The rich holdings of the National Art Library (NAL) at the V&A have long been a source of inspiration and enjoyment for artists, researchers and enthusiasts. As well as welcoming individual readers, NAL librarians and curators regularly host group visits and contribute to the museum's vibrant Learning Programme onsite and online. In 2019, the Learning Department invited Library staff to be involved in a new outreach project: Cognitive Stimulation Therapy.
What is Cognitive Stimulation Therapy (CST)?
Cognitive Stimulation Therapy (CST) is a brief, evidence-based treatment designed for people living with mild to moderate dementia. It was first developed at University College London (UCL) in the late 1990s by Professor Martin Orrell (now Director of the Institute of Mental Health, University of Nottingham) and Dr Aimee Spector (now Professor of Clinical Psychology of Ageing, UCL). As its name suggests, CST takes the form of activities that aim to improve cognitive skills and quality of life. It can be delivered to individuals or in a group, with the latter providing an opportunity for social interaction.
The key principles of CST and instructions on how to deliver it were first published by Orrell, Spector and their collaborators in Making a difference: an evidence-based group programme to offer Cognitive Stimulation Therapy (CST) to people with dementia (London: Hawker Publications, 2006). Since then, new editions of the manual have provided further guidance for group leaders and carers, and UCL is now home to the International Cognitive Stimulation Therapy (CST) Centre. CST programmes are currently being delivered in at least 35 countries across the globe and the manual has been translated into Chinese, Danish, Dutch, German, Italian, Japanese, Portuguese, Spanish, Norwegian and Swahili.
One reason for the increasing demand for CST is that dementia is a growing health issue. According to National Health Service (NHS) statistics, there are currently 944,000 people in the UK living with dementia and the NHS estimates that by 2030 this figure will rise to over one million.Footnote 1
While drug trials for dementia treatments are ongoing, there is also demand for non-pharmacological therapies. CST is seen as one of the most promising options having been clinically proven to improve the cognitive function of those living with mild to moderate dementia, in some cases over and above the effects of medication.Footnote 2 Participants of CST programmes frequently report improvements in their quality of life and wellbeing post-treatment and its proven cost effectiveness makes it applicable on a wide scale. For those reasons, the UK Government's National Institute for Health and Care Excellence (NICE) recommends that
People with mild/moderate dementia of all types should participate in group Cognitive Stimulation which should be commissioned and provided by a range of health and social care workers with training and supervision. This should be delivered irrespective of any anti-dementia drug received by the person with dementia.Footnote 3
As outlined in the Making a difference manual, the key principles of CST are that it should provide mental stimulation, encourage new ideas, focus on opinions rather than facts and be fun. The typical format for a group CST programme is 14 structured 45-minute sessions usually delivered twice per week over seven weeks. Each of the 14 sessions has a theme and these themes have been specifically chosen to challenge cognitive skills. They include physical games, childhood, food, current affairs, categorizing objects, orientation and using money.
The museum as a new setting for CST
The main purpose of CST at the V&A was to explore the effects of delivering this therapy in the non-clinical setting of the museum. By using the museum's collections to represent the 14 CST themes, it was hoped that participants might also gain from the known health benefits of engagement with the arts. Making the programme a success required the unique expertise of two external organizations: Resonate Arts and the Kensington, Chelsea and Westminster (KCW) Memory Service.
Resonate Arts are a community-based charity who serve the boroughs of Kensington, Chelsea and Westminster. They have extensive skills and experience in running projects for people living with dementia, their carers and their families. Resonate Arts’ goal is to eradicate the stigma that surrounds dementia and the social isolation that can affect those living with it. Their post-diagnostic opportunities for social connection and improved wellbeing include ‘Creative Spaces’ for visual art and movement, the ‘Music for Thought’ project where participants work with musicians from the Royal Academy of Music to compose their own pieces, and the ‘Singing with Friends’ choir run in partnership with Wigmore Hall. Resonate Arts provide facilitators for all V&A CST sessions. These facilitators are responsible for engaging and supporting participants to build their trust and confidence.
Clinical expertise and NHS referrals for the Programme are provided by KCW Memory Service. In addition to running a peer support initiative, they offer therapeutic and rehabilitative support through their charity and their contacts with other dementia organizations.
Funding for the V&A Programme is generously provided by the Gilbert Trust for the Arts who for several years have supported international research efforts to investigate the causes, prevention, diagnosis and treatments of dementia. The Gilbert Trust has a long-standing relationship with the V&A through Rosalinde and Arthur Gilbert's outstanding collection of European masterpieces of gold and silver, painted enamels and mosaics. The V&A has been the home of this collection since 2008 with many objects on display in the Museum's Gilbert Galleries.
Since embarking on the project in 2019, and despite disruption caused by COVID, the V&A CST Programme continues to develop with the invaluable support of these collaborators. It is now being delivered annually to around 10 to 20 participants each Spring and at the time of writing, colleagues are preparing for the fifth iteration of the project while continuing to gather feedback, clinical data and evaluations.
Image 1. V&A CST Session on Being Creative: viewing National Art Library collection items. Photograph courtesy of Resonate Arts.
The National Art Library's contribution
Each year of the Programme, Curators and Librarians from across the Museum are invited to adopt one of the 14 CST session themes and to select relevant objects from their collections to present to the group. Collection objects are chosen to challenge participants’ cognitive skills through close-looking, discussion and/or handling. Resonate Arts deliver training to curators and librarians before the sessions, giving advice on delivery and suggestions for objects that would work well. In the past, Resonate Arts’ guidance has been enriched by additional training from Dementia Friends.
Artist Zoe Gilmour is responsible for leading all V&A CST sessions. She previously worked with Resonate Arts as part of a six-week project at St Vincent's House Care Home where she drew inspiration from the V&A's Gilbert collection to help residents create their own personalised artworks.Footnote 4 In each V&A CST session, Zoe begins with a welcome, a physical warm-up, and a discussion about a current news story. The curatorial element which follows lasts about half an hour or so. Zoe then introduces a related creative activity, followed by a cool-down and gentle farewells. At about two hours in total, the V&A's CST sessions are much longer than the typical 45-minute sessions suggested in the Making a difference manual. This allows for more in-depth focus on the discussions and activities and, from feedback received, appears to be appreciated by the groups.
Curators and librarians attend the full session and participate in all group discussions and activities. Full involvement allows us to get a sense of where to pitch our contribution since we do not meet the participants before the sessions. It also helps to build an informal atmosphere since group CST is supposed to feel like a forum where opinions and experiences are shared, rather than a lecture to be listened to.
The backgrounds, personalities, interests and abilities within the group are always incredibly diverse. Some people will be visiting the V&A for the first time while others may be regulars; some are very keen on creative activities while others prefer to chat instead; and some will ask questions confidently whereas others require more encouragement. Physical support needs can also vary hugely, so facilitator numbers for CST are much higher than for a typical group. In one session for ten participants there may be as many as two curators, two staff from Resonate Arts and two from the Memory Service. This high facilitator to participant ratio means we can direct the relevant support and encouragement to where it is most needed.
Being Creative
Curators and librarians from the National Art Library have been involved in the project since its inception. Traditionally, NAL staff have helped facilitate two of the 14 themed sessions: one on Being Creative and another on Word Games.
For the Being Creative session, we lay out about a dozen collection objects on a table and gently introduce them to the group. We don't cover them all in detail; instead, we react to what the participants show an interest in. The key is getting the group to look closely, handling objects where possible and generating discussion.
Image 2. Artist's book, ‘You are here’ by Julie Chen, Flying Fish Press, Berkeley, California, 1992. Museum no. 38041993108018 © Victoria and Albert Museum, London.
One work we have shown in the past was You are here, a moveable artist's book from 1992 by Julie Chen of the Flying Fish Press in California. The book comes in a carry case with a cord attached, suggesting that it is to be worn around one's neck while on a journey. The little volume inside the case has pages that unfold to reveal a map of an imaginary landscape.
Being visually intriguing, tactile and performative might make this an ideal object for a CST session. Facilitators can ask opinion-based questions about it such as ‘Does it remind you of anything?’, ‘Do you like it?’ or ‘Do you think it belongs in a library?’ However, there are other factors to consider when selecting an object for CST. A small-scale, detailed item such as this may not be engaging if there are group members with visual impairments. In addition, its complexity and fragility require staff to do the handling, thereby depriving the group of the object's tactile qualities.
Another performative work, Endless Journey by illustrator Tom Gauld, is much simpler in format. It references eighteenth-century author Laurence Sterne's novel A sentimental journey through France and Italy of 1768 and takes the form of a myriorama consisting of 12 printed cards depicting different segments of a landscape. The cards can be arranged and re-arranged to create 479,001,600 possible views, with a continuous horizon line. Being so easy to handle, we were able to encourage members of the group to play with these cards, and it was pleasing to see them enjoy this direct engagement with the work.
Image 3. V&A CST Session on Being Creative: playing with Endless Journey, a myriorama by Tom Gauld (Coxwold: Laurence Sterne Trust, 2015). Photograph courtesy of Resonate Arts.
Another item shown in recent years was a set of Shell Guides. Published from 1934 and edited by John Betjeman, these guidebooks on the counties of Britain were aimed at the growing number of British motorists at the time. Their content is quirky and often humorous. For example, a volume on Dorset compiled by artist Paul Nash focuses on the area's primeval history and includes a photograph of a model dinosaur on the title page which Nash labels ‘former native’ of the county.
Shell Guides on Dorset, Cornwall and the West Coast of Scotland got one CST group reminiscing about childhood holidays. It is not harmful to talk about the past to people living with dementia but, for the purpose of CST, it can be limiting. This is because it can often involve recalling information that has been over-rehearsed and is no longer cognitively challenging. As the Making a difference manual indicates, CST should encourage new ideas, thoughts and associations rather than repeat previously learned information. So, when presenting these Shell Guides a facilitator might be tempted to ask, ‘What do you remember about your childhood holidays?’ but a more beneficial question would be, ‘Where would you advise a young family to go on holiday?’ The latter prompts new thoughts and opinions and might even provoke a healthy debate among the group.
After looking at collection objects, participants and facilitators create their own handmade books in a follow-up session led by Zoe. Colourful craft materials are laid out on tables but there is no pressure to make anything – some people prefer to write, draw or chat. At the end, everyone gets a chance to present what they made or reflect on what they enjoyed about the session.
Image 4. V&A CST Session on Being Creative: participants selecting materials to make their own books. Photograph courtesy of Resonate Arts.
Word Games
The second CST theme traditionally adopted by NAL staff is Word Games. In this session, we introduce some of the day-to-day equipment used in the Library. We demonstrate propping pages open with book snakes, tying fragile books with cotton tape to limit further damage, and we explain why we lay pest traps to protect our galleries and stores from hungry bugs. Tactile engagement can aid cognitive functioning, so we pass the equipment around, asking group members to comment on the texture and weight of the objects and what they think they might be used for.
As part of the Word Games theme, we draw particular attention to library equipment with surprising animal names: book snake weights, clamshell boxes for storing pamphlets, soft microfibre cleaning cloths known as ‘dust bunnies’ and sausage-shaped absorbent tubes for mopping up leaks and spills in an emergency which have the strangest name of all: ‘pig socks’. There is usually a lot of giggling as we ask the group what animals they think these items resemble before revealing the answers.
The follow-up activity for this session is a visit to the National Art Library Reading Rooms. We plan a comfortable route through the museum and guide the group there. Senior Librarian Vicky Worsfold then explains how visitors use the library and answers the group's questions about storage and the scope of the collection.
It can be a logistical challenge to guide the group from the Learning Department, through the busy galleries to the Library. However, we know that behind-the-scenes tours like this are memorable for any group, and we certainly saw the joy and appreciation of this visit reflected in our participants’ feedback.
Outcomes of the V&A CST Project
It will take several more years of data gathering and evaluations before bold conclusions can be drawn about the effectiveness of CST at the V&A. However, there are summations that can be made even at this early stage.
The KCW Memory Service carry out measures with participants before and after the programme to attempt to gauge any changes in their perceived wellbeing and their cognition. While this data set is still small, the improvements logged so far are in line with typical CST models. In addition, retention for the V&A sessions is higher than for standard programmes and this is attributed to the non-clinical setting of the museum being more comfortable and welcoming as well as the relationship building and check-in phone calls employed by Resonate Arts. The pleasant environment combined with the focus on the museum collections helps to shift attention away from the participants’ diagnoses and onto the enjoyment of learning new things.Footnote 5
More targeted forms of reflection and assessment have gradually been introduced over the years. In 2023, the group were joined by Beth Woolley, an MASc Creative Health student from UCL who observed the sessions and, with the support of Resonate Arts, made evaluations. These findings will inform her thesis and help shape future programmes.
Resonate Arts also gather extensive feedback from group members at the end of each programme. In this feedback, participants frequently say that they feel the benefit of getting out and meeting others. Even after the programme ends, most of them return to the V&A with their families or carers, seeing the museum as a free and ongoing source of support.Footnote 6 In the words of one,
The thing that blew my mind was how much we covered and how we were allowed to see behind the scenes of the V&A. It made me explore things, definitely working out my brain. Everything was so intriguing and stimulating, you go home and you are thinking about it a lot. Because of the nature of my memory problems, I was apprehensive, but everyone was supporting everyone. I didn't want it to end.Footnote 7
Carers and relatives who accompany their loved ones to the V&A but do not take part in the sessions can also feel the benefits. For them, the sessions offer a rare moment of respite or a chance to connect with others in similar situations.
There is plenty to be gained for facilitators, too. As a curator, the sessions challenged me to think about our collections in new ways that would provide meaningful interpretations for the group. While we must always consider our different audiences and their needs, there is a unique level of sensitivity and open-mindedness required of CST facilitators. I had to carefully consider which objects might generate group conversation and spark participants’ imagination without over-explanation from me. This approach has caused me to re-evaluate all the work I do with groups, and to be open to more conversational, informal formats.
More generally, the V&A's CST Programme revealed to me the enormous untapped potential for museums to connect with and empower people living with dementia. They were the most rewarding form of public engagement I have participated in in my time as a curator and I hope that by sharing my experience, many more will benefit from this remarkable initiative.
