The following essay was written in 2003 for the Catalyst exhibition catalogue. 
Revised 2009.
Copyright Nancy Tingey.

 

CATALYST

Art for Parkinson’s
Written by Nancy Tingey in 2003 and revised in 2009

Broadly speaking a Catalyst is something which produces change in something else without undergoing change itself. In a Parkinson’s art session the catalysts are the people who, using appropriate materials in a supportive environment, promote change for the better in the lives of people with Parkinson’s. The change might be simple, such as the feeling of satisfaction which comes out of making a mark, or of far-reaching significance, such as finding that self-expression brings relief from depression and rekindles zest for living. In any case it is important that certain criteria are met in carrying out a program if it is to be life-enhancing. This booklet records some of the experiences and theories which have helped make art sessions rewarding for people with Parkinson’s in the hope that it will itself act as a catalyst.

What is Parkinson’s disease?
Parkinson’s disease is a progressive neurological condition affecting movements such as walking, talking and writing. It results when there is a loss of the chemical messenger (neurotransmitter) dopamine in the part of the brain which controls movement, the basal ganglia. It is thought that when about 80% of dopamine is lost the symptoms of Parkinson’s will occur. Dopamine levels continue to diminish over many years. Dopamine works in tandem with another neurotransmitter (acetycholine); together they transmit messages between nerve cells to the muscles, enabling smooth acting movements and co-ordinated function.

Currently there is no cure for Parkinson’s disease but a range of medical, surgical and therapeutic treatment options are available to help to control the symptoms of tremor, rigidity and slowness of movement and maintain a quality of life that is acceptable. The main treatment option is pharmaceutical and people with Parkinson’s disease are heavily reliant upon cocktails of drugs to improve their daily living. In many cases the drug regimes are complex and the timings of the dosages complicated. The symptoms of Parkinson’s disease are alleviated but for many replaced with disagreeable side effects that can be compromising, challenging and disabling.[1] 

The effects of this condition can be devastating for all involved. Depression is common among those with Parkinson’s and their carers. They become socially isolated, feeling conspicuous and lacking confidence as ‘normal’ life eludes them. Activities which were once second nature become laboured or even impossible. Yet the mind may remain active and alert, still keen to absorb new information and learn new skills. Beneath the expressionless mask is a human being trying to communicate and play a part in society. 

Creativity art activity for Parkinson’s
It is important for people with Parkinson’s to keep as active as possible to combat depression. One of the activities which have been found to give relief is creative art work. Curiously, in research undertaken by Dutch neurologist Professor Lakke, it has been found that creative ability remains intact in spite of the neurological problems experienced by people with Parkinson’s. Lakke noted, for example, that the English artist Mervyn Peake ‘remained artistically productive despite very serious Parkinson’s-symptomatology’.[2] As long as the emphasis is on self-expression and creativity rather than fine motor skills, art-making is one activity in which people with Parkinson’s can participate without feeling inadequate.

As a community artist whose husband had Parkinson’s disease, I was interested in Lakke’s work. It was therefore with some degree of optimism that late in 1994, while living in Australia, I started an art group called Painting with Parkinsons. Drawing on teaching experience in adult education, I conceived the group simply as a recreational activity to help distract people from the trauma of having Parkinson’s. It was only when a member joined on the recommendation of her doctor, who was concerned about her mental state, I realized that without some art therapy training I would soon be out of my depth.

 I also found that, although everyone enjoyed producing lively original work, some members needed a great deal of help getting started: and learning to draw, or paint from life frustrated rather than relaxed participants. Clearly I needed to learn more about the relationship between Parkinson’s and the creative process if Painting with Parkinsons were to become a worthwhile venture.

Disability and art ability
In 1996 I travelled overseas from Australia to develop my understanding of how art works as a therapy for Parkinson’s. One of the first people with whom I studied was Ursula Hulme, founder of Conquest, The Society for Art for Physically Handicapped People, in Surrey, England. Years ago Ursula Hulme had identified the key issue in art activity for neurological conditions by observing that as participants became absorbed in the mark-making process their Parkinson’s symptoms tended to die down.  For example, one of the participants in a Parkinson’s workshop, Charles, found that his movements were erratic when he started drawing but after practising this activity for a few minutes he was able to take up a brush and surprise himself with smoothly flowing lines depicting Ducks in the painting which followed (plate 4). As a member of Painting with Parkinsons once said, ‘When I am painting, I forget about the Parkinson’s, and it forgets about me.’

 This is not to imply that lively artwork cannot evolve when the Parkinson’s symptoms stubbornly persist. Drawings by two Painting with Parkinsons members who exploited their disability illustrate this point. When Cliff’s attempts to use pen and ink to depict a Banksia flower produced strings of dots he declared, ’This is easy. You just hold the pen and the Parkinson’s does the rest!’ (fig 1). And Joanna’s first drawing with Painting with Parkinsons was expressive lines of marks, exploring what a felt pen could do (fig 2).

 As involvement with the process, rather than worry about the product, is essential if art is to be a therapy, it is helpful to think of the activity as a form of play. With this in mind Ursula Hulme devised various non-threatening exercises to relax her group members, among them doodling and drawing with eyes closed, which have become standard ‘kick-starting’ techniques for Parkinson’s art class participants. The concept links with Lakke’s theory that ‘autocuing’, or using clues and triggers to initiate activity - a technique commonly employed in the treatment of movement disorders – circumvents the effects of impaired motor programs. [3]    

Cues and prompts
According to the Conductive Education Centre in Birmingham. England, and the Movement Disorder Clinic in Melbourne, Australia, people with Parkinson’s can learn how to counteract adverse symptoms with appropriate prompts. For instance, if people with Parkinson’s are unable to walk, or handle a brush, cues are used to initiate the first step or move the tool. In walking the cue might be stepping over a line, in art work it might be dropping paint on paper. This triggers off the next action and if a rhythm is established, or prompts repeated, the walking or art activity will flow continuously. Both conductive education and art programs for Parkinson’s share a step by step approach to carrying out tasks. 

Building up images one step at a time is essentially how an work develops anyway. And it is common for artists in general to allow for a winding-down process to take place before they start. For instance the Australian painter Sidney Nolan used to play music for up to an hour before settling down to work.[4] For the person with Parkinson’s the process can be especially difficult but a trigger followed by rhythmic work, such as drawing freely to music, can subconsciously propel the art maker into the creative process. Although the artist Paul Klee did not have Parkinson’s he understood the power of this mechanism very clearly. His biographer wrote ‘Klee proceeds methodically. Like a musician he sets note next to note…until the final form emerges’.[5] The effectiveness of rhythmic music as a therapy for Parkinson’s is well documented.[6] The combination with step by step mark-making is a powerful mechanism for galvanising the nervous system into action. 

Other useful kick-starting techniques for art work are using both hands or the non-dominant hand (not easy to determine with Parkinson’s), finger painting as if playing the piano, taking a line for a walk, and squeezing or poking clay. As struggling with the conscious act induces stress in Parkinson’s, triggers often bear little resemblance to conventional drawing techniques. For instance, wavelike Tai Chi movements could develop into paintings of flowing water (plate 5). All these activities divert attention from thinking or worrying about making a finished work of art. Setting goals is counterproductive, rather like aiming to cross a room while having difficulty lifting your foot from the ground. As in walking, painting is a process to be followed one move at a time. If the first move seems to be irrelevant to the end product so much the better. Not for nothing do some people with Parkinson’s dance their way through doorways. 

The role of the subconscious
The idea is to trick the brain into action. A diversionary tactic, developed by Ursula Hulme for a Conquest class, would  be to draw an oval shape almost touching the sides of the rectangular sheet of paper, without any preconceived idea of what the oval might be used for, then follow the instruction to turn the oval into a bowl of fruit (plate 2). Another example, often used in therapy work, is to develop a doodle into an imaginary creature (fig 3), or what ever image the drawing suggests. 

This principle can be applied to art as a therapy for Parkinson’s by following the experience of Ann, a painter who enjoyed many art activities, but was constantly disappointed by her efforts to depict scenes she had conjured up in her mind before she arrived at the class. On the other hand she found painting to music satisfying and loved the kick-starting exercise ‘taking a line for a walk’, discovering shoe-shapes among her meanderings. Here she keyed into the experience recorded by artist Paul Klee of using a continuous line to release intellectual control of the picture. Through letting intuition and the unconscious communicate directly with the hand, eventually a form emerges, ‘Art does not render the visible, but makes visible’.[7] Eventually Ann realised that the more determined she was to achieve a set outcome the more likely she was to find the task beyond her, at the same time missing out on the creative ‘accidents’ along the way which might have opened up new paths of discovery. 

Artists with Parkinson’s
Ann’s experience relates to a difficulty sometimes encountered by people who have achieved status as artists in their own right before being affected by Parkinson’s. The temptation to continue in the same vein they have been used to may work for artists whose approach is naturally experimental and freely expressive, but if it is technically disciplined and demanding the stress of trying to maintain standards may be counterproductive. For instance, Jack was an accomplished pastel painter when he joined the group but found he was inadvertently smudging work as his Parkinson’s progressed. When he took up working in pen and brush and ink he experienced a new burst of creative energy. A portrait painter, Norma assumed she would continue her fine tonal drawings when she joined the group. When she became disillusioned by this task she played with inks which could be applied by dropper. As brilliant colour exploded before her eyes she became totally absorbed in this new medium and was motivated to produce exciting imagery. 

Ringing the changes
Both Jack and Norma benefitted from a change of routine in their art work. Observations at the Kingston Movement disorder Clinic in Melbourne suggest that people with Parkinson’s are able to learn new skills successfully but problems arise when skills become automatic as this response is impaired problems through Parkinson’s. Perhaps this explains why some artists become frustrated when trying to continue painting in their usual style after being diagnosed with Parkinson’s. Changes in materials, style, subject matter or approach can overcome this problem. Constant stimulation with new challenges presents more opportunities to develop powers of concentration. 

Art materials and creative play
Appropriate choice of materials is critical in art as therapy for Parkinson’s. For this reason the facilitator needs a thorough understanding of how various media work, using them in ways which reduce, rather than increase, stress levels. Watercolour is the preferred medium of Parkinson’s art therapist Attilia Cossio.  She had founded a Parkinson’s art group in Monza, Italy, in 1993, a year before Painting with Parkinsons began. Adopting a structured format for each class, Cossio guides her groups through an introductory settling down period, including some form of meditation, a painting or sculpture activity and then a time to discuss the work and the feelings it evokes. She draws on Rudolf Steiner’s teachings about the healing powers of colour therapy, each hue of the spectrum having special meditative qualities and stimulating a different emotion. Blue, as seen in Maggie’s ethereal watercolour, is thought to be particularly soothing for people with Parkinson’s (plate 6). 

Attilia Cossio also promotes Steiner’s research claiming that the process of spreading watercolour paint in mist-like layers has a calming and therapeutic effect on the mind. And when the hues are clear and luminous the participant will experience feelings of pleasure beneficial to their condition. Consequently the wet-on-wet watercolour technique is often used in art for Parkinson’s programs. For maximum effect the watercolour should be used at full strength, even straight from the tube, so that as it combines with the saturated paper it is almost breathtakingly exciting to watch. As the paint moves so the painter will take up the cue and, working with rather than against the flow, become inspired by what is taking place before their eyes to create something of their own on the paper using a brush or fingers. Rainbow paintings take advantage of this method (plate1). 

The tactile qualities offered by finger painting encourage creative play, especially when the manipulation of tools such as brushes presents problems. Touch itself can trigger a reciprocal response  - for instance a gentle tap on the foot to remind a person with Parkinson’s that this is the limb to move next can be helpful in starting the walking process – and encourages rhythmical work. Another sensual material is clay which can stimulate the creation of evocative forms when incised, prodded, stamped, bent or moulded. Facilitator Peter Latona inspired the Canberra group to produce remarkable work with these techniques (fig 4).  

The element of chance
Just as the uncontrollable character of watercolour can stimulate creativity so the accidental marks and textures in printmaking help promote original imagery. The mechanics of printmaking take control out of the hands of the artists to some extent so that, for example, linocuts gain added richness from the inking process and Norman’s monoprints revitalized the images from which they were taken (plate 3). To make his Flowers print Norman painted on a plastic surface then laid a sheet of damp paper over the work, mirroring the original form while enriching the surface texture. Trying to control involuntary movement can be such an exhausting aspect of Parkinson’s it is a relief to find that there are ways of achieving, through art activity, a satisfying outcome without strain.

 Art therapy and art as therapy
Attilia Cossio and British art therapists Rita Simon and Diane Waller have strongly influenced my work developing art as therapy programs for Parkinson’s as all three combine their considerable art therapy backgrounds with understanding of the neurological implications through caring for their husbands who, like mine, had Parkinson’s. Rita Simon, founder member and Honorary President of the British Association of Art Therapists (BAAT), endorsed my vision of running a specialised art program for Parkinson’s. Writing that ‘It is hard for any artist to work without encouragement and some support. People with disabilities may need physical help in setting up or preparing their materials. Yet it is these people especially who need an outlet for feelings that have no other form of expression. We do not need to be told what to create, indeed, who has the right to do that? But there may be real need for practical help and support for the adventure of creative work  - to see that there is an uninterrupted time and enough space, and that the materials are always within reach and ready for use’.[8] 

Meditation and the creative process
Art therapist Moya Cormick was my mentor in Australia. When Moya developed Parkinson’s she led a sentic cycle meditation program in a Painting with Parkinsons class taking participants through a range of emotions, from negative to positive.[9] Referring to drawings made before and after the program Moya was able to show that meditation was an effective tool in releasing pent-up feelings. The later drawings were uninhibited, even joyful, compared with the first ones (figs 5 and 6). Moya’s work supported my observation in Parkinson’s art groups that work done before the settling down process begins reflects more agitation than work carried out towards the  end of the session. As the creative act itself appears to stimulate free expression and release tension, the combination of meditation and art activity provides optimum conditions in which a person with Parkinson’s can function. 

The value of using meditation to slow down brain activity in the treatment of neurological conditions was reinforced on a visit to observe Midge Balkwill’s yoga group for people with Parkinson’s in Margate, England, as part of my Fellowship tour in 1996. By the end of the class participants had lost their masked look; they felt relaxed and were able to move comparatively easily. The meditative process seemed to overcome the lack of the missing chemical, dopamine. This might help to explain why participants in the art as therapy programs for Parkinson’s which include a meditative component appear to be able to operate relatively well whether or not their medication is working effectively at the time.

While in meditative or creative mode the brain is working subconsciously with low stress levels. Struggling with complicated conscious acts is by comparison stress-inducing in the person with Parkinson’s. For example, trying to join in a conversation can be frustrating as the composition of an original remark involves complex processes. These include finding the words, organizing them into a sentence then speaking it aloud, by which time the conversation has moved to another topic. By comparison many with Parkinson’s report their singing remains normal and they are still able to contribute effectively in choral work, at least for a little while. If we compare this process with that involved in creating a work of art, drawing on the subconscious rather then drawing from life, the ease of one and difficulty of the other may be appreciated. In drawing from life the intense interaction between artist and work surface is continually interrupted by looking up to refer to the subject. Drawing in this way can be disconcerting for the person with Parkinson’s. it seems that too many sequences are involved if the eyes have to leave the paper to look at something else and return. Art as a therapy for Parkinson’s draws on the artist within.

Communication
Drawing on the imagination is a useful tool in stimulating communication and a sense of belonging. As a side effect of Parkinson’s, eye contact may be difficult to achieve because of the way posture is affected by rigidity. The loss of body image and facial expression can allow the vehicle of diverting attention through an art work to come into its own. Describing how painting had helped Jock through his last few years, his wife wrote ‘When my husband was diagnosed with PD several years ago, I became his full-time carer. I read books, listened to cassettes, attended seminars, hoping to find a way to help this emotionally and physically limited man. It wasn’t until he reluctantly agreed to ‘try out’ the Art for Parkinson’s Group that I became aware of his need to find a way to express himself. Jock had been a professional soldier, used to commanding men. In the art group he ‘told’ the stories of this exciting life in colour on paper. Almost monosyllabic as dementia developed he became animated and lucid when talking about his paintings’.[10] 

Music and Movement
A similar outcome was manifested by Mary who, like Jock, had Parkinson’s with dementia. For weeks Mary appeared depressed and withdrawn, taking little interest in the art sessions. Then, one day, she became animated by the swirling forms the brush-marks made on the paper before her and started to sing. Taking up the cue, the group sang with her, and she finished the painting smiling and laughing, This was a turning point as Mary‘s depression then lifted and music stimulated more colourful work.  

The multi-sensory experience of using colour and rhythm to suggest sound and express joy is often reflected in Parkinson’s art work. The piece of music may become the subject or prompt invention.   

Revisiting a graphic experience is a favourite theme in a Parkinson’s art class. Drawing wave-like movements to music led Bob, a retired geologist whose work was based in Antarctica, to recall the ship’s motion on the journey south in his painting of the high seas (plate 7). Bob also used his art work to describe the feeling of being trapped by his condition. In Internet, a play on words, he used a felt pen to build up a complex mesh (fig 7). As he became absorbed in this activity, following a meditation exercise, the lines moved effortlessly over the paper. 

As the Painting with Parkinsons program developed in Australia we introduced breathing exercises, yoga and Tai Chi, gentle walks, poetry readings and creative visualization to de-stress members. Group art activities also encourage social interaction, for example, pass the painting, in which each person adds mark as music is played. Sometimes members move slowly round the table, applying paint from individual hand held trays with their fingers to the the communal work. The advantage of these examples is that as the work is shared so too is the burden of responsibility. On the downside participants often become so engrossed in the exercise they forget to move on! It is then time to reform and start individual projects. The winding-down exercise has completed its role. 

Outcomes
Fred joined an Art for Parkinson’s class with his wife and daughter, who hoped the activity might relieve his depression. For three weeks there was no observable change in his emotional state. He obligingly came to the class, idly tried a few things and hardly spoke. Then, as the fourth meeting loomed, to his family’s astonishment, Fred dressed himself and was ready for the class hours before time. He embraced the art activity with enthusiasm and contributed to the discussion afterwards. He continued to be motivated for the remaining art sessions. Some months later I asked his family how Fred was and was told that, not only was Fred no longer depressed but he was driving the car again and taking interest in activities he had long ago rejected. 

Although Fred’s reaction was the most positive I have encountered, participants often say that the art sessions are the highlight of the week. They enjoy the social benefits and comment on the increased sense of well-being which arises from their art activity. So many skills are affected by Parkinson’s, threatening the sense of self. Often people with Parkinson’s lose their ability to write, even to sign their name. No longer able to ‘make their mark’ they are reassured when they find they can make individual statements through art work. As Attilia Cossio  observes, ‘Art therapy doesn’t stop the illness, it doesn’t work miracles. But it enables the patient to get to know that his ego is vital, his creativeness intact’. [11]

Exhibiting work
When participants describe how the activity has affected them they turn to the work as evidence. In addition the result of the process is often so moving or attractive in itself that the desire to share the creative experience helps to lessen the sense of isolation felt by those with Parkinson’s.  When Painting with Parkinsons held exhibitions in the foyer of a Canberra hospital, each member’s work was accompanied by a short biography compiled with their approval. Staff at the hospital found the shows a great learning experience illustrating the positive ‘can do’ side of Parkinson’s and helping them to understand that, although people with Parkinson’s may appear disabled, they are still able.  Social integration and self-confidence can be reinforced by exhibiting work. 

As printmaker and present facilitator of Painting with Parkinsons John Pratt explained in a grant application, ‘An art for Parkinson’s class is a context where the participants gain considerable emotional and physical release throughout a range of activities including painting, printmaking and sculpture. The imagery is intrinsically rich and expressive, a testament to the inherent power of art therapy while representing a significant contribution to the wider arts community.’

________________________________________

(c) Nancy Tingey 2009

Figures

Figure 1 – Cliff, Banksia Flower, pen and ink

Figure 2 – Joanna, Marks, felt pen

Figure 3 – Sheila, Developing a Doodle, felt pen

Figure 4 – Group work by
Painting with Parkinsons, clay

Figure 5 – Drawing made before meditation

Figure 6 – Drawing made after meditation

 
Figure 7 – Bob, Internet, felt pen

Plates

Plate 1 – Jenna, Rainbow, watercolour

Plate 2 – Belle, Bowl of Fruit,
felt pen

Plate 3 – Norman, Flowers,
acrylic monoprint

Plate 4 – Charles, Ducks, watercolour

Plate 5 – Belle, Painting to Music, watercolour

Plate 6 – Maggie, Blue, watercolour

Plate 7 – Bob, Antarctic Waters, felt pen, watercolour and acrylic

Foot Notes