This article contributes to the burgeoning interest in the link between arts, health, and aging by exploring expressive arts as a means to engage socially isolated older adults living in rural areas. “Expressive arts” integrate a range of creative processes (visual, movement, drama, music, writing, etc.) to foster deep personal growth (International Expressive Arts Therapy Association [IEATA], n.d.) and has been used for the enhancement of health and well-being among older adults (Cohen, Reference Cohen2009). While there is increasing knowledge about the various types of innovative expressive arts programs that have emerged internationally (e.g., Moody & Phinney, Reference Moody and Phinney2012), there is a particular gap in understanding the emergence of volunteer-based expressive arts programs in the often under-resourced rural context (Joseph & Skinner, Reference Joseph and Skinner2012).
Employing a participatory arts-based research approach (Leavy, Reference Leavy2009), we have examined an example of such an innovative program – Visible Voices: Seniors Connecting with Seniors through Expressive Arts Making – which sought to address the issue of rural social isolation through the intervention of in-home volunteer-based expressive arts (Wilkinson, MacLeod, Skinner, & Reid, Reference Wilkinson, MacLeod, Skinner and Reid2013). With the support of a local arts council and led by an expressive arts practitioner (Wilkinson) and a team of community-university researchers (MacLeod, Skinner, and Reid), the program ran in the 2009–2010 time frame and involved eight older adult volunteers who were matched one-to-one with eight socially isolated older adults to conduct in-home, individual, intermodal art-making activities in their dyads over 10 sessions. These volunteers – who we recruited through word of mouth and trained in expressive arts techniques and communication – included retired artists, teachers, and nurses, among others. The project was based in a rural county of central Ontario with a population of 17,000 permanent residents, approximately 20 per cent of whom were over age 65 in 2011. Located 100 km from a regional urban centre (pop. 80,000), the rapidly aging county is a typical rural-recreational environment with the population more than tripling in summer months with the influx of seasonal residents (Bryant & Joseph, Reference Bryant and Joseph2001). Public services, seasonal tourism, and a vibrant arts community dominate the economy suffering from a chronic out-migration of young adults to urban areas, which increases the isolation, both physical and social, of older residents. It is the unique combination of rural aging and vibrant arts which makes the county and the Visible Voices program of particular analytical interest.
The program under investigation was funded by a grant from Human Resources and Development Canada and addressed recent calls for greater collaboration with older adults and community members as research stakeholders (Martin-Matthews, Reference Martin-Matthews2011). The program objectives were threefold: (1) to train and enable older volunteers to engage in meaningful expressive arts activities with socially isolated older adults; (2) to give isolated older adults the opportunity to engage with others through expressive arts activities; and (3) to provide researchers the opportunity to understand the role of volunteer-based expressive arts experiences in a rural home setting. The latter objective is the focus of this article, with a practice-oriented overview of the first two objectives discussed in Wilkinson et al. (Reference Wilkinson, MacLeod, Skinner and Reid2013).
We begin with a review of key developments in healthy aging as they relate to social isolation and creativity, volunteerism, and go on to arts and health research literatures. We then describe our participatory research design and methods. Our methodology has been influenced by social interactionism and pragmatism while considering that expressive art-making and arts-based methods require dialogue among researchers, the trained volunteer and older adult participants, and audience members to “give voice” to participants. Although the focus of inquiry was more descriptive in nature, individual empowerment was an important principle of the project. The qualitative interpretive research design that guided our analysis of the experiences of the participants and volunteers focused on their artistic creations, weekly logs, program leader field notes, and debriefing meeting minutes.
The research was participatory by design, where an advisory committee of older adult artists were developing research questions with the researchers and jointly pursuing means to answer the questions. The result was the following suite of collaboratively designed research questions: (a) what are the experiences of isolated older adults living in rural areas who participate in expressive arts with older adult volunteers; (b) what are the experiences of older adult volunteers who facilitate art-making with isolated older adults in the rural context; and (c) what are the opportunities and challenges involved in facilitating this experience in a rural community setting? Researchers played a larger role in the interpretive analysis of artistic pieces created by older adults and volunteers. The program leader (who was also a volunteer in a dyad) did frequent member checking in the context of the home-based intervention and shaped the public celebration and dialogue enabling participants to highlight key messages and their work. The presentation of our findings is followed by a discussion of the potential for volunteer-based expressive arts programs to inform policy and community responses to rural social isolation among older adults.
Literature Review
Our research addresses calls within the rural aging literature for greater attention to the issue of social isolation among older adults and the opportunities and challenges of volunteer-based interventions (Joseph & Skinner, Reference Joseph and Skinner2012). Of particular importance for this article is the increasing recognition of the link between art, social engagement, and healthy aging (Lander & Graham-Pole, Reference Lander and Graham-Pole2008; Moody & Phinney, Reference Moody and Phinney2012).
Healthy Aging and Creativity
While there is a diverse range of definitions of “healthy aging” (including “successful aging”, etc.) depending on the lens employed (Hansen-Kyle, Reference Hansen-Kyle2005; Menec, Means, Keating, Parkhurst, & Eales, Reference Menec, Means, Keating, Parkhurst and Eales2011), key concepts generally focus on the ability of older adults to adapt and compensate, given a slowing down of bodily processes. Resilience contributes to well-being, autonomy, independence, and the desire to participate in life (Hansen-Kyle, Reference Hansen-Kyle2005). Meaning-making in relation to others influences gerotranscendence, the final developmental stage of life (Wadensten, Reference Wadensten2007). In particular, when older people use their imagination and creativity, combined with meaningful social engagement, there is an improved sense of control and mastery affecting positive health outcomes (Cohen, Reference Cohen2009). Meaningful engagement in this last life stage is dependent on individual perception of past relationships and social isolation (Cloutier-Fisher, Kobayashi, & Smith, Reference Cloutier-Fisher, Kobayashi and Smith2011), and on preferred expressions of engagement. In particular, older adults engaged in artistic expressions have experienced positive health outcomes (Castora-Binkley, Noelker, Prohaska, & Satariano, Reference Castora-Binkley, Noelker, Prohaska and Satariano2010).Furthermore, volunteering opportunities that offer an expression of individualism and growth as part of serious leisure have demonstrated a positive association with a sense of community and social cohesion (Gallant, Arai, & Smale, Reference Gallant, Arai and Smale2013). Yet, in the contemporary era of individualism and urbanization, older adults living in rural areas face issues of reduced opportunities for paid work, social engagement, and meaningful leisure activities (Keating, Swindle, & Fletcher, Reference Keating, Swindle and Fletcher2011; Rozanova, Keating, & Eales, Reference Rozanova, Keating and Eales2012). In response, recent studies call for research into the health-promoting interventions and their outcomes using multi-sectoral involvement in different settings (Markle-Reid, Browne, & Gafni, Reference Markle-Reid, Browne and Gafni2013).
Volunteerism and Older Adults
Not surprisingly, there is also growing interest in the link between aging and volunteerism in relation to social isolation, especially in the context of under-serviced rural areas (Joseph & Skinner, Reference Joseph and Skinner2012). Older residents often seek volunteer opportunities that use their skills and life experiences to mentor others as well as support their own meaningful social engagement and transitions (Gallant et al., Reference Gallant, Arai and Smale2013). Indeed, the majority of volunteers are older women, retired from work in health, social services, or education (Cook & Speevak Sladowski, Reference Cook and Speevak Sladowski2013). They are motivated to volunteer to increase participation in meaningful activities, strengthen social involvement, and enhance their sense of worth (Gottlieb & Gillespie, Reference Gottlieb and Gillespie2008). Other scholars view volunteerism as contributing to their physical and mental health and well-being of the community (Brown, Hoye, & Nicholson, Reference Brown, Hoye and Nicholson2012). Community-based health promotion initiatives, using art, has been found to leverage motivated volunteers to positively impact social isolation, creating opportunities for meaningful social engagement that benefits the volunteers and the more vulnerable community members (Cox et al., Reference Cox, Lafreniere, Brett-MacLean, Collie, Cooley and Dunbrack2010; Moody & Phinney, Reference Moody and Phinney2012; White, Reference White2009). Moreover, home care, public health, and primary care providers are being encouraged to collaborate with the voluntary sector to use the arts to enhance well-being of individuals as well as populations (Tesch & Hansen, Reference Tesch and Hansen2013).
Arts and Health Research
Informed by the burgeoning interdisciplinary field of “arts and health” (Camic, Clift, & Daykin, Reference Camic, Clift and Daykin2009), there is recognition among health and social care practitioners, policy decision-makers and researchers of the opportunity to use arts-based methods to enhance the understanding of the underlying determinants, mechanisms, and strategies for healthy aging (Bungay & Clift, Reference Bungay and Clift2010; Fraser & Al Saya, Reference Fraser and Al Saya2011; Lander & Graham-Pole, Reference Lander and Graham-Pole2008). Marginalized groups such as older adults have used the arts to increase a sense of social inclusion and translate their experiences to a broader audience, creating a sense of empowerment (Moody & Phinney, Reference Moody and Phinney2012). Recent reviews have described the positive impact of art-based interventions (Castora-Binkley et al., Reference Castora-Binkley, Noelker, Prohaska and Satariano2010; Cox et al., Reference Cox, Lafreniere, Brett-MacLean, Collie, Cooley and Dunbrack2010; Fraser & Al Saya, Reference Fraser and Al Saya2011; Stuckey & Nobel, Reference Stuckey and Nobel2010; Tesch & Hansen, Reference Tesch and Hansen2013), with some emphasizing, both conceptually and empirically, the social aspects and benefits for addressing isolation (Bungay & Clift, Reference Bungay and Clift2010; Greaves & Farbus, Reference Greaves and Farbus2006). Cohen’s (Reference Cohen2009) work, for instance, provides a theoretical underpinning for using creative expression and social response to increase a sense of control and meaningful engagement to bolster protective factors contributing to well-being.
In order to extend the impact of art-making to support expression of the self in relation to others, expressive arts amplify personal expression by using different modalities whereby the focus is as much on the creative process as it is on the final outcome or product (Wilkinson et al., Reference Wilkinson, MacLeod, Skinner and Reid2013). In addition, arts-based participatory inquiry methods are most empowering for participants when designed to address relevant research questions (Fraser & Al Saya, Reference Fraser and Al Saya2011; Leavy, Reference Leavy2009). Given the emerging body of research that demonstrates the power of art-making to enhance well-being, health, and social engagement, we have examined the Visible Voices program as a means of understanding the role of expressive arts interventions using volunteers in addressing social isolation of older rural adults.
Arts-based methods lend themselves to participatory approaches and can be used for knowledge generation and knowledge translation (Fraser & Al Saya, Reference Fraser and Al Saya2011). This type of research draws upon participatory arts-based approaches to inquiry that are proving useful in addressing research questions that aim to “describe, explore and discover … while attentive to processes” (Leavy, Reference Leavy2009, p. 12). Underpinned by the reflective inquiry of pragmatism and the meaning made through interactionism (Corbin & Strauss, Reference Corbin and Strauss2008), the arts have been used, particularly with marginalized populations, to engage participants and create an opportunity for them to find their voice to make meaning and influence change (Finley, Reference Finley2003). Within this methodology, there are no standardized approaches to establish trustworthiness, authenticity, and value of the aesthetic quality of the work; rather, rigour is established through careful attention to the evocation of responses and connections between the audience and the artistic creator (Leavy, Reference Leavy2009). Dialogue among the audience, artistic creators, and researchers is thus an essential component of arts-based analysis to enhance interpretive validity (Fraser & Al Saya, Reference Fraser and Al Saya2011; Sandelowski & Barroso, Reference Sandelowski and Barroso2007). Opportunity for dialogue among participants, volunteers, researchers, and community members offers validation of the themes, and presents an informal opportunity for further higher-level analysis of themes through discussion of key impacts of the project with participants and older adults.
Research Design
A participatory approach was embedded in the design of the Visible Voices program, which takes its name from the view that the arts can be used to communicate the emotional and social complexities of vulnerable people to inform critical debates using their own voices. To this end, as noted earlier in the introduction, the program objectives were both applied (i.e., to train and enable older volunteers; to enable meaningful engagement using art-making among socially isolated older adults) as well as analytical (i.e., to understand the experience of older volunteers and older adults who engage in expressive arts). The latter objective was fulfilled using a community-based participatory approach in which the university-community researchers (MacLeod, Skinner, and Reid) worked with the program leader (Wilkinson) and a community advisory board of older adult volunteers, local older artists, and a local arts council to design the scope and nature of the research.
As previously described concerning this program (Wilkinson et al., Reference Wilkinson, MacLeod, Skinner and Reid2013), community advisory boards are an integral part of collaborative partnerships bringing community perspectives into the various conceptual, operational, and analytical aspects of the research (Newman et al., Reference Newman, Andrews, Magwood, Jenkins, Cox and Williamson2011). The community advisory group worked with researchers in developing the research questions, program goals, and then in seeking funding and other community agency collaborators for support. In this instance, the research team accepted recommendations of the program’s community advisory group not to seek quantitative measures of healthy aging, quality of life, or well-being (which are not necessarily congruent with arts-based approaches). Instead, emphasis was placed on building understanding qualitatively of the experiences of the older participants and older volunteers. The researchers worked with the program leader who was also an older adult volunteer, participating in volunteer debriefing meetings where interpretations of created pieces and experiences during the art making sessions were discussed. There was consensus among the participants and the volunteers in mounting, and participating in, a public installation of their work as a means to communicate their most important experiences and work to the broader community.
The intent of the public showing was to validate thematic findings and offer a venue for the participants to have dialogue with a broader audience to amplify often personally empowering experiences and to contribute to further analysis of the experience. During the project, many of the principles of participatory action research methodologies were evident such as its participatory nature, where researchers and participants were co-learners, both involved at every stage in the research process, balancing research and action (Minkler, Reference Minkler2000). However, the contribution of the participants in conducting interpretive analysis of text and visual art produced was limited to the project leader (an older adult volunteer) along with the researchers. Themes were validated with the participants at a public showing and through dialogue with community members and decision makers where key impacts were featured. This was the basis for further analysis by the research team and project leader. Although the process built capacity among individual participants who shared their voice with those of perceived greater power, the intent of the project was not to reflect some of the principles of participatory action research, such as exposing social constraints, addressing systems development and community capacity building (McTaggart, Reference McTaggart1991).
Sample
Theoretical sampling, understanding the subjective nature of social isolation (Cloutier-Fisher et al., Reference Cloutier-Fisher, Kobayashi and Smith2011), was the basis for recruiting participants, which proved to be difficult given restrictions of confidentiality. Sixteen volunteers and participants were recruited by the program leader (Wilkinson) in 2009 largely through word of mouth, and through letters of information provided to health and social service providers and volunteer organizations such as the local Arts Council, as well as through the local media and an open information meeting. The program involved eight older female volunteers (aged 55 to 75) and eight cognitively well, isolated older adults (two men and six women aged 65 to 95), six of whom were living in their homes and two in long-term care facilities. Paid professional personal support workers were not included in the intervention, but were occasionally in the same physical space during the art-making. Also infrequently present and not participating during sessions was a spouse who lived with one participant, and a daughter of another participant.
The volunteers included expressive arts facilitators who were graduates of a community college expressive arts post-diploma program, an artist, a social worker, retired teachers, an infant mental health specialist, and a nurse. With ethics approval from Trent University’s Research Ethics Board, which in practice involved written and informed consent, confidentiality agreements and release of art permission from all participants, volunteers, and research team members. The program leader obtained these documents after an information meeting with volunteers and individual meetings with the participants in their homes to explain the program and garner information about their own perceptions of social isolation, interests, home setting, and limitations. The program leader trained and supported volunteers regarding creating trusting relationships to facilitate expressive arts, recruited participants, made the volunteer and participant-dyad matches, served as a volunteer, facilitated debriefing meetings, and collected the data, including documenting the artwork digitally. The volunteer participant dyads were made based on geographic proximity, artistic interests, similar life histories, and experience of the volunteer.
Data Collection
The program leader organized data collection. A research assistant transcribed data and archived it by date, and added participant or volunteer initials. The data included the following:
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• the program leader’s field notes from four volunteer debriefing meetings, participant visits, and the public celebration,
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• four participant and eight volunteer weekly textual logs,
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• two digitally recorded audio logs of participants (due to participant fatigue), and
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• art created by all of the older adult participants and volunteers.
Two participants declined to keep logs. The participant written log submissions ranged in length from very brief (under 50 words) done three times, to a weekly submission including poetry and sketches each over three pages long, with the average being five times during the program. Permission to use their names connected to their artwork for use in public installations was acquired with informed consent; however, only pseudonyms are used in the reporting of the research results and in related publications and presentations. The volunteer training, matching of volunteers to participants and full description and evaluation of the program, a 10-week series of one-on-one intermodal art-making in the participants’ homes and institutional settings is discussed in a companion article (Wilkinson et al., Reference Wilkinson, MacLeod, Skinner and Reid2013).
Data Analysis
Consistent with the participatory approach, our thematic and narrative-based analysis was a collaborative, reflective process (Leavy, Reference Leavy2009) among the members of the research team, one of whom also had the additional roles of Visible Voices program leader. Completed in 2010–2011, the analysis involved ongoing email and telephone correspondence and three dedicated in-person meetings of the authors, which began with a discussion of our individual reviews of the data to identify emergent themes. Led by the lead researcher (MacLeod), the team did an initial review of a variety of data including field notes, debriefing meeting minutes, volunteer logs, artwork, evaluations, and media coverage to identify general characteristics of the context, the volunteer-participant interaction, and its meaning in relation to art created over time. In a second meeting, after further immersion with the narrative logs and digital photographs, themes were modified, some collapsed into others, and definitions arrived at through consensus. At the third meeting, duplicates of narrative logs and images of the created pieces were reviewed and literally cut into pieces, and grouped by themes using constant comparison. These quotes and artwork exemplars were used to illustrate each theme. The resultant interpretive findings were validated among the authors, including the program leader who offered contextual interpretation until there was consensus.
Credibility of the interpretive analysis was augmented through triangulation of data collected, such as use of participant and volunteer written logs and field notes of the four debriefing meeting minutes and those of the program leader after site visits at the beginning and end of the program. Understanding the context and processes can assist in constant comparison analysis to identify emerging categories, code these categories, and develop links (Corbin & Strauss, Reference Corbin and Strauss2008); for example, logs and notes were considered for context during the analysis. Dating and using alphabetical identifiers of artifacts allowed the researchers to discuss the coding and their interpretation of more abstract cases. These cases were discussed with the program leader, familiar with the context and each pairing. The use of the art did evoke dialogue between the broader community and socially isolated older adults and older volunteers – a typically unheard voice – during a public event and installation. Interviews with the researchers, decision makers, the media, service providers, volunteers and participants, reaffirmed the themes outlined in the findings. This venue allowed participants to discuss the findings with researchers and community members where there was informal analysis of factors affecting the perceived meaning of the experience to the dyads and individuals. Some participants shared highlighted priority messages with the media. This event subsequently provided impetus for the inclusion of organizations that use volunteers to support home-based clients (some of which participated in the Visible Voices program) being invited to be a part of a recently created network of service providers.
Findings
To address the collaboratively designed research questions regarding the experiences of isolated older adults and older volunteers, and the challenges of rural expressive arts programs, our findings are presented here according to the emergent themes from the thematic analysis. The participant and volunteer findings are presented together, with reference to their artwork and verbatim quotations for authenticity, since similar themes developed that inform our understanding of the experiences of the participants and volunteers participating in the program. Emerging from the artwork and narrative logs were the five main themes: (a) relationships between the volunteer and participant, (b) the participant’s own personal development, (c) the corresponding created meanings that ensued, (d) aesthetic appreciation of their created pieces, and (e) the theme of extension: thought, effort, and discussions related to but beyond the time of the visit and which were also revealed. The operational theme of logistics, which related to the program’s implementation, was discussed in our previously published practice-oriented companion article (Wilkinson et al., Reference Wilkinson, MacLeod, Skinner and Reid2013).
Relationships
The relationship between the older adult participant and paired volunteer developed over the 10 sessions. All four completed participant logs and two recordings demonstrated the theme of appreciation of the relationship with the volunteer. Each of the eight volunteers noted observations of their participant over time and included increased smiling, more openness, or a kiss on their cheek when they left towards the end of the program. As reported in seven of the eight volunteer logs, once the basis of a trusting safe environment was established, as the level of intimacy of the relationships increased, the participants demonstrated reciprocation and gratitude for the relationship. One volunteer wrote of her participant after their fourth visit:
She even asked when I would be coming to visit and at what time.
The paired participant’s digital recording of the same week stated:
I have never told this part of my past to anybody before. Thank you.
Field notes from the end of the program regarding this same participant indicated that staff reported that this resident in long-term care is smiling more often and has a different countenance, engaging more with the volunteer, and one staff member was heard to say, “I get it now.”
Similarly, all eight volunteers’ logs and artistic pieces discussed the relationship forged with the participant. They addressed aspects such as their intentional approach to creating a safe environment with their partnered participant. While volunteers were not recruited based on interests in making relationships, the created artwork and logs demonstrated the importance of forming a trusting relationship, co-creating artwork, witnessing creation of meaning, and coming to closure or transition in the relationship at the end of the program.
As illustrated in the previous participant quote and in Figure 1, childhood and transition stories offered context to the participant-volunteer relationship and laid the foundation of emotional connection and trust. This was captured succinctly by a volunteer at the beginning of their relationship in both the log entry cited below and related artwork shown in Figure 1:
Drawings of favourite places elicited childhood stories from us both. The drawings gave us a point of connection and focus.
Participant drawing of childhood home: pastel on paper
Towards the end of this relationship, the same volunteer wrote in her narrative log:
[The participant] was clearly more relaxed and enjoying herself and able to lead in hanging up her work. She was glowing with recognition, proud of her work, telling other residents (in the long-term care facility) “we made this.”
While it was clear that the volunteers intentionally tried to create a safe space to build trust as a foundation for co-creative experiences, establishing volunteer-participant relationship boundaries was a challenge in one dyad. The increasing depth of the relationship over time and attention to boundaries within the relationship provided an opportunity for the initially formal relationship to meld into more informal friendships in seven of the pairings – or not, as with one of the pairings. In this instance, a participant who was confined to a wheelchair made a clay inuksuk titled “I am here” (Figure 2). During the experience and conversation, the participant sought personal information from the volunteer. Post-session, the volunteer created a fabric-quilted piece in response to her need to delineate the volunteer-participant boundaries (Figure 3). Having the in-home visits in a rural remote setting offered an opportunity for intimacy, and to be in relationship in the person’s context, but also led this volunteer to feel vulnerable. It was noted in the debriefing meeting minutes, when referring to her quilted work, that art-making in the context of institutional settings often implies more formal boundaries between facilitators and the participants, leaving the volunteer to negotiate relationship boundaries more in the home setting.
Participant Inukshuk “I am here”: multimedia sculpture of rock and clay
Volunteer response to a home visit: sewn and quilted fabric
Seven of the eight volunteers expressed, in their logs, their own and their participant’s anticipatory grieving of the end of their art-making visits, a desire to reshape the new relationship into a friendship, or follow up with other potential relationships to continue art-making. As observed at the final celebratory art show and reception, all participants expressed appreciation for the relationship formed with the volunteer. This was highlighted as one of the most important aspects of the program in the participant and volunteer discussions with the audience. It was also apparent through observations of joyful facial expressions and hugging. Thus, the social component and engagement between the artistic creator and another, contributes to the co-creation of a meaningful, self-chosen activity as well as addressing the participant’s social isolation and expansion of their social network. While only one participant wrote about anticipatory grieving in their ninth log, one was teary and two others talked about how they would miss the visits. This is exemplified by the participant’s log:
We ended up with for now saying goodbye because this is my 10th (last) week. I’ll really miss the weekly sessions I know. But [name of the volunteer] comforted me by saying we’ll be in touch for sure. This is not the end …
In reference to the preceding quote, towards the end of the program, the same volunteer wrote in her narrative log:
[The participant] was clearly more relaxed and enjoying herself and able to lead in hanging up her work.
Personal Development
The preceding quote not only exemplifies a deepening connection between the volunteer and participant, but also exemplifies pride in their created works. Pride accompanying personal development of co-created work was evident in five of the volunteer logs and in the final volunteer group’s sandtray artwork. The exploration of personal boundaries in the fourth and final debriefing meetings spoke to the theme of personal development. For example, all eight volunteers reflected on their initial anxiety of forming new relationships and creating expressive arts with another. By the end of the program, feelings of anxiety about the relationships and art-making changed to a sense of pride of being able to form trusting relationships and create opportunities for their participant’s expression as previously illustrated in the public celebration and the aforementioned volunteer’s log.
During debriefing sessions, all of the volunteers indicated that the experience of volunteering had certainly created personal development in their expressive arts facilitation skills and meaning derived from reflection on their own aging, while gaining great satisfaction and personal development from creating the opportunity to use expressive arts to enhance well-being among socially isolated older adults.
In contrast to the volunteers, whose personal development focused on their growth area in interpersonal and facilitation skills and not necessarily on their own artistic creations, all eight participants discussed their own personal development through their artwork at the final celebration. This theme was also evident in the participant logs and in one piece of art where the word “potential” was written boldly. For instance, one participant wrote in the last log:
I learned something new. It was something that took me away from the everyday-ness of being here.
A different participant focused more on the personal development and aesthetics of his acrylic painting of a sailboat under sail, which was noted in three separate logs:
I paint to the best of my ability. I tried to capture speed coupled to quietness and stillness. The challenge is to portray the “forces” or the “idea” behind the object in question. Therefore, it is the viewer, not the “artist” that indicates what they perceive in the art form. I don’t know what I learned until maybe much later or never. I hope they have a big party at the end.
Discussion at the celebration indicated that all participants transitioned from feelings of anxiety and self-doubt to pride in their accomplishments, illustrating the theme of personal development. Pieces chosen to display at the public celebration reflected a variety of modalities and points of time in the program, but all were to illustrate works that were meaningful to the creator. Photographs of the event and media coverage illustrated that pride in participants and the volunteers.
Created Meanings
Though the art-making was a medium to address social isolation within the participant’s home, it was the relationship created between the volunteer and the participant that enabled participants to create pieces reflecting inner expressions. These works were meaningful to them, reflecting their personhood or personal potential. The three participants who explicitly wrote of the created meanings theme described a deeper understanding of self and use of different modalities to create pieces that offered new and evolving perspectives on their lives lived and accomplishments. Three participants wrote in their logs about their own life reflection and intentions on how they wished to age, qualitatively describing their view on healthy aging.
Their stories illustrated gerotranscendence and spoke to satisfaction of their life and its review. Particularly between the two eldest participants (aged 88 and 94), there was a sense of life fulfillment and resolution because of pieces created. Seven of the volunteer logs described participants’ meaning to their current life experiences, revealed in discussions as they co-created and reflected on previous significant events in their lives. The depth and range of methods and media used to express inner thoughts and feelings increased over time spent in the program. Reminiscence of losses, relationships, and accomplishments were common themes explored by participants using a variety of media, such as poetry, painting, story, and multimedia construction, influenced by their abilities and interests.
The following poems and painting of one participant illustrates a progression of depth of created meanings and personal development that occurred using a variety of modalities over the 10 weeks, from one of realization of the potential impact of expressive arts to self-discovery and growth. The first poem (untitled), was accompanied by a watercolour self-profile (Figure 4):
Far, far away in an ocean far beyond
The ship was sailing with an important cargo
Time is of the essence
The cargo cannot be spoiled
Away we go
We’ll meet you on the other side
Ready to embrace.
And before long
I’ll give birth to this special cargo
Participant abstract self-portrait – profile view: watercolour on paper
The second poem (“My Inner Soul”), was accompanied by a chalk pastel (Figure 5):
My inner soul should come out
Let it play as it never has
Even if there comes the occasional SHOUT
Let it go until you feel your best
Keep it that way
And one day
You will fall in love with
Your real you.
Participant emotional expression: pastel on paper
The same participant’s narrative log illustrated personal development, the theme referenced in the preceding section, as well as the importance of the volunteer’s role in honouring her voice to create meaning from expression.
I did not think what I wrote was so good, but if I read it somewhere else, I’d think wow that person can write well, and then, [the volunteer] read me back my poem and brought out my pictures of birth and potential. It baffled me at that time that it was me who did this work. I did not think I was capable of doing that. It has taught me to incorporate my thoughts into art and further expand it. Not always taking things the way you see it at first, but go beyond this. What can I do to see it from a different perspective? It brought out my inner thoughts; expressed through different mediums of art as well as express it in words.
The participant also wrote the following narrative log nearing the end of the program illustrating how expressive arts can support a progression towards well-being.
[The art created] has taught me to incorporate my thoughts into art and further expand it. I learned that while I review my work, that is time for me to give myself ‘me’ time. I got to know myself better and from there I can then help others.
The following is an excerpt from news coverage of the final public celebration (Gavan, Reference Gavan2010), which was accompanied by a mixed media “Tree of Life” (Figure 6):
[The participant`s art consisted of a large family tree, a huge collage in the form of a trunk and branches filled with important slices of her 88 years. “I was home alone and I had time,” says [name of participant]. “There’s a lot of stories on the tree; sad days and happy days; it’s a tree with a lot of stories – good and bad.” But she says that along with the cathartic work came those crucial memories, flowing out with the newspaper clippings, birthday cards, pictures of her family.
Participant “tree of life”: multimedia, photographs, and written text comments on cardboard
Similarly, in the corresponding volunteer’s narrative log, the following was written about her participant:
[Participant’s name] said that she didn’t realize what a full life she has had until we started on this project. She went through photo albums and dug up newspaper clippings to add to her tree of life – reminiscing and weeping as events came flooding back to her. She feels she has a new perspective on her life and is filled with gratitude for her good fortune.
The theme of created meanings described in five volunteers’ artwork and narrative logs expressed satisfaction as a result of enabling and witnessing another’s life review, a sense of increased personal meaning from their contributions, and self-appreciation for their own abilities. Further support of the impact of self-reflection enhancing life satisfaction and healthy aging is found in this quote from the same volunteer about how this preceding work (see Figure 6) created meaning for her:
This program touched me very deeply. In exploring [the participant’s] “Tree of Life” [artwork] with her, I gained a new perception of my own life.
Aesthetic Appreciation
The preceding quotes by participants from the four participant logs and other examples of works created by participants depict a self-appreciation and critique of their created aesthetic representations. In comparison, all eight volunteers reflected on the participant’s process in work creating art, writing logs, and talking at debriefing meetings, with only one writing of their own artistic creations made in response to their experience as a volunteer. Through bearing witness to gerotranscendence and healthy aging, meaning was expressed by the volunteer following appreciation of poetry and stories of one of the eldest participants, as captured in the following volunteer narrative log and sandtray created in the final debriefing meeting. The volunteer selected a miniature treasure chest (Figure 7), which represented her experience of the program with the 94-year-old participant.
How has art been interwoven into our time together? I guess through photography and through sharing narratives, poetry, and short stories. [The participant] was sharing who she was and what she treasures most. Ideas and words come quickly, and she needs to write them down. The same is true of her motivation to sketch or paint. She really knows who she is and what she can and cannot do. Motivation comes from within … [quoting the participant] “Motivation, self-direction and creative expression grow from childhood … through encouragement and sensitive guidance.” I think I am witnessing the art of life and the art of relationships. Celebrations are so essential. I’m pleased that [participant’s name] birthday happened at a time that we could celebrate her life as well as her amazing talents. The context for the Visible Voices Celebration with her friends just seemed to fit. [Participant name]’s story is now part of the community narrative!
Volunteer sandtray response: multimedia, miniature wooden treasure box in sand
The aesthetic appreciation of their meaningful work culminated with an end of program public celebration hosted in the hospital/long-term care facility where two participants lived. Works were mounted in a professional manner; and members of the media, decision makers, friends, family, health and social service providers, and the research team listened to stories by volunteers and participants about their created artwork that spoke to the authenticity of the themes and ability to make visible their inner voices. At the reception, all volunteers and participants noted that they were pleased with what they had produced together and were able to share something meaningful with the audience.
Extension
Extension was considered the work done by volunteers and participants beyond the structured program visitation and facilitation of art-making. For three of the participants, travelling to the celebration required significant support. Even though the volunteers only visited once per week on average, the extension theme was identified in the narrative logs of three participants and all eight volunteers. This theme included data of seven participants who engaged with the expressive arts process between or after sessions and during discussions about their created works with others in different contexts. For instance, a participant’s log noted that she not only worked on her pictorial family tree (see Figure 6 above) but also had dialogue with others on her reflections:
I’d look for things for the next week. I went through old photo albums that I’d not looked at in years. There were good and bad things looking through them. It brought back a lot of memories.
Similarly, extensions of the artwork influenced family relationships and reactions in another pairing as illustrated by a volunteer’s log entry about the untitled participant poem cited earlier:
[The participant] said she had shown her work to her daughter who was initially rather dismissive, saying her poetry did not make sense. It appears [the participant] was not affected, as she was pleased with what she had created. The daughter acknowledged that this was a new side to her mother, which she didn’t know about.
An unintended extension also stemmed from poems read and life stories shared between another volunteer-participant pairing where the participant shared a dream of hers to make a long-distance trip to visit a prominent museum where she was an honoured employee for decades. Her volunteer and family caregivers were able to join in the celebrations and help her live out her dream of visiting a large metropolitan museum as outlined in the volunteer’s log:
I invited her (the caregiver) and a community friend and retired nurse, to come to the [museum] as well. When the perceived supports were in place, the whole tone for the plans changed. She (the caregiver) was excited and supportive.
All eight of the volunteers wrote and created art in response to their own personal development and meaning made as a result of their interaction with their matched participant that extended well beyond their time together. The impact of these experiences that illustrated extension of impact long after the art-making sessions were completed was captured during the volunteers’ comments and art-making (see Figure 7) during the final debriefing meeting:
All the experience in the world could not have prepared me for the amazing experience I shared with [her participant]. Life … is the skill set. Being in the moment, enjoying every opportunity that came our way. Being flexible, listening for the feelings as well as the information, celebrating moments, cups of tea and laughter. Just allowing the experience to flow and grow. This program is about being real … and growing together. It has been a meandering journey, (she began drawing paths in the sandtray as she spoke) with many unknowns, [her participant] was a treasure (she opened the treasure chest and began putting sand in it.) I have found a treasure in [her participant]. Many doors have opened up for me personally.
As articulated so eloquently above, there is much more complexity involved in the experiences of volunteers (and older participants) that requires the attention of health and social care researchers, decision makers, and those who facilitate community-based care and programming.
Discussion and Concluding Comments
The Visible Voices program provided rich data that allowed us to examine what happened to socially isolated older adults and their paired volunteers when engaged in expressive arts in the home and long-term care context in rural areas, without access to outpatient or institutionally based arts and health programs. The findings we have described highlight the opportunities created by a volunteer-based expressive arts program that reached out to socially isolated older adults, which uniquely contributed to their own gerotranscendence and well-being as well as influencing that of the matched volunteer. The impact and meanings made as a result of the co-created expressive art was largely dependent on the relationship forged between the participant and the volunteer. Even in the short duration of a 10-week program, a person-centred approach, with control of expression resting with the older adult who identified a need for more social contact, was very personally empowering. This clearly supports the notion of Cohen’s (Reference Cohen2009) theory that the mediators of positive health outcomes experienced by older adults when creativity is engaged are the social aspects, control, and mastery of meaningful expression.
The importance of establishing a trusting relationship reinforces the need to provide training to the volunteers in developing a person-centred approach. McCance, McCormack, and Dewing (Reference McCance, McCormack and Dewing2012, p. 1) explained that therapeutic patient- (or person-) centred care is embraced by not only nurses but by “all that are involved with health and social care … It is underpinned by values of respect for persons, individual right to self determination, mutual respect and understanding.” While the language reflects nursing practice in institutions where most arts and health programs take place, the principles apply to informal volunteers extending the reach of health promoting initiatives to enhance well-being, particularly to those community-dwelling older adults experiencing social isolation. The population of older adults who perceived themselves as being socially isolated, likely living with less control and mastery in their daily lives compared to their younger selves, offered fertile ground to develop a trusting relationship and co-create meaningful expressive art.
Acknowledging personhood, past life experiences, and relationships of both the older adult and the volunteer will influence what is perceived as social isolation and what is meaningful (Cloutier-Fisher et al., Reference Cloutier-Fisher, Kobayashi and Smith2011). The findings regarding the theme of creating meaning around healthy aging and gerotranscendence were closely related to the relationship in the dyad, forged after careful matching to reflect common interests and experiences. Only when individual interests are acknowledged when undertaking serious leisure pursuits will individual growth occur (Gallant et al., Reference Gallant, Arai and Smale2013). With the foundation of a trusting person-centred relationship, the findings illustrate that the older adults were able to explore their own life reflection, enhancing meaning in their last stage of their life, with another who heard their voice, and were witness to a life lived. The volunteers, on the other hand – as a result of their facilitation, reflection, and own art-making – viewed their own aging in a different light, in which personal development was their main focus.
Ultimately, in a rural region featured by outmigration of immediate kin and fewer formal social and health services, employment, and leisure opportunities (Joseph & Skinner, Reference Joseph and Skinner2012; Rozanova et al., Reference Rozanova, Keating and Eales2012), with support the volunteers were able to reach out to socially isolated adults. They formed trusting relationships and laid the foundation for personal development and creation of meaning for themselves as aging individuals. Furthermore, the volunteers were able to acknowledge the older adults’ unique lives, co-create meaning through art to portray highlights of their lives, facilitate their sense of mastery to communicate the essence to a larger community, and contribute to a sense of well-being and belonging. The individual expression of voice by a largely unheard group of people at the public celebration (via media coverage telling the stories that became a part of the community fabric) support Gallant et al.’s (Reference Gallant, Arai and Smale2013) notion of serious leisure enhancing the sense of community and social cohesion. This further illustrates the theme of extension, an outcome that carries on far after the completion of the Visible Voices program and potentially touching others by the stories told. The broader community could realize an even greater impact if there were a more permanent installation that could raise awareness of experiences and talents of older adults.
Another means to increase potential impact would be to enhance the duration of the intervention and professional supervision of volunteers doing this type of work on an ongoing basis, as they manage the complexities in the home environment. Volunteers brought to the experience their own abilities to manage these therapeutic relationships and relational boundaries through their past roles as nurses, social workers, teachers, and expressive arts facilitators. To extend the reach of health-promoting activities to socially isolated community-dwelling older adults living in rural areas and with the greatest barriers to access formal support services, further support is needed on an ongoing basis. This need could be met as retired professionals familiar with institutional professional-client boundaries attempt to facilitate informal care, encountering the complexities and uniqueness of each home setting. Although an initial 25 hours of volunteer training aimed to prepare volunteers with enhanced communication skills and practice with art-making modalities, telephone support and face-to-face group debriefing meetings were imperative to enable the program to exist outside of the controlled environment of an institution or outpatient clinic. Of particular importance to address anticipatory grief of ending or shifting the relationship was the person-centred approach and skills to prepare both the older adult and the volunteer participant for termination of, or shift in, the relationship upon program completion.
Notwithstanding these limitations and challenges, government officials, policy decision-makers and researchers call for community-based health promotion initiatives to encourage older adults to remain as independent and autonomous as possible (Canadian Institute of Health Information [CIHI], 2011; Forbes & Edge, Reference Forbes and Edge2009; Markle-Reid et al., Reference Markle-Reid, Browne and Gafni2013; Sinha, Reference Sinha2013). The findings presented herein support the argument that the voluntary sector can augment the efforts of formal in-home care providers to reduce social isolation but only with careful attention to also meeting the attendant needs of volunteers. Our research serves as a reminder to policy decision-makers that, while volunteerism is an attractive and often appropriate community resource, targeted support for volunteers in terms of, for example, skills and funding is required to ensure the sustainability of volunteer-based programs. Further research would also be needed to identify which community-dwelling older adults would be more likely to benefit from a volunteer-led expressive arts visitation program and who among health and social service and voluntary sectors would be best positioned to initiate the connection, particularly in under-serviced areas. There is a growing call in research and policy for means to optimize local resources to enable formal and informal care providers and volunteers to support older adults aging in place through reducing restrictions on eligibility for tax credits and other financial and social barriers (Cook & Speevak Sladowski, Reference Cook and Speevak Sladowski2013; Crooks et al., Reference Crooks, Williams, Stajduhar, Robin Cohen, Allan and Brazil2012; Rozanova et al., Reference Rozanova, Keating and Eales2012). Particularly in under-resourced rural areas, it is essential that service providers and decision makers direct funds to organizations to train and provide ongoing support in order to reduce volunteer burnout and ensure delivery of a high-quality service (Cook & Speevak Sladowski, Reference Cook and Speevak Sladowski2013; Gottlieb & Gillespie, Reference Gottlieb and Gillespie2008; Joseph & Skinner, Reference Joseph and Skinner2012). Serious leisure, are chosen leisure activities that enhance personal growth (Gallant et al., Reference Gallant, Arai and Smale2013). Community health and social service collaborations which enable volunteers to interact in meaningful ways with older adults with art as the medium, was shown to contribute towards personal growth of both the older adult participants and the volunteers. As related work demonstrates, local non-profit community organizations that have home-visiting volunteers are ideally situated to be part of a circle of care with primary care and home care providers (MacLeod, Skinner & Low, Reference MacLeod, Skinner and Low2012). Home-visiting volunteers can help support aging in place, so long as adequate resources are directed to their support and communication with the formal health and social care providers.
In closing, the findings from our examination of the Visible Voices program point to the potential of extending the reach of participatory arts interventions, which have been largely confined to group settings in urban areas or within institutions (Moody & Phinney, Reference Moody and Phinney2012; Stickley & Hui, Reference Stickley and Hui2012; White, Reference White2009). The findings illustrate the importance of the relationship between the volunteer and the participant where social engagement, creativity, and self-expression were nurtured. Supported volunteer expressive arts sessions and other health promotion activities could supplement locally provided informal and formal home care services traditionally rationed for health care and activities of daily living, without dramatically increasing the cost to government, (Markle-Reid et al., Reference Markle-Reid, Browne and Gafni2013), while providing an opportunity for meaningful interactions near the end of life. As municipalities, regional health authorities, home care, public health, and primary care providers are being called upon to contribute to “age friendly communities” (Public Health Agency of Canada [PHAC], 2007), the arts and arts-based research should be part of a comprehensive approach that can be used specifically to address social inclusion and participation, civic participation, community support, and communication. To this end, we note that art is now considered a determinant of health by some (Lander & Graham-Pole, Reference Lander and Graham-Pole2008) and that the National Collaborating Centre of Determinants of Health has been part of an encouraging movement of artists, policy makers, health, and social service providers, educators, and researchers that are advancing arts-based research methods and interventions to promote health (Tesch & Hansen, Reference Tesch and Hansen2013). “Arts and health” researchers and practitioners in Canada and internationally have the opportunity to learn from successful community-based expressive arts interventions targeted at both the individual and community levels to enhance the well-being of vulnerable people and vulnerable communities (White, Reference White2009; Stuckey & Nobel, Reference Stuckey and Nobel2010).
