paint)

•

Intervention 12: Group Mural: “Community Quilt” (Paint, Paper)

31

Conclusion
This group art therapy curriculum was designed to foster self-expression and build social
connections within communities of residents in nursing homes, assisted living, and other longterm care facilities. By structuring this curriculum to allow for a flexible, open setting that
welcomes new participants and leaves space for returning participants, the curriculum
encourages a person-driven pursuit of group connection that is cultivated through shared
experience, discussion prompts, and the potential for bonding that creativity offers. The
following section provides a detailed look at the curriculum and all that it includes.

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Section IV: Curriculum
The group art therapy curriculum, presented in Appendix A, is comprised of twelve
interventions specifically designed for residents of nursing homes, assisted living, and other
long-term care facilities to promote creativity, foster personal reflection, and build social
connection among older adults. Group members will have the opportunity to use a variety of
developmentally appropriate tools and materials to create projects that address different topics
related to this stage of late life. Some topics include Grief and Loss, Life’s Story, Personal
Strengths, and Connection Building.
Each intervention is a standalone project with processing prompts and differentiation
ideas provided and can be sped up or slowed down as necessary. They are also not presented in a
particular order and the art therapist or mental health professional using this curriculum is able to
rearrange or pick and choose the interventions that would be most beneficial to their clients and
their practice. Due to the nature of residential care settings, this curriculum encourages an open
group format, welcoming new and returning group members each session. This means
participants may be working on different projects with different materials depending on the
timeline of interventions and varying abilities of the group members. These interventions can be
adapted to individual art therapy sessions as well and could possibly be differentiated for varying
age groups.
Conclusion
This section has provided an overview and summary of the group art therapy curriculum,
comprised of twelve interventions, that was designed for residents of nursing homes, assisted
living, and other long-term care facilities to promote creativity, foster personal reflection, and
build social connection. The complete curriculum is provided in Appendix A. The final section
of this paper discusses the implications of this type of work, as well as its limitations and will
provide suggestions for further research to benefit this older adult population.

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Section V: Discussion
The Artful Aging curriculum was inspired by a need in the community to bring
therapeutic creative activities centered on self-expression and community development
throughout local nursing home facilities. The curriculum follows a Person Centered, Positive
Psychology approach that views each individual as the expert of their experience with the ability
to continue to strengthen their own physical and mental wellbeing. The mission of this
curriculum is to provide art therapy interventions specifically tailored to the older adult
population that offers a variety of expressive avenues for facing the various challenges and
triumphs of life.
Brief Summary of the Research
The current research on the older adult population in the United States shows that people
are living longer (Mather & Scommenga, 2024), and many older adults require additional care in
the form of a nursing home, assisted living, or other long-term care facility (National Library of
Medicine, 2022). Making the transition into these types of facilities can be a shock to an
individual. It can often feel like a loss of independence, maybe a loss in their mobility, a loss in
friendships, and the loss of their old life. Often a drastic change like this can lead to deeper
physical and mental issues. Research has found that, with residents dealing with physical
ailments, mental or emotional ailments often go unchecked and can be clouded by what is going
on physically (Fielden, 1992, p. 291).
Creativity offers a means of addressing some of these physical and mental health issues
in a way that is approachable and enjoyable. A variety of research has been conducted on the
benefits of participating in creative activities, i.e. painting, theater, writing, etc. for older adults
(Cohen, 2006). These types of activities encourage brain flexibility and cognitive training. They
can also help to develop an older adult’s sense of mastery mechanism, which can increase their

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self-esteem and purpose. Creating in a group also allows participants to bond over the creative
process and build a sense of community with their fellow artists, which has been known to
improve health outcomes (Cohen, 2006).
Discussion
In an individualistic society, like the one in the United States, circumstances and
expectations often force families to make decisions that lead to older adults moving into longterm care residential settings to receive more comprehensive care. Because of this, these
facilities and the number of their residents have risen dramatically across the country in recent
years. Moving into a long-term care residential setting is often the best decision for the
individual but can still be very painful for everyone involved. Research has shown that this type
of move can disrupt physical and emotional wellbeing and can exacerbate pre-existing ailments
(Kropf, 2018). It is vital, then, to provide the best holistic care and attention in these facilities
and to foster purpose and community among residents so they have an outlet to express the
difficulties they are facing.
Ultimately, I believe that this population can often go unrecognized and, possibly,
forgotten. However, this is the population that we can learn the most from, their life experiences,
various perspectives on what they have seen and learned, challenges they have faced, things they
would have approached differently, and their celebrations in life. This is all evidence of a long
life lived and, while it has all been purposeful to the individual, it could also provide insight for
others as well. One of the best ways to process and share this long life is to create art about it.
The act of reflection and discussion on the various aspects of life and the ability to produce
something tangible as a result of this introspection is the beauty of art therapy. This, combined
with the bonding experience of making art surrounded by other people makes art therapy a
valuable and necessary resource for those living in assisted and skilled nursing communities.

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Limitations
This curriculum is entirely theoretical and has not yet been put into practice within this
population. While every component of the curriculum, its interventions, prompts, materials, and
goals are based on literature research and limited experience with older adult residents, the
curriculum has not yet been used practically. Therefore, there is room for development and better
understanding of materials and directives as they are used with residents. Suggestions and
adaptations are welcomed by art therapists utilizing this curriculum as we work to bring efficacy
into group art therapy within these facilities.
Another limitation of this curriculum might be its open group policy that could inhibit
some of the structure and routine often found in closed groups. An open group format seems to
be the most beneficial for this population and type of facility, however art therapists and
facilitators may find it challenging to build rapport with participants and keep group members on
similar art making tasks. Art therapists may find that group members are working on different
projects depending on attendance and drying times for different materials.
While the materials and costs of materials for each intervention have been kept low and
there is overlap with certain material use for different interventions, the curriculum might
suggest supplies that are out of budget. However, the curriculum has been designed so that there
is flexibility in tools and materials and most interventions can be adapted to the resources on
hand. This flexibility extends to each participants’ motor and cognitive abilities as there may be
different levels of assistance required for different interventions.
Suggestions for Future Research
Further research on the longer-term mental health effects of incorporating creativity and
art making into the routines of this older adult population is important, as well as understanding
the role that social creative connection plays in wellbeing. Additionally, it may be pertinent to

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research the impacts positive mental health has on physical health through these art making
activities, which would strengthen the case for offering art therapy in these settings. Another
potential area of research is understanding the benefit of participating in creative activities for
older adults who are independent and those who are residents in these long-term care settings
and any possible distinction between these benefits. Further understanding of the differences
between an open and closed group format would be beneficial, especially if assessments were to
show that one format were to yield better results than another. Adaptations of this curriculum for
use with other populations, potentially children in the foster care system, individuals working
through drug and alcohol programs, or other in-patient type settings could provide a wider reach
of these interventions. Finally, research on material adaptations and their impact on the outcome
of a session would be important as art therapists are encouraged to use materials they have and
are comfortable with.

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Conclusion
The population of the United States is becoming older than it has ever been. Over 1.3
million individuals require the type of comprehensive health care typically found in long-term
care facilities (National Library of Medicine, 2022). As older adults, and their families, make the
decision to move into nursing homes, assisted living, and other long-term care centers, a variety
of physical, emotional, and social challenges may have not only been the cause, but will often be
the effect of this type of transition. Research has shown that this type of move can disrupt
physical and emotional wellbeing and can exacerbate pre-existing ailments (Kropf, 2018).
Growing older and transitioning into a new phase of life can offer opportunity for new social
connections, personal reflection, and self-expression, all through the modality of art therapy.
Cohen’s (2006) Creative Aging Study showed that creative group pursuits have a positive
impact on the mental and physical health of older adults. These creative pursuits help to
encourage social connection and a sense of belonging, help to enhance the brain’s flexibility, and
foster empowerment through problem solving and a sense of control. Group art therapy
interventions work towards bringing all of these aspects together and providing a space for
residents to be themselves without the weight of their aliments or challenges, and delight in the
creative process, at least for a little while.
The proposed group art therapy curriculum strives to provide developmentally
appropriate art therapy interventions focused on self-expression, personal reflection, and social
connection. This type of work has the potential to uplift an individual’s experience in a
residential care setting and, if there is anything to be learned about positive mental health, it is
that one individual shining their light can have tremendous impact on everyone around them.

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