WORKING WITH ELDERLY ASIAN CLIENTS
This article is based on two and a half years’ work running a weekly art therapy group for an Asian Day Centre in Bristol, from Autumn 1996 to Spring 1999. It was part of my work with the Inner City Mental Health Team (ICMHT) covering a multi-cultural client group in central Bristol.
The ICMHT was founded in 1988 to fill the identified gap in mental health services for African-Caribbean, Asian and homeless clients in the inner city area of Bristol. It set out to provide a culturally appropriate service to these three identified groups, concentrating on those with severe and enduring mental illness. A deliberate effort was made to recruit African-Caribbean, Asian and other black professionals to the staff team. (Liebmann 1999). At the time of my work with the Asian Day Centre, there were three members of the ICMHT of Asian background (with different backgrounds and languages), all community psychiatric nurses.
The most senior Asian CPN, Sohail Elahi, had gathered statistics on the Asian population in Avon, showing that, at the time of the 1991 census, there were 14,735 Asians in Avon, of whom 10,376 lived in Bristol (OPCS 1991). They were concentrated in inner city wards, which exhibited several deprivation factors, such as overcrowding, poor housing, low income and unemployment. The majority of Asians in Bristol were of working age, with small numbers over 65. Using a model developed by Goldberg and Huxley (1992), Elahi suggested that 2.4% or 353 Asian clients per year should be seeking help from mainstream mental health services. In common with other cities, far more Asian women were seen by mental health services than Asian men. The most spoken Asian language was Punjabi, followed by Gujerati, Bangladeshi, Urdu, Hindi, Cantonese and Vietnamese (Elahi 1998).
Asian Day Centre
Sohail Elahi had also been active in helping to set up the Asian Day Centre in 1994. This was the outcome of the formation of the Asian Health & Social Care Organisation, which researched the needs of elderly Asian people, and found significant problems of isolation and other difficulties. These needs often remained unmet because many Asian elders found existing services culturally alien to them. So the Asian Day Centre was started to cater for the needs of Asian elderly people, prioritising clients who were:
- Depressed or suffering from other mental health problems.
- Isolated and lonely.
- Suffering adverse family circumstances, resulting in an impact on physical, mental or social health.
- Discharged from hospital, where their needs could be met by the Day Centre.
At the time of my involvement, the Asian Day Centre was based in a busy community centre, where it hired a large room (used for discos at the weekend) four days a week. It was also working towards acquiring its own premises. It had an active committee which included several Day Centre clients. A Community Transport minibus fetched many of the Day Centre clients from all over the city. The Day Centre coordinator, Salim Allibhai, was an energetic Asian man from a business background, who cared deeply about the clients and their needs: he often set an example by helping to serve the lunch. Lunch was a central feature: vegetarian (so that no food laws would be violated) and freshly cooked on the premises. It was often the only proper meal the elderly people received if they were living alone, so was very important physically, socially and culturally. On the days I worked at the Day Centre, I ate with the clients, as did other tutors and helpers - food and meals are a much more central part of Asian culture than of British culture.
Salim wanted the best for his clients, and organised a rich programme of activities, including English classes, keep fit, yoga, swimming, crafts, talks, discussions, videos and excursions, both local and to other cities. A chiropodist held regular sessions, and advice was available on any matter of concern to members. Salim also held open days on particular themes, such as ‘Health’, to which he invited all the Day Centre clients and also outside organisations, many of whom provided information stalls. All the Asian religious festivals were celebrated equally, from Diwali (Hindu festival of light) to Eid (Muslim end of fast of Ramadan).
Art therapy group
Since my arrival at the ICMHT in February 1995, I had had several discussions with staff about how art therapy might be practised in a culturally sensitive and relevant way. Sohail raised the possibility of starting an art therapy group at the Asian Day Centre, to see if it was culturally relevant to members there. Salim was enthusiastic and I made two visits to the Day Centre to explain art therapy and ask members how it could be made accessible to them. They seemed keen to try it out. The purposes of the group were seen as:
- outreach to the Asian community (use of art therapy)
- help with expression of thoughts and feelings
- positive form of activity, enhancing concentration and creativity
- promoting conversation between men and women
- helping people to share in an unselfconscious way
- involving those with mental health problems in a non-stigmatising way
The practical arrangements proved somewhat problematic. We worked on some tables at the end of the main room, so that it was difficult to prevent interruptions, despite many efforts. Moreover, Salim in his enthusiasm sometimes timetabled several activities and visitors at the same time, which resulted in unhelpful competition for participants. We started in the morning slot (12-1), but the minibus was late so often that we moved the session to after lunch - psychologically less good as many elderly people feel quite tired then (and the homeward minibus sometimes left early).
Men and women sat separately at the art therapy tables, as they did at the lunch tables, according to Asian custom. Some of them had physical disabilities, so much of my time was taken up with bringing art materials to them rather than expecting them to fetch what they needed. One or two of the younger and fitter members were happy to help with this and with clearing away at the end. I also had some help from art therapy students on placement for several months. The group included a wide range of experience and ability, from those who had never used art materials to a retired teacher of art and embroidery.
I brought a big crate of art materials and paper from my base at the ICMHT and stored them in a cupboard at the community centre. Chunky felt tip pens were the most popular medium, as they were colourful, easy to use and clean - many of the women wore beautiful saris and did not want to get them messed up. However, other materials were also used by some: oil pastels, paints, clay, coloured pencils.
I had hoped that we would work as a group, starting and finishing together, with time for art work and time for sharing as a group for those who wanted to. However, the very different concentration spans (some people got tired very quickly) and the open situation meant that people joined and left at different times. In the initial conversations with people, they had expressed an interest in having some themes to work to, but the couple of times I suggested one, it was ignored - so I was happy to proceed in ‘open group’ mode, with everyone choosing what to draw or paint. People with no idea what to do usually started by copying what their friends were doing.
Language proved an obstacle at times. I often felt an outsider, especially when there was a joke being shared. (Perhaps this is a salutory reminder of how Asians often feel in British society.) I had hoped to have one of the Day Centre helpers as an assistant, both to help with translation and to help establish the group as part of the Day Centre. However this proved impossible, as the Centre was always short-staffed; my attempts to involve one of the Asian CPNs had a similar outcome.
During the first session I asked everyone to both say their names and to write them on strips of card in English and in their own script. From this I learnt that Hindi, Gujerati, Punjabi and Urdu were all represented in the group. People had come to England from India, Pakistan and East African countries (Kenya, Uganda and Tanzania), and included mostly Hindus, Sikhs and Muslims (and different sub-groups of these). I learnt that there were occasions when Centre members had difficulty communicating with each other if they did not share a language. Most people spoke English, but some of them with difficulty, especially the language needed to talk about their pictures.
The art therapy group was very popular with members, with initial attendances of 10 to 15 each week. Although numbers decreased whenever the weather was cold (and people were ill) or when the transport did not run, the average attendance over two years was between 6 and 12 members each week. Both men and women attended, with slightly more women than men (in line with attendance at the Centre). Having a male art therapy student two years running may have been helpful in encouraging the men, but I had the impression that they were keen to come anyway.
At the end of the first term (Dec 1996), I carried out an informal evaluation among members. This was done by a simple questionnaire, which staff translated verbally to each client, and then recorded their answers in English on the form. 11 responses were collected in this way, covering about two thirds of the regular attenders. Of these, 3 enjoyed the art therapy sessions very much, 3 a lot, and 4 quite a bit. When asked why the sessions were important to them, they said:
- It gives me a fulfilling outlet for my time at the Centre.
- This kind of therapy is good for the elderly. My depression goes.
- It makes me happy.
- It makes me happy, being able to draw and paint. I love painting birds and flowers.
- It makes me feel a little better. It’s something to do - but I haven’t seen the therapy side.
- I like drawing anyway.
- I enjoy it a lot.
- It makes me happy and it’s a new skill to learn.
When asked to suggest any changes, 6 wanted the sessions to continue as they were, one wanted more help with drawing, one wanted more input on the ‘therapy side’.
At one point Salim mentioned how one client who was in a lot of pain, had found the art therapy group particularly helpful. There was general satisfaction with the group, and both Salim and Sohail felt that group work provided a good way into art therapy for members of the Asian Day Centre. They observed that, as time went on, members were using the sessions more ‘therapeutically’, to express their feelings.
After two years the Centre experienced some funding problems, and was unable to accept new clients, so attendance (and morale) dropped. Those who remained seemed to be under implicit pressure to attend, and had lost their enthusiasm. After consultation with staff and members, it seemed best to lay the group down until the Centre moved into its planned new premises with better facilities for art therapy, and had some new members.
The art work produced seemed to fall into several distinct categories.
These were pictures of stylised flowers, often in a pattern, sometimes copied from a sari border.
Figure 1 shows three corn plants, drawn with thick felt tip pens, by a Sikh woman who spoke good English - she tried to get me to guess what they were, then told me she had grown corn herself, in her life before coming to England.
Figure 2 shows a decorative multi-coloured flower pattern, using felt tip pens, by a Muslim woman with limited English. Even so, she was able to tell me that she had painted a lot when she lived in Kenya, ‘all kinds of things’.
Birds and animals
These included single animals and birds, or a whole series of birds in a pattern. Some of the birds had religious significance, such as the peacock.
Figure 3 shows a picture in black felt tip by a Sikh man, showing sunflowers and fish. On other occasions he drew peacocks and other birds. He drew with great concentration and said very little about his pictures. A few months after I had started work there, he died, greatly mourned by everyone there. When Salim later organised an exhibition (see below), there was a special request that his man’s work should also be included.
Many members included these in their pictures, or drew them as the main feature of their picture, such as the ‘Om’ sign (Hindu) or a crescent shape (Muslim). Religious artefacts such as temple oil lamps were also subjects of pictures. It seemed to me that members of the Centre were much less inhibited or self conscious about including religious symbolism in their pictures than western people. Religion plays a large part in Asian arts, and religion in the East has been seen as playing a similar role to psychotherapy in the West (Watts 1961).
Figure 4 shows a picture by a Hindu man, which he had taken from the border of a sari. It shows a vertical row of swastikas on the left, then a row of elephants, both with religious symbolic meaning; and a horizontal row of temple lamps.
Memories of places
Quite a few people drew memories of places they remembered, in India, Kenya or Uganda. These drawings might be seen as similar to reminiscence work undertaken by elderly people in NHS art therapy groups (Drucker 1990).
Figure 5, by the same person as figure 4, is a picture of Mombasa, Kenya, where he had lived until coming to England 16 years before. He had been born in India, but had left in 1944 because of trouble there - then later had to leave Kenya too. He had worked in tailoring, in a dry dock, as a ship’s engineer and as an electrician. The picture shows the harbour with ships and houses roundabout. He used a mixture of felt tip pens and paint. He spoke good English and often helped others with materials and encouragement.
Some members enjoyed drawing real-life objects, such as fruit or cups or other household objects. These were different in style from the stylised patterns mentioned above, in being tangibly more ‘realistic’ in manner of drawing and detail.
Figure 6 shows a pineapple drawn by a Sikh man. He spent two sessions concentrating hard on the drawing, taking the subject from some table mats he had seen and liked. He was very proud of his drawing and showed it to the group - when he had joined the group a month before, he had been convinced he couldn’t draw.
One man drew and painted several pictures of Indian film stars.
Over the course of weeks, many members of the group began to experiment with different media and different ideas, extending their range of creativity in many ways, and gaining satisfaction in doing this.
One person in particular attended very regularly and became much more involved in the process of doing her pictures. She had been a teacher of art and embroidery, and her perfect patterns of fruit and flowers were the admiration of all the other members. Figure 7 shows one such picture, stylised mango fruits, mostly in felt tip pens. She had used such drawings in the past as the basis for traditional embroidery.
Then she started being more experimental. Figure 8 shows a woman and a vase of flowers, but with greater freedom of expression and use of paint.
Figure 9 shows a later one with trees, lush vegetation, fishes in a river, birds on the bank and a painted sky. She would often spend as long as four sessions on these paintings and seemed deeply satisfied with the results, despite her tiredness at the end of each session.
Mental health clients
I tried to include known mental health clients in the group, although their various symptoms and behaviours made this quite difficult. One man produced virtually the same drawing week after week; but his ability to sit with the group improved over time, and others remarked that he seemed more able to hold a simple conversation. A woman suffering from dementia managed to draw with increasing concentration - however, she needed full-time attention from staff, and was in the end too much for the Day Centre. A woman suffering from paranoia sometimes joined the group, and on good days drew a tiny flower in the corner of her paper. A younger client, referred because of his depression and isolation, drew houses and landscapes from Uganda and gained affirmation and relief from doing so. All these members were included in the group without mention being made of their special difficulties.
Every time there was a Centre event, Salim insisted on including an art exhibition. He wanted to show everyone the different activities going on at the Centre. It was useless to protest that exhibitions were not usually part of art therapy: it was not understood. So I found a way round - I asked each member to choose two or three pictures, so that the exhibition was inclusive and not based on ‘marks out of 10’. The pictures then went up without names or captions. The members seemed to feel this was an affirmation of their efforts, and visitors commented on the brightness of the display.
I usually managed to avoid being roped in for ‘poster making’ by explaining that I was not there for that purpose, but Salim was particularly insistent on a the group producing a poster ‘Cooperation is better than Conflict’ for a recycling competition (using junk materials in creative ways). I agreed to give over one art therapy session to helping members with the actual cutting and sticking if he organised all the materials. It was an interesting occasion in that it attracted some members who didn’t usually join in, and was a cooperative venture for the whole group. And the Day Centre group won the competition.
This experience has brought up many questions for me, mostly concerned with cultural aspects of art therapy.
Art therapists might see the description of the group activity as ‘therapeutic art’ (in which people gain benefit from drawing or painting on its own) rather than conventional ‘art therapy’ (in which the art work is a vehicle for working on personal problems). Does this mean that art therapy is not relevant for this particular group, or does it mean that art therapy should be redefined to include this way of operation?
For much of the time I felt I was trying to introduce/ protect/ reinforce aspects and ground rules of art therapy as defined in western practice, e.g. time boundaries, group norms, encouragement for individual self expression, using art materials to look at problems, distancing myself from a teaching role. How far was this appropriate? Would it have been better to try to develop a model more in sympathy with their values (e.g. using a teaching model)? How could I have done this?
What does ‘therapy’ mean in different cultures?
How can we be more ‘culturally appropriate’? Whose definition(s) are relevant here? (for instance, should Asian staff work with Asian clients?)
Do the closer links between Asian arts and religion/ spirituality mean that the arts are more oriented to personal growth, taking the place of western psychology?
It was clear that the art therapy group fulfilled a positive role at the Asian Day Centre. Centre members derived a great deal of pleasure and personal involvement, and the group also had a social role. It was clearly understood that the group was there for everyone who wanted to join in, that artistic talent was not a requirement. Some members also began to use the group to develop their own process of using the art materials in a more experimental way to do more personal pictures.
There are still many questions to answer concerning the relationship of this group to art therapy, and how far the concepts of art therapy fit with the background and assumptions of the Asian Day Centre members. This would be an interesting and worthwhile topic for further research.
Drucker, K. (1990) ‘Swimming Upstream: Art Therapy with the Psychogeriatric Population in One Health District’ in M. Liebmann (1990) Art Therapy in Practice. London: Jessica Kingsley Publishers.
Elahi, S. (1995) Asian Health and Social Care Organisation: Criteria for Accepting Clients. Bristol: Asian Health and Social Care Organisation.
Elahi, S. (1998) Asian Community Single Mental Health Trust: The way forward (discussion paper).
Liebmann, M. (1999) ‘Being White’ in J. Campbell, M. Liebmann, F. Brooks, J. Jones and C. Ward (eds) Art Therapy, Race and Culture. London: Jessica Kingsley Publishers.
Office of Population, Censuses and Surveys (OPCS) (1991) 1991 Census. London: HMSO.
Watts, A. (1961) Psychotherapy East and West. Harmondsworth: Penguin.
Address for correspondence
Inner City Mental Health Service
Bristol BS2 9RU
Tel: 0117 955 6098
Fax: 0117 954 1954
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