Linda Levine Madori Ph.D.

Using the TTAP method in Finland, Journal of Dementia Care, Finnish Association for Dementia Care

Author: Kirsi Laako, Recreation Therapist and Dementia Care Specialist

According to my experience and observations recreational, creative and therapeutic group activity for the elderly in Finland is very varied and the implementation of the activity is strongly affected by who is doing it. The education of the professional is also very varied. I strongly feel that my work with elderly and people with dementia is meaningful and important and I want to learn more and take a part in developing this field. These are some of the reasons why I participated the course Therapeutic Thematic Arts Programming in Hämeenlinna, Finland HAMK in the University of Applied Sciences in International Culture, Creativity and Wellness Summer School in 2006 and 2007. The purpose of this short article is to shed some light on the TTAP-Method© and my experiences and observations of using it with differed client groups of mine in Tammilehto Service centre.

The Therapeutic Thematic Arts Programming- The TTAP Method©

The TTAP Method© is structured, goal-directed method which is using different art and activity forms with a unifying theme. According to my experience using the same theme makes the nine steps of one theme at the same time shared and individual process. The structure of the method is allusive so naturally the therapist can use the parts of the method that are most suitable for this specific group in this specific time. Method proceeds in nine steps. Every step is based on the previous and the theme is connecting them all together.

The instructor of the course was the developer of the method Prof. Linda Levine Madori (Ph.D., C.T.R.S., ATR-BC) from New York USA. She is a Professor of Recreation and Leisure Studies in St. Thomas Aquinas College NY. Before joining the Faculty of the College Prof. Levine Madori has served for example as Art Therapist Program Supervisor, Consultant Art Therapist and as Creative Arts Program Supervisor. Currently she has studied the effects of therapeutic recreation and cognition in Alzheimer’s disease in New York University and she has presented papers, workshops, and seminars and also developed international educational courses in the specialized area of Alzheimer’s disease. 

The basics of the method

TTAP-Method is based on the information of the research on brain functioning, Alzheimer’s disease and the mechanisms of learning. Research is indicating how environment, education, profession, activity and participation are impacting on the brain. Levine Madori was specially pointing out the importance of the well being of hippocampus that is connected with the activity of an individual and using of the brain. Using right and left side of the brain equally and diverse is particularly important for well-being and trough that the size of the hippocampus. And according to research on brain the size of the Hippocampus correlates with the probability of having the Alzheimer’s disease. The TTAP-Method creates possibilities and ways to use all different parts of the brain. For instance making a sculpture or charts on paper requires using of the frontal lobe and touching different materials stimulates parietal lobe. 

Theoretical framework of the method is also based on Developmental, Lifespan and Activity theories. As the neuroscience proves the activity of an individual is correlating with activity and well being of the brain and of the holistic well being of the individual as well. And this holds true with every one of us. If I simplify a little it can be said that working-age people should take care that their everyday life is offering them both logical and creative challenges that requires using left and right side of the brain equally. Naturally part of a good care of the people with some dementia is creative, recreational activity and person- cantered. This will strengthen brain functioning and presumably slow down the progress of the Alzheimer’s disease.

I think that special strength of the TTAP-Method is that therapist can support clients’ individuality and still clients work as a group and benefit from the group too. The group is approaching and dealing with the theme and it challenges by discussing, sharing and trying out the same art forms and activities. At the same time the approach is based on individual memories, experiences, thoughts and feelings of each participant and the way of self-expression is as individual as the skills and will of the client. Familiar and remembered things are interesting and they motivate to participate. Dealing with familiar things and that way feeling of competence is supporting the identity and self-confidence of the client. During the TTAP-Method such topics are coming up and will be discussed which wouldn’t come up otherwise in everyday life of the elderly. Theme programming has an innate flexible and individual approach that allows overcoming clients´ differences in culture and skills. Every client has an opportunity to be individual and experience self esteem and self worth. So in a group a client that has a need to tell stories and specifically to be heard can do so and a client that has a difficulty to produce words and talk can express him or her self by other means like through pictures or movement. The size of the group is up to the skills of the clients likewise the state of their disease. However the group shouldn’t be too big so that everybody has an equal opportunity to self-expression and to be heard. 

Utilizing Themes within the nine steps

TTAP-method© is carried out in nine steps with a unifying theme that helps focusing on current activity and explore different sides of a the topic in the present as well as in the past. Theme can be chosen with the clients through discussion. Using the same theme also supports the therapist creativity because the same topic is used in this many sessions process and because therapist can utilize everyone’s personal experiences, thoughts and views. This way the process is always the image of the participants. Theme creates a natural, meaningful, adult like and all the time deeper way of learning, understanding and acting.

TTAP-method© proceeds through nine steps. The steps can be used flexibly in the best way suitable for the group. The same music and Guided imagery can be used to remembering the theme and earlier steps of the programming. It’s good to recall together the earlier sessions and the work done before like sculptures or stories in the beginning of a new session. Concentrating and calming down are important parts of the successful group session. At the end of the programming it’s useful to pay attention to the results, for instance everybody gets to tell about their work, the making process and the feelings that come up. The honest feedback of peers is an important part of supporting the self-confidence, as it is therapeutic to give feedback to others.

At the first step the theme is handled together and for instance can be thought what comes to everyone’s mind about the concept countryside. Most of my clients are part of rural population. They have been born in farming community and worked there as well. The theme countryside is discussed and shared ideas are placed on paper using descriptive charts and patterns. I have foud that using the overhead projector is especially effective. My clients seemed to enjoy the feeling like we were actually working in an office. I observed that my clients were enjoying the feeling of sharing and being useful and heard at the same time. It’s wonderful and natural how sharing and placing ideas on paper or transparency to everybody to see makes the theme and discussion seem more meaningful and valuable.
An old lady who normally doesn’t join the discussion independently was listening the discussion of a group in skilled nursing home for elderly with dementia. This time she was really concentrating, following the discussion and how I wrote the ideas on the transparency. Our theme was Finnish woman. It took her a while but then she stated with determination in her voice: ”I am a Finnish woman!” And she really looked pleased with herself. Furthermore shared group ideas the theme can be discussed also via more individual approach. What comes to mind about client’s own bird home in the country or what kind of memories comes to mind about femininity?

Next step music and sounds rises up rich imagery. The impacts of music on our brain is widely researched and acknowledged. After listening to music the individual images is discussed and shared with others. In the next step these images and memories from mind’s eye are utilized to make pictures, paintings, drawings or for instance collages. Music can be very helpful also in this step. According to my experience client can feel starting the picture making too difficult and little pressuring, but music and guided imagery or meditation helps to focus, remember the memories and ideas as well as direct attention to the task at hand. Most elderly Finnish don’t have much experience in self-expression through picture making so it is easily first seen either as too childish or difficult if not impossible. It is significant to discuss together about the objectives of the group participation and the task at hand. I tell my clients that I think that the most important thing is to participate, feel, think, share and be together as a group, it is like brain workout. It is not the objective of the group to produce great artwork, we can just see what comes out of it. 

Step four proceeds from pictures into the sculpture that can be made out of clay, found objects of something else. Now pictures, memories and ideas get a three-dimensional form. Using clay can be first even more challenging than making pictures but theme, images and memories are recalled again before starting the sculpting and music and guided imagery are used as well. 

In step five theme is being explored trough music, movement and dance. A group of women had femininity as a theme. Fist the group was remembering and trying out together the traditional Finnish Female Gymnastic movements as well as feminine movements in general. Then clients danced together waltz and tango. In addition to music movement can be enliven with objects like balls, scarves and hoops or musical instruments.

Step six uses words in stories, poems, songs or, say, in a crossword puzzle, still taking into consideration the skills of the participants. Some clients can easily write themselves and others need help. Words can be surprising and effective. One client of mine was in doubt about her sculpture and still thought that it was ugly when she was painting it even thought her peers had give her complements about it all a long. When the client got to tell the story of her sculpture, the red dressed little girl named Milla, the object got a totally new meaning and rank. The client was telling smiling broadly and laughter in her voice about little girl named Milla, her grandchild.

Step seven must be pleasant for the most of us, food. Food can be utilized in many ways like by baking, exploring different fruits or even preparing a meal. Food can be utilized in brain activity as well by counting or categorizing, food for thought. Carrying out this step like all of them, creativity is allowed, the sky is the limit. In the course we heard from Prof. Levine Madori that elderly in the USA make sculptures and flowers out of fruits. None of us could imagine that the Finnish elderly that we know would ever agree to play with food like that! Such are the cultural differences. But ever the less food, thoughts of food and different tastes bring out memories in all of us. How would you like to taste mämmi (an old Finnish Easter pudding, treat that I think looks like mud) or famous Finnish milk chocolate by Karl Fazer that almost takes your breath away? What kind of things do you feel and what comes to your mind about food? 

Step eight brings the thoughts and ideas into a theme event, party or exhibition that the group is at least partly prepared. These special theme events are an opportunity to display the objects and efforts of the group, create experiences of success and get feedback outside of the group from friends, neighbors or family.
The last step nine on the TTAP-method is photography, photographs, pictures and memories. For instance the pictures of clients can be used to make one common collage or clients can prepare their pictures in frames and take home with them. I was photographing one of my fist TTAP-groups from the beginning with digital camera and utilized the pictures in remembering the earlier steps by showing them on computer. During the last group session I showed the pictures of the work and the group in action like dancing. Documenting the events and work, photographing as such seemed to be important experience to the group. They seemed to feel more appreciated because somebody was interested enough to take pictures of them and their work. The whole experience and process was interesting to go through by pictures with the group. This way it was possible to go back in different steps together. Pictures once more brought up thousand words.

The benefits of the TTAP-method

Multidimensional and diverse TTAP-method has many benefits in everyday work as a therapist. It supports the creativity of the therapist and the client, stimulates different parts of the brain and works as a part of the rehabilitation. Involvement, safe environment, utilizing and finding individual skills and strengths, feedback and feeling of success are building up the self-esteem. Physical activity, sensations of touch, relaxation and meditation in addition to all good impacts improve the experience of body in space as well as balance. Focusing, feeling connected to others and being part of a group endorses social, mental and spiritual well-being and cognition.

Participating in TTAP-group doesn’t require good short-term memory but the stimulus and memory connections created by various activities are supporting remembering and the continuance of the theme. Using the method and theme programming is encouraging the clients to take part in activities of all kinds, self-expression, sharing thoughts and feelings with others in many ways with words, pictures, actions and movement. Discussions, recalling the theme and memories are useful in many ways. Being a part of TTAP-group is advancing the clients by getting to know and understand others. At the same time an individual can recall again who she of he is again and what has been their life like and what has been the meaning of different things in their life. In addition the structured method utilizes the research on the impacts of the therapeutic recreation. And so it can help to develop and further the field of therapeutic recreation as well as hopefully bring much needed attention, appreciation and resources to the field. A human is holistic being so in addition to the medical and physical professional fields also the field that facilitates spiritual, psychological and social well-being should be appreciated and supported. 

Sources:
Prof. Linda Levine Madori’s lectures and material
Linda Levine Madori, Therapeutic Thematic Arts Programming for older adults
Pre-publication materials, 2006, Health Professions Press, Baltimore

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