Stigma is referred to as negative attitudes and biases held about persons that could be result of some diagnosis (Dinos et al., 2004). A lack of knowledge regarding dementia can cause an unwarranted stigma toward persons living with the disease, illustrated by a theory known as stereotype embodiment (Levy, 2009). The theory suggests stereotypes are manifested when their understanding is driven from external sources which create self-definitions that impact functioning and health. Stigma-driven thoughts held by individuals can often lead to negative response, prejudice, and/or avoidance from a population (Corrigan and Watson, 2002). Therefore, it is important for emerging adults to gain the necessary knowledge of dementia to reduce the stigma surrounding it.

Emerging adults may particularly benefit from experiences that aim to reduce stigma for people with dementia. Prior research suggests that education, awareness, and experience with people with dementia may increase positive outcomes. For example, previous research has shown that emerging adults showed statistically significant levels of dementia stigma, whereas professional care-workers showed more dementia-positive attitudes (Kane et al., 2018).

In a 2004 anti-stigma study regarding people with dementia, only 4% of lay persons believed that people with dementia were at fault for their behaviors. Rather, the participants were more inclined to help people with dementia and see them as individuals in need of guidance (Werner and Davidson, 2004). To further add to this, a 2018 study used an intergenerational choir participation intervention with college students, persons with Alzheimer’s disease, and their relatives. The study resulted in reduced social isolation of persons with Alzheimer’s and their families and stigma among college students (Harris and Caporella, 2018).

Notably, seeing people with dementia as people who need constant care can lead to an attitude that people with dementia are helpless, also known as infantilization (Jongsma and Schweda, 2018). People do not want to be infantilized or seen as helpless, so they will often disregard the signs of early-stage dementia to ignore the pervasive cultural trope (Jongsma and Schweda, 2018). Evidence-based, experiential learning programs can address these nuances through targeted education and person-to-person interactions. Research has shown that in addition to education, exposure to and experience with people with dementia matter. For example, stigma was lower in persons who had experience with people with dementia, who were younger and more educated about dementia, and who thought treatment was available for dementia (Cheng et al., 2011). Thus, there is a need for public health interventions to alleviate dementia stigma. BATL is one such paradigm, working to decrease stigma and fear while highlighting the personhood of people with dementia by experientially increasing empathy.

Empathy is defined as “understanding a person from his or her frame of reference rather than one’s own, or vicariously experiencing that person’s feelings, perceptions, and thoughts” (APA Dictionary of Psychology, American Psychological Association, 2018). There is a robust literature available regarding personhood and empathetic approaches in dementia care. Firstly, Thomas Kitwood shifted the perspective from a biomedical view to one focused on the lived experience of people with dementia, with techniques such as dementia care mapping (Kitwood, 1997). Additionally, he and Kathleen Bredin focused on a person-centered approach emphasizing life quality and dignity rather than deficit and loss (Kitwood and Bredin, 1992). Kitwood’s book, Dementia Reconsidered (Kitwood, 1997), and his work with Bredin are foundational components for the field still used in clinical training for dementia care (Mitchell and Agnelli, 2015).

The personhood perspective differs greatly from the perspective of dementia as a “social death” (Sweeting and Gilhooly, 2008), a concept that is rooted in deficit-based, biomedical mechanisms often attributed to earlier works like those of Mace and Rabins (1981). For example, studies on dementia care models (e.g., Kitwood, 1997) highlight the need for sustained empathy and ongoing education in dementia care. Kitwood’s work demonstrates that dementia care should prioritize understanding and affirming the person’s identity and unique preferences. Sustained empathy and continued education provide the needed foundational skills to adapt to changing needs and maintain a respectful, individualized approach, thereby reducing “social death” risks for people with dementia. Research related to resisting societal disenfranchisement is one example of how researchers have challenged the narrative of “Alzheimer’s patients” to be more identity-centered (Beard and Fox, 2008).

Bringing Art to Life aims to expand on the work of colleagues, such as Beard and Fox, through its building of identity-centered intergenerational relationships between emerging adult students and people with dementia. Research suggests that increased training and understanding of emotive empathy in caregivers improves the level of care provided to older adults living with neurological diseases through improved emotional intelligence (Maximiano-Barreto et al., 2022). The lack of empathy training correlates with a lack of proper care for people with dementia, as these individuals are not commonly included in creating their own care plan, and most choices are made by a family member or other primary caregiver(s) (Wackerbarth, 1999). Although it is important for these family members and caregivers to provide guidance, previous research shows that people with dementia want to be part of their medical decisions, and physicians found their participation beneficial to providing people with dementia with quality care (Iezzoni et al., 2021). Institutionalized people with dementia (those residing in nursing homes, specialty care assisted living facilities, and other outlets of dementia care services) acknowledged their preference for individualized and person-centered care, which emphasizes the need for close bonds grounded on empathy (Wehrmann et al., 2021). Poor understanding of individualized quality care for people with dementia can lead to caregiver burnout (De Alves et al., 2019) and reduced empathy. In contrast, BATL creates an environment in which the focus on personhood and experiential acquisition of knowledge provides opportunities to gain empathy for people with dementia.

Few educational opportunities exist for emerging, college-aged adults (about age 18–29) to understand the lived experience of people with dementia (Peisachovich et al., 2023; Arnett, 2007; Reifman et al., 2007), and this lack of knowledge and awareness may contribute to lost opportunities for compassionate care of, and interactions with, such persons. Currently, the BATL program is being implemented across multiple sites with somewhat varying target participants, both in terms of learners and points of service delivery for people with dementia. In this manuscript, we describe an evaluation of the seminal BATL program involving college students and people with dementia in adult day service programs. Students undergo several weeks of education and training during a 16-week semester while simultaneously being paired with people with dementia in the treatment setting.

Students assist in group art therapy sessions once a week under the direction of an art therapist, and interact with their peers, people with dementia, and the art therapist about both the art that is produced and the creative process itself. Art therapy directives (activities) planned by the art therapist focus on several of life’s most cherished aspects, such as family, food and childhood. Examples of these directives include “Your Grandmother’s Breakfast” (prompt: “Think of a typical breakfast that you would have enjoyed with your grandmother and create art to represent that breakfast.”), “Hands Directive” (prompt: “Trace your hands in a favorite color and create an artistic representation of something unique about yourself.”), or the “Shaving Cream Art Directive” (participants and students spread a layer of shaving cream into an aluminum pan, add droplets of food coloring, swirl with a Q tip, blot with watercolor paper, then rake off the shaving cream with a straight edge to reveal marbled artistic designs). The art over which BATL students and people with dementia interact is thus produced.

Students are trained in effective communication methods for interacting with people with dementia. Mindfulness training is provided primarily as a means of enhancing the relational impact of the art therapy sessions through better listening, enhanced capacity for compassion and empathy, increased self-awareness, and as a check against prejudgments and emotional reactivity. It also may provide students with a new lens to engage discomfort, a potentially beneficial skill supporting wellness later in their lives and careers. Several student creative writing assignments and weekly journal entries about the art therapy experience and interactions with people with dementia across the semester require students to reflect experientially on course themes.

Didactic course content includes comprehensive lectures from neurologists about the neuroscience of memory, Alzheimer’s disease, and other dementias, including topics such as epidemiology, pathophysiology, common clinical manifestations and their pathophysiological correlations, diagnosis and imaging, methods of cognitive assessment, prevention, treatment, and updates on research related to racial/ethnic, health disparities and inequity in dementia care. Lectures on the history, theory, and practice of art therapy and other expressive arts therapies and a discussion of art therapy directives are offered as well as lectures on caregiving, aging, and mindfulness. Additionally, students participate in simulated, first-person, embodied dementia experiences via the Virtual Dementia Tour from Second Wind Dreams and virtual-reality training modules from Embodied Labs. Prior research has demonstrated effectiveness of the Virtual Dementia Tour, indicating that students showed significant improvements in empathy and understanding of the lives of people with dementia after training (Peng et al., 2020). Similarly, virtual reality training modules from Embodied Labs have demonstrated efficacy among medical students, who reported significant increases in understanding of the needs of people with dementia, the needs of a caregiver of someone with dementia, and the impact dementia can have on the entire family (Bard et al., 2023).

When discussing components of BATL, it is integral to highlight the importance of expressive arts programming to this intergenerational program. The current project emphasizes the need for intergenerational, experiential opportunities, such as BATL, for emerging adults and pre-healthcare students through using the mechanism and depth of expressive arts therapies. The art therapy component of BATL allows for a tangible focus and scaffold on which to build a sense of relatedness between students and people with dementia that they might not otherwise recognize. Throughout the many years of this course, students first display feelings of hesitancy and nervousness about meeting people with dementia. However, as the course continues it is clear that the collaborative art activities create a common ground that takes away feelings of wariness, nurturing a greater natural connection.

There is an extensive literature on the use of expressive arts interventions for people with dementia, highlighting quality of life over medical outcomes. This literature further highlights the need for expressive arts programming in intergenerational learning settings not only for students, but also for people with dementia. A shift in focus from behavioral issue reduction to meaningful interaction is highlighted in several studies by means of arts activities, personalized music interventions and group singing, and expressive arts in general (Gerdner, 2000; Jones and Sutherland, 2005; Noice and Noice, 2006; Creech and Hallam, 2013; Creech et al., 2013). Attention to this literature can deepen the understanding and necessity for creative interventions as a means of fostering connection and life story for people with dementia.

The current sequential mixed methods study aims to understand the potential impact of the BATL experiential learning course on emerging adults’ empathy, mindfulness, and attitudes toward older adults, people with dementia, and interest in community service and health-related careers. Across seven semesters, college students enrolled in BATL completed surveys and were compared with students enrolled in didactic Introductory Psychology or a 300-level Psychology and Aging course. Attitudes toward older adults, individuals with dementia, community service and additional outcomes including positive and negative affect, time perspective, psychological flexibility, mindfulness, and empathy were measured via online surveys at the beginning and end of the semester. It was expected that students enrolled in the experiential BATL course would, as measured via surveys, demonstrate more positive attitudes toward older adults and people with dementia as well as improved emotional functioning across a semester in comparison with students in Intro Psychology or Psychology and Aging, as indicated by significant time by course interaction terms.

In addition to quantitative surveys, students enrolled in BATL wrote qualitative weekly journal entries as a course requirement, and these entries were coded for emergent themes. Qualitative content coding of BATL student journals are a main source of data explanation that provide an illustrative and rich narrative. Ultimately, qualitative description of student journals complements and extends the quantitative data and is the best approach for qualitative data of the present kind, where “straight descriptions” of experiences are warranted (Sandelowski, 2000). Moreover, numbers are used in descriptive qualitative research to establish the significance, document what is known, and generate meaning from the qualitative student journal data (Sandelowski, 2001).

The study was ethically approved by the [blinded for review] Institutional Review Board. Students enrolled in one of the courses described were provided with an online consent form stating that participation was voluntary, and they could skip any questions or discontinue participation at any time. Additionally, BATL class members provided 10 journal entries across each semester to capture first-person descriptions of student experiences. There were no inclusion or exclusion criteria other than enrollment in one of the courses and providing survey data at the beginning and end of the semester of enrollment.

In addition to demographics all participants completed the following measures.

The Student Assisted Independent Living (SAIL; Pillemer and Schultz, 2002). This scale is a 20-item attitudinal scale rated on a seven-point Likert scale ranging from “strongly disagree” to “strongly agree” measuring four dimensions of attitudes toward individuals with dementia (i.e., older adults, community service, older adults with dementia, and working with geriatric patients and individuals with dementia). Yamashita et al. (2011) reported good reliability and validity with Chronbach’s α’s ranging from α = 0.64 to α = 0.76.

The Positive and Negative Affect Schedule (PANAS; Watson et al., 1988) measures students’ experiences of positive and negative emotions in the present moment. The questionnaire has a total of 20 items, with each item rated on a five-point Likert scale ranging from “very slightly or not at all” to “extremely.” The PANAS has good internal consistency for the positive affect (PA) Cronbach’s α = 0.84 and for the negative affect (NA) Cronbach’s α = 0.87 scales. The two scales have good discriminate validity as they correlate −0.09.

The Future Time Perspective Scale (FTPS; Carstensen and Lang, 1996) measures students’ experiences of time perspective related to an individual’s motivation/approach to their own life, with a total of 10 items, each rated on a seven-point Likert scale ranging from “very untrue” to “very true.” Individuals who score below 50 are said to view time as limited, while those who score above 50 have a more open time perspective. A recent systematic review and meta-analysis reports a mean Cronbach’s α = 0.84 for this scale (Kooij et al., 2018).

The Mindful Attention Awareness Scale (MAAS; Brown and Ryan, 2003) measures students’ trait-like experiences of attention and awareness. The questionnaire has a total of 15 items, with each item rated on a six-point Likert scale ranging from “almost always” to “almost never.” MacKillop and Anderson (2007) reported Cronbach’s α indicated good internal reliability, α = 0.89.

The Empathy Quotient Short Form (EQ; Lawrence et al., 2004; Muncer and Ling, 2006) assesses three facets of empathy: cognitive empathy, emotional reactivity and social skills. The Lawrence et al. version of the scale was made with 28 items and then shortened to a 15-item version by Muncer and Ling. The scale is a self-report measure designed to capture empathy in adults, with each item rated on a four-point Likert scale ranging from “strongly in disagreement” to “strongly in agreement.” Cronbach’s α for the short form is α = 0.88 (Wakabayashi et al., 2006).

A qualitative analysis of student journals was completed using the Framework approach, as it is a systematic approach of analyzing qualitative data which aims to uncover practice-oriented findings (Green and Thorogood, 2004). This approach utilizes five stages: (a) familiarization; (b) identifying a thematic framework; (c) indexing; (d) charting; and (e) mapping and interpretation. For the familiarization stage, researchers read all transcribed interviews thoroughly. From the initial read through, each member of the qualitative analysis team (LBP, BCT, JBT, KDC, and RSA) independently developed a framework based on all journal entries for a particular individual in each of two different semesters to develop the initial thematic framework. The primary qualitative coders (LBP, BCT, and JBT) all met and discussed the categories uncovered until a final consensus was reached to create a final framework. The indexing stage allowed the thematic framework to be applied to all data. Tables were then created for each of the identified themes, including participant quotes, to allow a visual aid to better organize the data and to recognize and establish patterns.

Rigor, trustworthiness and an awareness of reflexivity, credibility, and believability (Creswell, 2014; Russell and Gregory, 2003) were increased by directly examining reflexivity, or what the coder brings to the coding of qualitative data, through the use of investigator triangulation (Archibald, 2016). This investigator triangulation peer review helps to keep investigators’ interpretations in check and support basic awareness of potential bias while facilitating solid evidence for the interpretation of the data (Valencia, 2022; Holt and Thorpe, 2007). Discrepancies were discussed until consensus was reached, with any areas of disagreement in the primary coding team were resolved by the two senior qualitative experts (KDC, RSA).

For the quantitative, pre-post analyses, participants were recruited from only four semesters. Descriptive characteristics of the sample are presented in Table 1 and data for all surveys at the beginning and end of semesters for each class are presented in Table 2. A one-way ANOVA revealed the mean age of students varied depending on the course in which they were enrolled, F(2,365) = 218.78, p < 0.001, with Introduction to Psychology students being significantly younger than BATL students who also were slightly younger than Psychology of Aging students (see Table 1). Student self-reported gender differed across the three courses, with a higher percentage of women in the BATL course. Experience interacting with older adults with dementia also significantly differed, indicating a self-selection bias for students enrolled in Psychology of Aging and especially BATL, wherein students in these courses reported greater prior interactions with people with dementia, Χ²(2) = 20.77, p < 0.001. Self-reported prior volunteerism in nursing homes or in intergenerational service-learning experiences did not differ significantly.

The qualitative coding team (LBP, BCT, JBT, KDC, and RSA) discovered four themes and six subthemes in the student journals: (1) attitudes with subthemes of (a) toward older adults; (b) toward people with dementia; (2) relationship building creates existential awareness and self-development with subthemes of (a) relationship building process; (b) existential awareness and self-development; (3) art fosters social interaction and mindfulness with subthemes of (a) interaction with art; (b) meaningful social interaction, and (4) perceived program effectiveness. Notably, the themes that emerged in this sequential mixed methods design reflect and elucidate the quantitative findings from survey data (Creswell, 2014). See Table 3 for definitions of themes and exemplar quotes.

For this theme, the team kept a count of journal entries related to program efficacy from the beginning to the end of each semester concluding their work with the people with dementia in BATL. For feelings students expressed, it was found that (1) 28 students described gaining a new perspective toward working with older adults and being forever impacted; (2) 13 students described feelings of greater empathy, gratitude, and respect; and (3) six students described feeling humbled and honored by the opportunity. Simply, the students enrolled in BATL perceived the experience to be effective and life changing, both for them and for the people with dementia (see Tables 2, 3).

In summary, the themes discovered in the student journals indicate that existential awareness fosters mindfulness and empathy that subsequently leads a change from ageist attitudes toward celebrating the personhood of the people with dementia (see Table 3). The findings also show that social engagement facilitated by engagement with art was a strong predictor of intergenerational relationship building. These results suggest experiential learning opportunities are a critical component to student education to create both enthusiasm and respect for working with people with dementia, potentially influencing future career paths.

As with any research, the present study has limitations. Of note, the selection bias inherent in the quantitative comparison of students in BATL to those in Psychology of Aging and Introductory Psychology is endemic to this research and findings should be interpreted with this limitation in mind. Second, interpretation of the current results must consider the lack of diversity in region. BATL is currently only offered in two states: Alabama and Illinois. An increase in the demographic reach of BATL may spread its impact on pre-healthcare students’ empathy and attitudes across the nation. To decrease the likelihood of social desirability bias faced by quantitative survey research, future analysis of additional geographically dispersed student journals based in experiential learning courses in other regions would be helpful.

Despite these limitations, findings from this study have the potential to incentivize experiential learning course offerings throughout the nation that may facilitate choice of future career paths in health professions involving older adults, and particularly people with dementia. Moreover, an increased dementia care workforce would create positive changes in adult day service centers and other long-term care settings in which people with dementia may receive services. Students in such experiential learning courses may become pioneers for shifting dementia care toward an inclusive, person-centered lens, carrying with them for a lifetime the principles of personhood and anti-stigma learned in their work with people with dementia during class. These outcomes were facilitated by the use of expressive arts-based therapies to enhance the quality and speed of relationship building by providing concrete behavioral scaffolds for meaningful social interaction. It is because of the interaction between art, life story, and intergenerational relationship building that the outcomes noted in quantitative surveys and student journals support our conclusion that experiential learning courses incorporating art therapy should be standard training for practice careers in the health and health-related sciences.

In terms of future research, a study that utilizes experiential learning course content like BATL but with a focus on caregivers of people with dementia could be beneficial. This would allow researchers to understand the impact the course has on not only the relationship between student and people with dementia but also caregiver and people with dementia, as they are often handling the heavy load of care. The impact BATL has on empathy, mindfulness, and interest in service beyond that of college students could be explored by conducting research in this area. In addition, further research should be conducted in a manner that focuses on the impact BATL has on the emotional, physical, and verbal skills of people with dementia (Reel et al., 2022). Reel and colleagues found the social interactions between BATL students and people with dementia were more powerful indicators of program success than specific interactions with art per se, but art was still an integral tool to enhancing interactions between BATL students and people with dementia. It would be beneficial to explore the impact BATL has on other individuals involved in maintaining the well-being of people with dementia.

The potential for experiential, intergenerational programs that foster relationship building through expressive arts-based therapies have the potential to reach a scope far beyond the population of this study. BATL is a program that can be implemented in various settings including, but not limited to, healthcare settings, church settings, and high school settings. When considering this, there is ample opportunity to utilize a program such as BATL to create an understanding society that not only acknowledges but embraces the personhood of people with dementia. These intergenerational programs can steadily decrease ageism and discrimination against dementia by teaching impactful person-centered care skills. Implementation of such programs have the potential to enhance social justice and support person-centered culture change in dementia care.