An innovative program affirms the therapeutic power of the arts to reach clients with mental retardation and developmental disabilities.
Lights dim and the audience stills. Costumes and fans, movement and masks, rhythm and voice merge in practiced harmony to weave an ancient tale. This night's performance is Lemminkainen's Mother, a production that unites two disparate cultures and artistic forms--a Japanese Noh play retelling an epic Finnish myth. It is a story of life, of loss, of love--a story cathartic in its message and for the storytellers who bring it. At performance's end, the players remove their masks and bow to the ready applause of family, VIPs, colleagues, and friends. For the performers--clients with mental retardation and the therapists who work with them--the success is not in the performance, but in the process.
The inherent ability of the arts to improve the quality of life is well understood and widely accepted. From a ceramics class at the neighborhood recreation center to the community theater's spring production of Guys and Dolls, people find no lack of opportunities for personal enrichment through creative self-expression. What is not as well understood nor as widely accepted is the relative value of the arts as a therapeutic medium, and programs that explore this linkage are few and far between.
Covered by Medicaid, the Art and Drama Therapy Institute (ADTI) in Washington, D.C., fully integrates the arts into the therapeutic process; in fact, the arts are the primary catalyst for therapeutic intervention. ADTI uses the visual and performing arts to reach individuals with mental retardation and promote self-esteem, reinforce skill development, and enrich the lives of its clients.
Art and Drama Therapy
A DTI is a private corporation founded in 1991 by Margaret "Muggy Do" Dickinson (Dr. Do) and Sirkku Sky Hiltunen (Dr. Sky). Located in Northeast Washington, D.C., ADTI provides medically supervised therapeutic day treatment services for adults with mental retardation. Therapists combine unconventional behavior management techniques and art-based activities--such as drama, music, movement, puppetry, weaving, and painting--in group and individual treatment of clients.
Drs. Sky and Do met in 1972 as volunteers at the Camphill Community, a residential facility in England for adults with mental retardation. Jointly, they later founded the first group home for profoundly to mildly retarded children in Dr. Sky's native Finland. The two relocated to Washington in 1977 when Dr. Do came to work for the District of Columbia's Bureau of Developmental Disabilities--today, the Mental Retardation and Developmental Services Administration. Dr. Sky operated a not-for-profit center in the District of Columbia that provided support services--specifically, art and drama therapy--to clients from other city agencies. A shared vision for the arts as a therapeutic medium led the two to found ADTI in 1992.
"I have a background in drama theater studies specializing in dramatic voice, dramatization, and directing," Dr. Sky explains, "but I found the theater profession very self-centered . . . When Dr. Do and I met at Camphill, we both had the dream to do something very special with [the mentally retarded] population--to devote our life's work to this."
ADTI has 38 staff members, most of whom work directly with clients in a therapeutic capacity. Program therapists must have bachelor of science or bachelor of arts degrees, or comparable experience working with the mentally retarded population; and assistant program therapists work with them to implement treatment plans. Also on staff are a nutritionist, who provides support therapy to clients with weight problems, and a speech therapist. Dr. Sky, a registered art and drama therapist, supervises the expressive arts therapy program; Dr. Do, a transpersonal psychologist and behavior therapist, is the institute's clinical director and writes the behavior management plans for ADTI clients.
Clients are referred to the institute by various city agencies and group homes, and Medicaid pays for 100 percent of the program costs for each client. With 69 clients enrolled, the program is full and currently has a waiting list. ADTI has acquired additional space, however, which is expected to allow for 40 additional clients. This expansion phase, called "Pegasus," will focus on obesity and weight management, emphasizing physical fitness and behavior management for clients with severe behavior problems.
Citing deeply personal events, the founders credit the arts as a healing influence in their own lives. "I have found art to be a great facilitator of my personal healing," says Dr. Do. In agreement, Dr. Sky attests to the transforming power of the arts, particularly drama, in her own life. An unlikely encounter kindled her imagination and exposed her to what has become the cornerstone of ADTI's therapeutic approach. A Japanese touring group visited the drama school in Helsinki where Dr. Sky was a student. The group introduced the students to Japanese Noh theater, a highly stylized form of drama steeped in mystery and tradition. Intrigued by' what she had learned, Dr. Sky later traveled to Kyoto, Japan, to witness firsthand an authentic Noh performance.
"I didn't understand anything they said," she recalls, "but I was so taken by the performance--I was mesmerized at the performers' capacity to communicate. It was such a wonderful experience for me that I wanted to use it to bring about a change in individuals." Her vision for replicating the Noh experience in her work with mentally retarded people took 22 years to consummate, during which time she studied Noh theory and technique both in Europe and in Japan.
Therapeutic Noh Theater
Noh is an ancient Japanese dramatic art form that uses music, singing, chanting, dance, and stylized mime to tell a story. The origins of Noh date back to 14th-century spiritual festivals and sacred temple rituals. The disciplined movement patterns, known as kihon-no-kata; a meditative approach; the use of character masks during self-confrontation before a mirror; and mask pantomime provide the foundation for therapeutic intervention.(1)
Masks are central to the Noh therapy approach, and different kinds of masks are used. Therapy sessions with clients use gray masks that depict a variety of emotions; during performances, decorative masks that portray specific character roles are used. "We very much separate the therapeutic intervention from the performance, even though the performance has therapeutic impact," Dr. Sky explains.
One therapeutic technique involves a client donning a character mask to act out emotions. The client is asked to choose a mask that reflects how he or she is feeling on that particular day. The client must first look into a mirror and state his or her name. "This is necessary," Dr. Sky insists, "because we want to be sure the individual is certain of his own identity before assuming another." Once the mask is put on, the client is encouraged to use a combination of movement, gesture, and vocalization to express the character assumed. The mask serves as a screen on which group members can project personal experiences that may be different from those of the masquer. The therapist's role is to explore the character, emotions, and experiences acted out by the masquer and the group. Interplay among group members, whether they are the individual wearing the mask or the "audience," is emphasized. The masked exercise provides a basis for discussing experiences in a nonthreatening way. "The clients know that it's okay to do things in the therapeutic setting," Dr. Sky explains, "because there's always a person to guide them through. Also it's safe because with a mask on, nobody will know who you are."
Process Versus Performance
Shakespeare proclaimed, "The play's the thing"; and certainly conventional performance artists are driven to perfect their craft for each night's curtain. By contrast, the emphasis in therapeutic theater is on the process, rather than the product. Public or private performances are viewed as part of an ongoing means to promote the self-esteem and confidence of the performers. The goal of the performance is not a flawless end product but rather to serve as a vehicle that offers fresh expression and validation to the players. No two performances will be alike.
"Performance is a very important part of the process, so that clients have the exposure and the reassurance and acceptance of the audience," Dr. Sky explains. "We have had clients at levels of total nonparticipation, total noncompliance. To get them to a point where they are able to participate and become a part of their own team--that is a tremendous accomplishment. We are looking at such different degrees of accomplishment ... we are looking at the process itself and what it does for individual people."
Dr. Sky maintains that among the benefits derived from this process are increased self-esteem, self-awareness, and awareness of body concepts, and better emotional and physical control. Noh therapy seeks to involve the audience in the therapeutic process as well. "It's not just the actors and participants in the performance that should be experiencing therapeutic impact. I want to change [the audience] somehow--maybe their views about clients, themselves, or whatever. For me, Noh theater represents change, catharsis, transformation. It is very powerful."
"It makes me laugh--I feel different," says Thomas Ludley, an ADTI client and member of the Therapeutic Theater Company, as he talks about his role as Leimminkainen in the Noh production.
Art As an Enabler
Drama is but one of the vehicles ADTI uses to encourage personal expression and to support therapeutic intervention. During the course of a week, a client may take part in a lively jam session with percussion instruments; learn a new expression in sign language class; lead an improvised group-movement exercise; interact with nationally known recording artists, such as vocal group Boyz II Men, during an onsite performance; retell a fairy tale using puppets; rehearse a comic monologue for the monthly talent show; or create a new masterpiece in watercolor or pastels.
"People with mental retardation have such a vast variety of capacities and challenges," Dr. Sky says. ADTI takes care to formulate a treatment plan that not only considers a client's cognitive and physical abilities, but also reflects the individual's personal artistic and recreational preferences. Quarterly and monthly goals are set for each client, and evaluations are conducted regularly.
Music instructor Mohan Kartha, for example, works regularly with 34 clients in individual and group sessions. Operating from the model of Swiss developmental psychologist Jean Piaget, and using a variety of stimuli to enhance the clients' development, Kartha uses several different techniques to obtain the specific goals of each treatment plan. For example, several clients work with percussion instruments to increase finger flexibility and develop other sensorimotor skills. Some sessions focus on communication skills, as clients listen and respond to a variety of musical styles and then are invited to discuss their experiences. One client with a history of disruptive behavior was taught how to use the dundun, an African talking drum, to express her emotions. Other clients, many of whom have well-developed musical talents, enjoy the opportunity for personal expression that playing the piano, strumming a guitar, or singing provides.
A Healing Environment
Consistent with its creative philosophy, ADTI's physical setting is more like an interior design gallery than a treatment facility. Formerly an abandoned bakery and warehouse, the facility was decorated by Drs. Do and Sky, who personally gathered the antique furnishings, ornate wall hangings, ethnic artwork, and other extraordinary artifacts that adorn each treatment room and office. The eclectic decor provides a visually stimulating environment for clients and staff that contradicts the institutional barrenness of many hospitals and group homes. The centerpiece of the facility is the newly constructed Keiko Komatsubara Noh Stage, believed to be only the second permanent Noh stage ever built in the United States.
"The antiques are very strong pieces, with history," Dr. Do explains. "You can experience the power and love behind them, the beauty and strength. Aesthetics heal. The whole environment heals."
Although behavior management is an integral component of ADTI's treatment plan, Dr. Do acknowledges that ADTI's unorthodox approach sometimes puts her at odds with the traditional professional community. "The therapeutic concept today is to get behind closed doors. I open doors and make the environment therapeutic not only to the client but also to the facilitator."
One difficulty has been getting staff, who have been trained in traditional behavior management techniques, to adopt an unorthodox approach. "Usually, I have to help staff unlearn the old ways," Dr. Do says. "They want to handle clients--they want to pull, restrain, seclude, or restrict. I try to get a response with a loving posture."
She continues, "Traditionally, ADTI has received clients who have been unsuccessful in many other programs. They are combative or psychotic, they have been labeled `dually diagnosed' with both mental illness and mental retardation, and they have severe emotional outbursts. Many of them have inappropriate avenues for their latent aggression and frustration. Because of that history, they bring with them unresolved issues of rage. We have a high percentage of clients who have been institutionalized and now have been outplaced. We put them in an environment that honors them and extends itself in a loving way." Dr. Do maintains that ADTI's greatest achievement is in the positive change in client behaviors. She is convinced that the combined approach of creative behavior-management techniques and artistic therapies is responsible. "The arts deserve a renaissance in these times for healing," she states emphatically. "It's been way overdue."
Just as an art connoisseur weighs the relative merits of a work of art by using largely subjective criteria, the success of art and drama therapies among clients with mental and physical disabilities is difficult to measure objectively. Nevertheless, several indicators suggest that the use of the creative arts results in multiple benefits to clients. In gauging the success of ADTI's programs, for example, Dr. Do points to several factors, including:
* Significant reductions in psychotropic medications. Of the 69 clients who participate in ADTI art therapies, only 2 remain on such medication.
* Decrease in reports of unusual incidents. In 1994, ADTI had 15 episodes of aggressive behavior--a level that day treatment programs of like size may experience weekly.
* Lower client-to-staff ratios. A decrease in the number of clients with significant behavior problems requiring one-on-one supervision has allowed a client-to-staff ratio that do not exceed 6:1 for any treatment session.
* High client attendance rates. Averaging 90 percent for all clients, attendance rates for ADTI are the highest in Washington, D.C., for day treatment programs, which typically range from 40 to 50 percent. In December 1994, for example, where one might expect seasonal aberrations, the client census reflected an 88.85 percent attendance level; nearly one-third of clients had attendance rates of 95 to 100 percent.
Hailed as a national model by the President's Committee on Mental Retardation for its innovative approach to treatment, ADTI is praised by colleagues who attest to the transforming power of the arts in the lives of clients.
"I can remember when [the clients] couldn't tie a shoe or even repeat their names," wrote a retired worker from a city facility for the mentally ill after viewing an ADTI performance. "I cried because I was so happy to see such improvement."
A mental-health therapist claims, "The layers of careful professionalism from the supporters of the clients... [made] the `special' status of the clients stand out in a new way, almost like royalty ... It was rather magical."
That the arts contribute to promoting the self-esteem and emotional well-being of individuals with special needs is echoed in the sentiment of Ethel Mann, former artistic director of the National Institute of Art and Disabilities (NIAD) in Richmond, California. "Our members have developmental disabilities. They now identify themselves as artists--they concentrate on their ability, not disabilities."(2) NIAD provides open studio space and art instruction for artists with disabilities. Artists may also exhibit their work through the NIAD-sponsored professional exhibition program.(3)
Perhaps ADTI's most emotional measure of success is the reaction of the families of clients. "The performance made me feel extremely proud and hopeful ... I watched as they commandeered their roles with such prideful spirit. The performance was joyful!" said one audience member after the performance of Leimminkainen's Mother.
The change in America's political landscape promises sweeping changes in human service programs and priorities. Both the arts and human service programs, including Medicaid, are being examined as places to begin reducing government spending. In responding to the mandate for greater program efficiency, more successful outcomes, and belt-tightening overall, however, public welfare administrators are earnestly seeking creative means to ensure that the needs of those whom they serve are best being met. With change comes the opportunity to reexamine traditional methods and try something new. The effective integration of the arts into conventional therapeutic settings is one more alternative--along with waivers, collaborations, and other innovative approaches--that merits a second look.
Michelle Y. Green is a freelance writer, living in the Washington, D.C., area; author of the Willie Pearl children's book series; and a former assistant editor of PUBLIC WELFARE. Rick Reinhard is a freelance photographer in Washington, D.C.
Dr. Sky helps client Debbie Pitts get dressed into her Japanese-style costume.