Creativity During COVID-19: Evaluating an Online TimeSlips Storytelling Program for People Living With Dementia During Quarantine in Colombia

Abstract

Background and Objectives

Since its first implementation in 1998, evidence has been presented of the positive impact of the TimeSlips storytelling method for people with dementia in long-term care (LTC) settings. This article extends this evidence in important new directions: it is the longest TimeSlips study to date and the first to evaluate the feasibility of online delivery of the method (in response to the coronavirus disease 2019 [COVID-19] quarantine) and the impact of this on the personhood, quality of life, and psychological well-being of Spanish-speaking participants in non-LTC settings in the Global South.

Research Design and Methods

Trained facilitators provided weekly, 1-hr TimeSlips sessions via Zoom over 32 consecutive weeks to 8 participants with dementia. Semistructured interviews of participants and care partners were conducted within 1 week of the final intervention. Thematic analysis evaluated the resultant qualitative data.

Results

This online implementation of the TimeSlips creative expression (CE) method reinforced key facets of participants’ personhood (self-expression and self-perception, which led in turn to increased care partner appreciation), had a positive impact on key domains of quality of life (mood, energy levels, and cognitive function), and stimulated a key aspect of psychological well-being (the formation and maintenance of social ties).

Discussion and Implications

The online delivery of the TimeSlips method to participants who remain in their own homes is feasible and effective. Future research should compare the benefits of online versus face-to-face delivery of this CE method.

Background and Objectives

There are 55 million people currently living with dementia, but this is expected to rise to 140 million by 2050 (World Health Organization [WHO], 2021). Dementia care costs $1.3 trillion a year but will rise to $2.8 trillion a year by 2050 (WHO, 2021). Although a global disease, dementia prevalence is rising most rapidly in low- and middle-income countries: 60% of people living with the disease are now in the developing world, and this will rise to 71% by 2050 (Alzheimer’s Disease International, 2017).

Despite the prevalence and cost of dementia, pharmacological trials have experienced a near-100% failure rate and there remain no curative drugs for the disease (Cummings et al., 2019). Those drugs that are administered to people living with dementia (cholinesterase inhibitors, glutamate receptor antagonists) are not shown to be disease-modifying. Despite these limitations, public perceptions of dementia remain influenced by a pathological paradigm that focuses on symptoms of neurodegeneration, such as aphasia, agnosia, and amnesia (Kitwood, 1997; Sabat, 2018). Such a deficit-focused episteme has led to a pejorative and oftentimes alarmist public discourse that portrays people with dementia as suffering from an “erosion of the self” or even a “living death” (D’cruz, 2021; Hill, 2008).

The scant success of pharmacological treatments for dementia has stimulated the emergence of evidence-based research into nonpharmacological interventions to ameliorate some of the common symptoms of the disease, with cognitive stimulation therapies, validation therapies, sensory stimulation, and reminiscence therapies all producing promising results (de Medeiros & Basting, 2013; Olarazán et al., 2010).

Of particular interest because of its potential to ameliorate dementia symptoms and counteract the aforementioned pathological paradigm is arts-based research that directs attention toward the resilient capacities of people living with dementia. Among such arts-based interventions, creative expression (CE) programs offer particularly rich opportunities to foreground the social, expressive, aesthetic, and imaginative capabilities of people with dementia. TimeSlips is a CE method based on group storytelling that uses engaging visual stimuli and open-ended questioning to elicit imaginative contributions to a shared narrative in a failure-free environment that privileges ad libitum creativity over personal reminiscence in order to “forget” memory and focus instead on the freedom of imagination (Basting, 2009). The TimeSlips method, originally devised by Anne Basting in 1998, has been deployed in several previous studies in LTC settings in the United States, the Netherlands, and China. Collectively, this research suggests that engagement with the TimeSlips method can heighten alertness (Fritsch et al., 2009), increase the incidence of assertive responses (Bahlke et al., 2010), increase people with dementia’s expressions of pleasure (Phillips et al., 2010), positively impact physicians’ attitudes toward people with the disease (George et al., 2011), increase the quantity and quality of communication acts between LTC residents and care staff (George & Houser, 2014; Vigliotti et al., 2017), offer opportunities for cathartic play (Swinnen & de Medeiros, 2017), improve cognitive function, communication and emotion status (Lin et al., 2019), and stimulate empathy and mutual care between people with dementia (Kim et al., 2020).

The present study recognizes and engages with the important debate on the validity of its key concepts of personhood, quality of life, and psychological well-being in dementia research (Curtis et al., 2018; Gray et al., 2018). The personhood approach emerged in Dementia Studies from the 1990s in the seminal work of researchers such as Tom Kitwood (1990, 1992 [with Bredin], 1997), Steven Sabat (1994 [with Harré], 2001, 2018), and Anne Basting (2000, 2001, 2009). Personhood counters what Post (2000) calls the “hypercognitive” conceptualization of personal identity that posits human subjectivity as inextricably linked to rational and chronological thought and action (which can be made problematic by dementia). Personhood rather places emphasis on broader psychosocial capacities that include the use of language or other forms of self-expression, creativity, self-perception, and the appreciation of these capacities by others, all of which became key analytical nodes in this study.

Quality of life is a dynamic psychological construct that remains one of the most important variables in the evaluation of interventions for people with dementia (Crespo et al., 2011; Klaassen et al., 2021). Although there is no universally accepted definition of quality of life, our study followed previous approaches in Colombia (Henck et al., 2021) and sought to collect participants’ perceptions of their physical and cognitive function, energy, mood, ability to perform tasks and have fun (Logsdon et al., 1999; Thorgrimsen et al., 2003).

Similarly, psychological well-being is a complex and multimodal construct for which no universal definition is sustainable. This study took its lead from Casullo’s (2002) Psychological Well-being Scale (validated with a Spanish-speaking population) and sought to gauge participants’ ability to establish social relationships, their autonomy, acceptance/control of the positive and negative aspects of life, and ability and interest in setting goals.

We acknowledge some convergences between the psychosocial domains identified as indicative of each of the above concepts but perceive sufficient divergences for them to remain important guiding principles for this study and, we suggest, for future qualitative research into CE programs for (and potentially by) people with dementia.

The current study builds on the prior research to make a number of novel contributions to the knowledge of the therapeutic benefits of CE programs for people with dementia. It represents the first evaluation of the online delivery of a TimeSlips intervention in the Global South and, at 32 weeks, is the longest application of this method in the current literature (the average duration of the studies cited earlier being 8.4 weeks). The study’s fundamental objective was to investigate the impact of an online TimeSlips program on the personhood, quality of life, and psychological well-being of people with dementia in Medellín, Colombia.

Method

TimeSlips Group Storytelling

The strict quarantine imposed in Colombia on March 17, 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic halted our face-to-face workshops (after three sessions) and enforced an experimental redesign from a mixed-method to a qualitative study, in which the original objectives remained the same. After a short hiatus, we successfully initiated online TimeSlips workshops (on the Zoom platform) using a slightly modified method with eight participants (who all received initial technical support from their care partners) divided into two groups of four (see Discussion & Implication for further reflection on the practical adaptations needed for online delivery of the workshops). Each session began with the on-screen sharing of a visual stimulus selected by the facilitators (initially from TimeSlips’ image library and subsequently from alternative online sources) and an invitation to observe the image for a few moments in silence. The group storytelling process was then initiated with open questions (the visual stimulus remaining visible throughout) followed by the TimeSlips-recommended validation and prompt of “Yes, and …” to elicit further ad libitum creativity and reinforce the failure-free ethos of the intervention. Although all contributions were transcribed by the cofacilitator (either in electronic or manual form), participants could not visualize the development of their stories on a flipchart as they would have during face-to-face sessions. The use of Zoom’s chat function as a substitute for the flipchart was considered, but it was felt that on-screen “pop-ups” could have caused unhelpful distractions from the visual stimulus and the facilitators’ questions. In keeping with the TimeSlips method, however, the developing story was recounted to the participants by the cofacilitator approximately half-way through each session, and this recounting was used by both facilitators and participants to pursue new lines of questioning or storytelling. At the end of each session, participants were asked to generate a title for the story (with several possible titles often being suggested and recorded).

Study Population

The intervention cohort included two women and six men. The cohort was selected from the study-participant database of the Grupo de Neurociencia de Antioquia (GNA). All participants had received a formal dementia diagnosis in the 6 months prior to the study start date using the Mini-Mental State Examination (MMSE; Folstein et al., 1975), CERAD-Col (Aguirre-Acevedo, 2007), and other neuropsychological instruments. All had previously participated in cognitive stimulation activities organized by the GNA, and all were able to give their informed consent to participate in this study. People with severe impairment in verbal communication or whose capacity to consent could not be confirmed were not considered for participation. No exclusion criteria were established in relation to age or type of dementia. The inclusion and exclusion criteria were maintained in the migration to online implementation of the study, although having access to the Internet and to a care partner who could provide technical support did become pragmatic conditions for continued participation. All care partners were family members who reside with their relatives.

Ethics

The study was approved by the Bioethics Committee of the Faculty of Medicine of the University of Antioquia and the Research Ethics Committee of the School of Social Sciences and Humanities of Aston University. In-person, written informed consent was obtained from all participants (in the presence of their care partners) in the week prior to the initiation of the intervention. Participants were informed that their involvement in the study was voluntary and that they could leave the study at any time.

Research Team

The research team consisted of one speech therapist (L. Hincapié Henao), one psychologist and disability research specialist (M. García-Toro), one medical humanities scholar (S. M. Fay), and one social worker and project manager (A. Andrade Villegas), all formally trained in the TimeSlips method (through the organization’s online course). In rotating pairs, L. Hincapié Henao, M. García-Toro, and S. M. Fay shared the facilitation of the 32 group storytelling sessions (alternating between questioning and transcribing participant contributions). A. Andrade Villegas was not involved in the session facilitation and so conducted all data acquisition to avoid social desirability bias. L. Hincapié Henao, M. García-Toro, and S. M. Fay conducted all data analysis.

Data Acquisition and Analysis

Our qualitative semistructured interview was designed to evaluate the key psychosocial domains associated with personhood, quality of life, and psychological well-being discussed earlier (see Supplementary Materials for the full interview guide). The poststudy interviews were conducted by videoconference (Zoom) in participant-care partner dyads in all except one case in which the participant was interviewed alone because of care partner unavailability. Following the recommendations made by Beuscher and Grando (2009), we asked the participant and care partner to connect to the interview from a familiar place with few distractions to avoid lapses in concentration. In echo of the TimeSlips method used in the storytelling sessions, we allowed ample time to respond to all questions and validated each participant response before moving on. Care partners did not interject when the question was directed at the primary participant, but did at times reformulate questions in a language that was more familiar to the participant.

The study’s qualitative data analysis (following Miles & Huberman, 1994) consisted of: (a) Data reduction (dividing each testimony into textual units, each of which was coded into categories drawn from the psychosocial domains identified as most relevant to the concepts of personhood, quality of life, and psychological well-being); (b) Visualization (preparing category maps that allowed observation of the distribution and interweaving of categories); (c) Verification (among the research team and between them and the existing literature); and (d) Conclusion (the revision of the data based on this reflective and responsive dialogue). At steps (a) and (b) coding was carried out using the Nvivo software (license number 20.3.0.535), and a preliminary map of a priori categories was created (Figure 1). At step (c), all codes and categories were revised, and the results were compared through a calculation of both percentage of agreement and Cohen’s Kappa coefficient to identify interrater concordance. All stage (c) coding obtained an intercoder agreement of between 91.22% and 100%, but Cohen’s Kappa coefficient showed values lower than 0.7 in 13.3% of cases. Forty-six text fragments were therefore subjected to a second revision by three of the researchers until a Cohen’s Kappa coefficient of greater than 0.7 was obtained. This verification led, at step (d), to the creation of the definitive categories map (Figure 2).

Results

Participant Characteristics

The sociodemographic characteristics of the participant-care partner dyads and the communicative fluency levels of the participants are provided in Table 1.

Finding 1. Creative Storytelling Stimulated Key Domains of Personhood

Of the key psychosocial capacities associated with personhood, respondents reported positive affects on participants’ self-expression (which they saw taking place through the medium of creativity), self-perception (which they reported leading to renewed self-respect), and on others’ appreciation of these capacities (which led in some cases to changes in care partner behaviors).

Creative self-expression

Participation in the study was a channel for novel, creative and spontaneous self-expression. Despite their unfamiliarity with authoring their own stories, participants spoke positively of the experience of “making thoughts,” “inventing a story,” or being “carried into the imagination.” Commenting on the immediate impression made upon him by the visual stimuli used in the workshops, H. spoke of the “burst” of creativity that these provoked: “When I saw the images, I immediately started to turn things over in my mind: ‘What’s going to happen?’, ‘What will they say?’, How will it end?” H.’s response points to the ad libitum quality of participants’ engagement in the study, both in terms of their extempore creative contributions to the shared stories and the sense of liberation that this provided them, which H. described as the “freedom of expression” he felt defined the workshops (H 14.12).

Self-perception and self-respect

Participation in the study was a catalyst for acknowledgment of the impact of dementia on participants, but this was accompanied by positive recognition of their resilient capacities. L. spoke of a “deterioration” in her cognitive abilities, which she attributed to a combination of her age and retirement from professional life, but saw her participation in the study as a purposeful replacement of those activities and an important corrective to such deterioration: “We had the opportunity to stay connected, to be mentally active, to want to learn a bit more […]. Those stories gave us a reason to hold ideas in our minds, gave us a task, and that was fundamental” (L 10.12). For H., the realization that vibrant creativity persisted despite the effects of dementia gave him clear consolation: “As you lose your memory you start to worry that you won’t know where you’re heading. But the simple act of taking part in the exercise and remembering things, making things up […], I think that inspired a kind of confidence in us, gave us a bit more tranquility” (H 14.12). In M.’s opinion: “I wouldn’t say that we’re the best or ranked very highly or anything like that (he laughs), but neither did we allow the opportunity to escape us […], and that makes one feel good” (M 7.01). This expression of satisfaction, even modest pride, in the resilient creative abilities that the study enabled M. to exercise is particularly notable in a participant whose contributions to the stories were mostly monosyllabic until the fourth session and then underwent a marked increase in duration, fluency, and enthusiasm.

Care partner perceptions and behavior adjustments

The observation of the study by care partners was a catalyst for a novel appreciation of their relatives’ resilient capabilities and a complementary recalibration of their own behaviors. The comments by D.’s care partner are illustrative: “I really loved the stories they used to create […]. D. might have made up a story that was very different from L.’s story or H.’s story. They all had their own stories in their heads but would come together to create a single story. Wonderful!” (D 14.12—c). Beyond appreciation, two care partners spoke of the “formative” effect the workshops had on their own interactions with their relatives. G.’s care partner recounted adjustments she made in her observational and listening strategies: “We could apply that same technique later at home. With even the smallest thing, we would start by asking, by observing, by listening to what he had to say, how he said it, and what he would focus on” (G 13.05—c). For her part, H.’s care partner suggested that the study had demonstrated “that life goes on and that everything can be managed a lot more gently” (H 14.12—c) and had stimulated a renewed recognition of the need for patience, tolerance, and comprehension toward her husband.

Finding 2. Creative Storytelling Stimulated Key Domains of Quality of Life

Of the key psychosocial domains associated with quality of life, respondents reported positive effects on participants’ mood and energy levels (between which they didn’t distinguish) and on several cognitive functions, including observational abilities, concentration levels, motivation, and memory.

Positive mood and energy

L., D., R., and G. reported feeling “contented,” “very happy,” “special,” or “very good” (in English in the original) and H. spoke of the workshops as “the injection we needed” (H 14.12). Several care partners reported similar positive effects on mood and energy, with M.’s partner comparing his usual “overcast” mood upon waking in the mornings with the enthusiasm and vitality he displayed on Wednesday workshop mornings: “When he sat there that hour flew by and he was always reluctant to get up until everything was over. When it was, he would leap up full of energy: ‘How can I help? What can I do?’” (M 07.01—c). For H.: “I came out with a different perspective, in a different world, with a different way of seeing things, and really enjoying everything I did see.” (H 14.12), a particularly powerful illustration of the positive impact of the sessions on participant emotions.

Cognitive function

G.’s care partner illustrated the manifold cognitive stimulations of the study clearly: “The storytelling sessions made them talk […], offer opinions, watch, observe […]. It would touch on lots of aspects of their daily lives and make them find themselves, make connections, talk to each other, give opinions, and build the stories” (G 13.05—c). M.’s care partner compared the cognitive stimulation of the workshops to that provided by other sources: “He doesn’t like to read. I bought him a Tablet but he doesn’t like it. But that hour really took him away from it all and distracted him with thoughts about what he was being asked, made him concentrate his attention, which is what they really struggle with” (M 07.01—c). This sentiment was echoed by the participants who reported that the workshops gave them the opportunity to “get our minds ready” (G 13.05), to “want to learn a bit more” (L 10.12) or to “clear out the mind and put new things in there. Imagine things” (H 14.12).

Memory

Although the TimeSlips method eschews an explicit focus on recall and reminiscence in favor of atemporal creativity, reminiscence was indicated by participants and care partners alike as playing a significant and positive part in the workshops’ creative and cognitive processes. In creative terms, care partners spoke of the interweaving of abstract imagination and evocative memories in the workshops, with M.’s carer suggesting that “in some way those workshops took him back to his childhood. He would even say: ‘Ah, I started working with my father on that farm when I was so young’,” (M 7.01—c). This fusion of imagination and memorialization is evident in several of the stories produced by the participants and becomes particularly powerful when episodic memory and spatial memory coincide in recollections of rural childhoods (see “The Happy Couple” in Supplementary Materials). In cognitive terms, evidence from several interviews indicates that participants still recalled specific images, themes, and storylines from workshops that took place several weeks before the poststudy interview.

Finding 3. Creative Group Storytelling Stimulated Key Domains of Psychological Well-Being

Of the key domains associated with psychological well-being, respondents offered little comment on the workshops’ impact on participants’ autonomy, acceptance/control indicators, or goal setting. Respondents offered ample evidence, however, of the formation and maintenance of new social ties among participants (to which the online delivery of the project was no obstacle) and on a particular kind of interconnectivity that occurred through the shared imaginative process.

Social ties

R. spoke of a sense of solidarity that developed in the sessions in which “I felt really good with all my friends. We were all in it together” (R 16.12). For his part, H. spoke of the bond engendered by the recognition of the common challenges of dementia and by the shared experience of the study: “they would tell us about their experiences and we would tell them ours and we saw that there were other people who had problems just like me” (H 14.12). For M.’s partner, the safe space of the workshops enabled strong social bonds to develop between her husband and the other participants: “He would say to himself ‘I know them and I feel good with them and I feel committed to what we’re doing and I don’t feel intimidated at all’” (M 07.01—c). In terms of the “virtual” nature of this socialization, several care partners expressed surprise that such strong bonds could be forged among people meeting exclusively in an online forum: “it was like getting together with friends that he’s known for a long, long time, although he’s only ever seen them on the screen” (M 07.01—c). For her part, G.’s care partner anchored the experience in the context of the COVID-19 pandemic: “I think it’s wonderful because this pandemic has isolated us all, we were all alone, and the sessions were a way of holding onto the connection with other people, with the rest of the world” (G 13.05—c). The opportunity for online socialization offered by the study was thus seen as particularly valuable at a time when face-to-face interactions beyond households had been practically eliminated.

Imaginative interconnectivity

A key facet of the TimeSlips method is that the creative narratives it facilitates are collective. Although contributions to the stories are individual (even idiosyncratic) and minimal narrative coherence is pursued, the shared storytelling experience in this study became increasingly dialogic as participants became familiar with each other, with the facilitators, and with TimeSlips’ failure-free method. G. pointed clearly to this creative interconnectivity: “It was very good because we had to do everything together and everyone knew that we all had to play our part to do everything well” (G 13.05). M.’s care partner echoed this in her description of the fluid “interlacing” of individuals’ imaginative contributions to the stories: “Those sessions really helped them to imagine different things and link one thing to another. By helping each other, lots of different ideas would flow and all lead to one beautiful ending” (M 07.01—c). Interestingly, despite TimeSlips’ failure-free ethos, respondents spoke of candid “editorial” exchanges during the workshops that point to a shared quest for narrative coherence and a shared accountability for the “rectitude” of the final stories. G., for example, was adamant that “when someone was doing something wrong: ‘No, not like that. Do it like this or like this’. That way everything turned out right” (G 13.05).

Finding 4. Online Delivery of the TimeSlips Storytelling Program is Feasible and Effective

Respondents evaluated the online delivery of this CE method as feasible and effective, pointing to the particular importance of skillful facilitation of the study for the creation of a stimulating safe space.

Feasibility and effectiveness

Respondents judged the TimeSlips method to be effective: “That way of doing it, I mean, there are lots of different therapies, but that narrative therapy is absolutely fabulous!” (G 13.05—c). They also reported that the online delivery of the study had not interfered with its perceived success: “I don’t know what the classes were like when they were face-to-face because we didn’t go in, but if they were just as good and had the same results, excellent, excellent, and great that it’ll continue on the screen because we can’t get out yet” (M 07.01—c). As indicated earlier, this online feasibility and effectiveness were seen a particularly valuable at a time when COVID-19 quarantine measures in Colombia meant face-to-face interactions beyond the household were extremely limited.

Skillful facilitation

Twenty-three of the 63 references initially coded to the “Appraisal of the project” category stressed the importance of the skillful online facilitation of the storytelling sessions, including the careful on-screen coordination of contributions from participants who were physically separate: “I think it’s fantastic […], that way of leading them all and including them all, because it’s really not easy to integrate so many people in that kind of situation” (R 16.12—c). The contribution of the facilitators to the formation of a safe space in the virtual workshops was also commented on, with R.’s care partner pointing to it as integral to the participants’ ad libitum creativity: “The facilitators were incredible, their patience, the way they would speak to the storytellers, the way they would motivate them to carry on thinking, to carry on creating” (R 16.12—c). In M.’s testimony, the online workshops of this study simply offered: “a place where we could, how can I put it … a place where we could all feel good” (M 07.01).

Discussion and Implications

The current study builds on previous research to make a number of novel contributions to the knowledge of the therapeutic benefits of TimeSlips for people with dementia. It is the first study to translate the TimeSlips method into Spanish and apply it in a middle-income country with participants who remain in family homes (rather than LTC settings). With more than 2.5 million people with dementia in Latin America (most of whom remain at home postdiagnosis) and a predicted 180% increase in prevalence to 2050 (compared with a 70% increase in Europe), these are important precedents (Alzheimer’s Disease International, 2017; GBD Dementia Collaborators, 2022). Importantly, this is also the first study to evaluate the feasibility and effectiveness of the online delivery of a TimeSlips program (a methodological adaptation implemented in response to the COVID-19 pandemic). Although unable to conduct the mixed-method analysis envisaged prepandemic, our extensive interviewing of participants and care partners addressed the lack of participant-provided qualitative data indicated in previous studies (George & Houser, 2014; Vigliotti et al., 2018). The online delivery of the intervention also meant we were able to extend the original 10-week duration to 32 storytelling workshops over nine months, thus becoming the longest known TimeSlips program and addressing the limited study duration identified in earlier studies (Bahlke et al., 2010; George & Houser, 2014).

Participation in the study was a powerful channel for imaginative self-expression that had a positive impact on participants’ assessment and appreciation of their own resilient capacities. In several cases, this appreciation inspired tranquility, confidence and pride, which in turn led to greater motivation, participation, and agency in the storytelling sessions. These positive participant assessments were echoed by care partners whose observation of the intervention led in some cases to behavior changes toward the kinds of recognition, validation, and celebration of their relatives identified as key elements of person-centered dementia care (Kitwood, 1997). In combination, this bilateral appreciation of resilient capacities that had persisted despite dementia led to a recognition and reaffirmation of important facets of participants’ identities. Applied more widely, this online CE intervention could therefore help combat “eroded self” stigmas that still surround dementia and could contribute to the UN-advocated paradigm shift away from a deficit-focused to a resilient-capacity-focused approach to thinking about older people (WHO, 2020).

Although the TimeSlips method eschews explicit reminiscence in favor of atemporal creativity, we found that memory played a crucial role in the imaginative processes at work in the study. In several of the sessions, the visual stimuli used gave renewed access to long-term memories, which in turn enabled participants to reidentify with their childhoods and early adulthoods, an experience that was simultaneously soothing and invigorating (see “The Happy Couple” story in Supplementary Materials). In this, our findings echo Swinnen and de Medeiros’ suggestion that imagination and memory “feed into each other” in TimeSlips sessions (2017, p. 267), suggesting that the most beneficial CE interventions will allow, and even design for, memory and imagination to coexist.

The study’s findings on social ties were particularly relevant during the COVID-19 quarantine in which the participants were largely housebound, but remain so postpandemic given the high levels of social isolation typically experienced by people with dementia. It is worth emphasizing that our online TimeSlips sessions served as catalysts for remarkably open and candid interactions (including disagreements) between participants that led to notable and fruitful cohesion within the study groups. As others have observed (Bahlke et al., 2010; Swinnen & de Medeiros, 2017), this candor and cohesion developed gradually as participants became familiar with each other and the facilitators, thus emphasizing the significance of extended exposure to the method (at 32 weeks the present study is three times longer than the average duration of previous TimeSlips studies).

In terms of creative interconnectivity, we follow Swinnen and de Medeiros in observing that the ludic potential of TimeSlips offered participants opportunities to accept differences, self-monitor, and build intimacy within a “circle of trust” (2017, p. 266). Interestingly, the candid social interactions commented upon by this study’s participants and care partners extended to the storytelling process in which TimeSlips’ failure-free ethos was sometimes set aside in favor of “editorial” interventions that “corrected” some contributions in the pursuit of storyteller-determined narrative integrity. This authorial agency within the creative, safe space of TimeSlips sessions should be acknowledged and carefully catered to in future interventions.

In terms of methodological precedents, our findings suggest that the online delivery of TimeSlips CE programs is an effective, accessible, and low-cost intervention that could be extended to very large populations, with some potential obstacles. In this study, some of these obstacles arose immediately upon switching from presential to virtual workshops: a lack of familiarity with the virtual environment on the part of participants, care partners, and the facilitators themselves (and a resultant lack of online interactive fluency); the difficulty of seeing all participants simultaneously on the screen (and the inhibitory effect of this); the high levels of background noise in participants’ homes (which affected participant interaction and facilitator transcription of the narratives); internet connectivity problems (that interrupted some sessions). Beyond developing online fluency as the project progressed, we found that these obstacles could be overcome with: (a) technical support from caregivers (or another person in the household) and the creation of “quiet areas” for the duration of the sessions; (b) the use of computers or tablets (instead of mobile phones) with larger screens to allow participants and facilitators to see each other simultaneously and to reduce connectivity problems; and (c) the careful facilitation of sessions by TimeSlips-trained and skillful researchers (indicated by the incidence of its mention in interviews as a key facet of project’s success).

In addition, while eight to 10 participants were appropriate for face-to-face sessions, that number proved unmanageable in online sessions. Groups of four proved optimal for the sustained concentration and participation of the storytellers and fluent moderation by the facilitators (including managed turn-taking, validation, and transcription of all participant contributions).

In every other sense, the application of TimeSlips’ principles and techniques remained unchanged: the facilitators used engaging visual stimuli (see the example in Supplementary Materials), asked open-ended questions, and echoed, affirmed, and validated every answer, including gestures, sounds, and “non-sensical” answers.

We recognize that access to the equipment and internet connectivity needed to engage with this kind of online CE program is not a given in low- and middle-income countries such as Colombia (or even in many high-income countries). In our own experience with participants living in multigenerational households in a large metropolis, economic, technological, or data literacy obstacles did not impede the delivery of the intervention. Nevertheless, all would need to be accounted for in studies with more rural, less affluent, less data literate, or otherwise excluded populations.

Although our findings provide evidence of the effectiveness of an online TimeSlips program (with implications for online arts-based psychosocial interventions more broadly), we acknowledge the study’s limitations. First, the transition to online delivery reduced the number of participants because of limited internet access or insufficient care partner support and made the poststudy application of quantitative instruments impossible. Although the analysis of qualitative-only data from a small study cohort is not an inherent limitation, or even uncommon, in research on the impact of arts-based interventions on health and well-being, we nevertheless recognize that mixed-method approaches can be the most powerful means of demonstrating the efficacy of such interventions. These limitations should be addressed in new and complementary research that should also carry out more explicit comparative analysis of the effectiveness of online versus face-to-face CE interventions.

The online delivery of a TimeSlips program reinforced fundamental facets of personhood, boosted important aspects of quality of life, and enabled the formation of meaningful social bonds, even in conditions of acute isolation. These positive findings should encourage researchers and practitioners to further explore the online delivery of arts-based psychosocial interventions to refocus attention on the resilient abilities and creative potential of people with dementia and to provide cumulative data for the postpandemic reconfiguration of arts-based services for these people and their families.

Funding

This work was supported by Research England’s Global Challenges Research Fund (University of Aston QR grant code: 28012).

Conflict of Interest

None declared.

Data Availability

Figures 1 and 2 illustrate the coding process applied in this research. The full semistructured interview guide and an example of the creative narratives produced during the research are available in Supplementary Materials (both translated from Spanish by S. M. Fay). Further narratives (in Spanish) are available on the project’s website: https://cuidarmecuidarte.org/narrativas/. This study was not preregistered.

Acknowledgments

We thank Aston University for the GCRF-linked financial support for this research. We thank the participants and their care partners and the Grupo de Neurociencias de Antioquia for making this research possible.

References