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Florence Nightingale Journal of Nursing logoLink to Florence Nightingale Journal of Nursing
. 2021 Oct 1;29(3):271–284. doi: 10.5152/FNJN.2021.20224

The Effect of Group Art Therapy on Loneliness and Hopelessness Levels of Older Adults Living Alone: A Randomized Controlled Study

Merve Aydın 1,✉, Fatma Yasemin Kutlu 2
PMCID: PMC8939254  PMID: 35110167

Abstract

Aim

This study was aimed to test group art therapy using clay as a medium as a method to cope with feelings of loneliness and hopelessness in older adults.

Method

This study was a randomized controlled study. A total of 60 older adults who lived alone were enrolled in the study. Thirty subjects were randomly assigned to six 1.5-hour weekly sessions of group art therapy using clay, and interviewed face-to-face twice (intervention group (IG)), and 30 subjects were randomly assigned to be interviewed face-to-face twice (control group (CG)). The effects of interventions were measured using the UCLA Loneliness Scale (UCLA-LS) and the Beck Hopelessness Scale (BHS). Loneliness and hopelessness levels in the IG and CG were measured at the beginning (pre-test) and the end (post-test) of the study. This study was conducted using the CONSORT statement. The group art therapy trial is registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT04295083.

Results

A statistically significant difference was found between the pre-test and post-test scores of the IG and CG, with respect to the loneliness and hopelessness levels among older adults living alone.

Conclusion

Clay-based group art therapy can contribute toward decreasing the sense of loneliness and hopelessness in older adults. Nurses using group art therapy for older adults will realize the psychological healing aspects and effectiveness of this intervention and recognize it as an effective method for the psychological growth of older adults and the reduction in their levels of loneliness and hopelessness.

Keywords: Art therapy, hopelessness, loneliness, nurse, older adults

Introduction

The aging global population is one of the most significant social changes in today’s world (Gökbunar et al., 2016). It has been estimated that the population of those aged 65 and over will increase from 550 million to 973 million between 2000 and 2030, and the ratio of this age group to the total population will increase from 6.9% to 12.0% (World Health Organization, 2015). The increase in the elderly population will also lead to a serious increase in the number of older individuals living alone. In Turkey, the proportion of older adults living alone is 18.0% (76.4% female and 23.6% male) (Aile, Çalışma ve Sosyal Hizmetler Bakanlığı, 2019).

For older adults, who constitute the risk group in terms of mental health, living alone brings many problems such as despair, insecurity, fear, depression, anxiety about the future, and the longing for a close relationship (Bahar et al., 2009). Therefore, older individuals may experience negative emotions such as feelings of worthlessness, loneliness, and hopelessness.

One of the most common feelings among older adults today is loneliness (Gardiner et al., 2018; Kim et al., 2017 b; Tufan et al., 2019). It has been reported that 80% of the adults over the age of 65 experience loneliness, most commonly around the age of 70 (Akgül & Yeşilyaprak, 2018). According to a report published in the UK in 2017, nine million people felt often or always lonely. In 2018, the Ministry of Loneliness was established, to deal with loneliness in the UK. The projects planned by the Ministry of Loneliness aim to motivate people to socialize and communicate by bringing them together (Dossey, 2020). This UK project is supported by Canada, Australia, New Zealand, and Germany. In Turkey, the year 2019 was declared as the “Senior Year,” and accordingly, the Aging Council was held. The main theme of the council was stated as “promoting active aging and strengthening the rights of older adults.”

Loneliness occurs more intensely when emotional and social relationships are absent or limited (Dereli et al., 2010). According to Julsing et al. (2016), older adults experience severe loneliness, and loneliness is associated with living alone, being single, and having a low educational level. The feeling of loneliness may cause these individuals to think that their lives are aimless and useless, and experience a sense of emptiness and abandonment (Erol et al., 2016). It can even lead some older adults to commit suicide as their despair increases over time (Eskin, 2001). In a review study by Crewdson (2016), loneliness was found to affect the dimensions of physical, behavioral, and psychiatric health among older adults. Steptoe et al. (2013) argued that loneliness increased mortality, in their study with 6500 older individuals.

Another frequently experienced feeling among older adults is hopelessness (Tercanlı & Demir, 2012). According to the definition by the American Psychological Association, hopelessness is a subjective emotional state in which people have no freedom of choice, or their options are limited and, thus, they cannot activate their power (Yıldız & Yıldız, 2016). With hopelessness, the meaning attributed to life begins to disappear, with regret about their past life (Demirel et al., 2015). Individuals feeling hopeless lose the ability to cope with problems and may experience depressive symptoms as they perceive their problems as insoluble (Beck, 1961).

The literature suggests three basic approaches to dealing with loneliness (McWhirter et al., 1996; Rook, 1984; Schoenmakers et al., 2012), as social support groups, social skills training, and cognitive-behavioral approach (Hamamcı & Duy, 2005). Kim et al. (2017b) pointed out that physical activity during leisure time reduces loneliness and promotes the quality of life and psychological well-being. Garcia and Gomez (2003) conducted a study by assigning 122 older adults to aerobics, handicrafts, computer, and painting groups, and found that these activities reduced the levels of depression and loneliness in this population and increased their life satisfaction.

Art therapy, which is a supportive method suitable for a biopsychosocial approach, is recommended to cope with feelings of loneliness and hopelessness (Mann et al., 2017). Art therapy, included in the Nursing Intervention Classification (Bulechek et al., 2017), is a supportive method that helps individuals express themselves, gain coping skills, increase resilience, improve interpersonal skills, solve conflicts and problems, reduce stress, manage their behavior, increase self-esteem and self-confidence, and gain insight by using art as a tool (Çam & Altınköprü, 2013; Rubin, 2010). The types of art therapy include drama, music, dance, painting, writing, narrative, photography, and clay therapy (Çam & Altınköprü, 2013).

Art therapy can be either be applied individually or integrated into group work and applied in the form of group artworks. Those participating in group work can also benefit from the mirroring and supporting functions of the group (Çıtakbaş & Üçok, 2019). As the process progresses, they can feel like an important part of a valuable, useful, and meaningful whole (Yalom, 2018).

Some studies have highlighted the effect of art-related activities on the health of older adults (DiNapoli et al., 2016; Elkis-Abuhoff et al., 2008; Kim et al., 2017 a; Ueda et al., 2013). According to the literature, utilizing art in the form of individual or group work for older individuals improves their physical and psychosocial health status ( Kim et al., 2017 a), reduces functional impairment (Masika et al., 2021), increases life satisfaction and quality ( DiNapoli et al., 2016), and improves self-confidence (Ching-Teng et al., 2019).

Owing to its composition, clay is a substance that can be manipulated and deformed many times. A person working with clay can make objects without fear of damaging them, due to the material’s plastic and durable structure. It is an appropriate art form for older individuals in neurocognitive decline, because it has the advantage of being easily manipulated ( Kim et al., 2017 a).

Studies on this art form have found that clay manipulation helps to transform the emotions into physical shapes through the tactile interventions it involves, revealing emotions within given patterns, and relaxing the individual (Rahmani et al., 2010). Clay can provide concretization and catharsis (Eren, 2019) because of its three-dimensional characteristics (Foster, 1997), along with the added benefit of using physical energy in the creative process. It has been reported that art therapy using clay facilitates the expression and discharge of emotions, reveals subliminal content, improves verbal communication, reveals strong emotions (Sholt & Gavron, 2006), produces healing results through concretization processes and symbolic mechanisms, increases the harmony of treatment (Kar & Toros, 2015), and reduces hopelessness (Akhan et al., 2017). In addition, evidence shows that clay therapy helps to reduce stress (Kimport & Robins, 2012) and anxiety (Kimport & Hartzell, 2015; Morais et al., 2014), enhances personal power, helps release suppressed emotions such as feelings of abandonment or depression, and contributes to physical and mental well-being while guiding reality (Ciasca et al., 2018; Jang & Choi, 2012; Kimport & Robins, 2012). However, to our knowledge, no studies have investigated the effects of clay work as a method to develop socials skills and reduce loneliness and hopelessness in older adults.

This study was carried out to determine the effect of clay-based group art therapy on the loneliness and hopelessness levels of older adults living alone.

Research Hypotheses

  • H1: The loneliness level of older adults living alone who participate in clay-based group art therapy will be lower than that of older adults who do not.

  • H2: The hopelessness level of older adults living alone who participate in clay-based group art therapy will be lower than that of older adults who do not.

Method

Study Design

This study was a randomized controlled study.

Sample

The study population consisted of individuals over 65 years of age living alone in the Trabzon-Ortahisar district, between May 2018 and November 2018 (n = 4.334). Power analysis was performed to determine the sample of the research. The power of the test was calculated using the G*Power 3.1 program. No studies have reported the effect of clay and similar interventions on loneliness and hopelessness in older adults living alone. Therefore, the effect size in power calculation was taken as .50, of medium size. It was found that in determining the strength of the study to exceed 95%, a total of at least 42 individuals should be reached in the two groups with 21 participants in each group at a 5% significance level and .50 effect size (df = 1; F = 4.085). The data were obtained from 60 older adults over 65 years old living alone in Turkey and who met the inclusion criteria (n = 60). Of these, 76.4% and 23.6% were women and men, respectively (Engelli ve Yaşlı İstatistik Bülteni, 2019). Accordingly, it was decided that the sample size would represent the population when it was determined to be 60; 47 participants were women (78.0%) and 13 men (22.0%). The inclusion criteria of the study were being 65 years old and above, obtaining a score of 19 or above in the Mini-Mental Status Examination scale, obtaining less than 30 points in the Beck Depression Scale, obtaining 32 points and more in the UCLA Loneliness Scale (UCLA-LS), obtaining four points or more in the Beck Hopelessness Scale (BHS), not having a perception disorder that could prevent communication, not having a neurological or physical condition (e.g., paralysis, or rheumatoid arthritis, among others) that could affect the hands, not having a mental disorder diagnosis, and volunteering to participate in the study.

A total of 60 older adults who met the inclusion criteria were grouped by the researcher using stratified randomization according to age, gender, and duration of living alone. Then, participants were assigned to the intervention group (IG) and control group (CG) using a block randomization method. It was not possible to blind participants and researchers because of the nature of the interventions.

Data Collection

Research data were collected at the “Senior Assistance Center” in Trabzon, Turkey, between May 2018 and November 2018. The Senior Assistance Center was established in 2018 by the Trabzon Metropolitan Municipality under the coordination of the Governorship of Trabzon, within the scope of the Senior Assistance Program of the Ministry of Family and Social Policies, to provide social support for people over 65 years of age. The Senior Assistance Center, having two personnel working between 8 a.m. and 5 p.m. on weekdays, is conveniently located, welllit, and easily accessible by the public transportation network.

Data Collection Tools

The data of the study were collected with face-to-face interviews by the researcher, using a questionnaire developed by the researchers, the UCLA-LS, and the BHS.

Questionnaire Form

This form consists of 15 questions prepared by the researchers, in line with the literature, to determine the individual and lifestyle characteristics of older adults (Gardiner et al., 2018; Kim et al., 2017 b) such as age, parental status, the number of children, gender, education level, the place where they have lived the longest, occupation, employment status, perception of social-economic level, status of having a chronic disease, and regular use of medication, duration of living alone, frequency of spending time with family members, frequency of spending time with neighbors, and leisure activities.

The UCLA-Loneliness Scale (UCLA-LS)

The UCLA-LS, developed by Russell et al. (1978), is a 20-point total self-assessment scale used to determine the degree of loneliness of an individual. Russell (1996) revised the psychometric properties of the scale and presented its final version, including nine positive and 11 negative items. The scale has a 4-point Likert-type rating. Positive statements (1, 4, 5, 6, 10, 15, 16, 19, and 20) are scored inverted, contrary to negative statements. The highest and lowest scores to be obtained are 80 and 20, respectively. Higher scores indicate that individuals are experiencing a greater degree of loneliness. Scores between 20–31, 32–41, 42–53, 54–67, and 68–80 indicate “Not feeling lonely at all,” “Mildly feeling a little lonely,” “Feeling a little lonely,” “Feeling lonely,” and “Feeling completely lonely,” respectively. The Turkish validity and reliability study of the scale was conducted by Demir (1989), who determined Cronbach’s alpha internal consistency coefficient to be .96. In this study, Cronbach’s alpha reliability coefficient was .86.

The Beck Hopelessness Scale (BHS)

Developed by Beck et al. (1974), the BHS is a self-assessment scale comprised of 20 items. The scale is scored between zero and one (0–1) point. In items 2, 4, 7, 9, 11, 12, 14, 16, 17, 18, and 20 of the scale, the “Yes” option gets one point, and in items 1, 3, 5, 6, 8, 10, 13, 15, and 19, the “No” option gets one point. The total score obtained from the scale forms the individual’s “hopelessness score.” When the score is high, the level of the hopelessness in the individual is assumed to be high (Özmen et al., 2008). Scores between 0–3, 4–8, 9–14, and 15–20 indicate “Not being hopeless,” “Low hopelessness,” “Moderate hopelessness,” and “High hopelessness,” respectively. Nine points or more can be an indicator of suicide risk. The Turkish adaptation of the scale was accomplished by Seber et al. (1993), and then Durak and Palabıyıkoğlu (1994) obtained detailed information about the validity, reliability, and factor structure of the scale by revising it. Durak and Palabıyıkoğlu (1994) conducted a study with two groups (normal group and psychiatric patients), and Cronbach’s alpha reliability coefficient was determined to be .85. In the current study, Cronbach’s alpha reliability coefficient was .82.

Procedure

A randomized controlled study was conducted using the CONSORT statement (see the schematic flow chart for details, Figure 1). The clay-based group art therapy trial is registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT04295083.

The UCLA-LS and BHS were applied to older adults in the IG and CG by the researcher, using a face-to-face interview method before the clay-based group art therapy (pre-test), and one week after the clay-based group art therapy sessions (post-test).

The IG was divided into three subgroups of 10 participants (group 1: 5 men, 5 women; group 2: 2 men, 8 women; group 3: 10 women), and weekly clay-based group art therapy sessions of 60–90 minutes were carried out for six weeks. The application was completed after 6 weeks, with one session every week. Before the clay-based group art therapy started, the individuals were offered tea, coffee, and snacks, and the sessions started by asking how they spent the last week. Each session was structured as opening, interaction, clay study, verbal expression, and closing, respectively. The clay study was carried out in the clay workshop prepared for this study at the Senior Assistance Center. The necessary materials for the session were provided before the session. The sessions were held using the “Clay Work Activity Booklet for Older Adults,” including structured and semi-structured activities prepared by the researcher, in line with the literature, to help individuals aged 65 and over who experience loneliness and hopelessness gain new solutions and life skills to reduce their levels of loneliness and hopelessness and share their feelings, thoughts, and memories with other individuals (Altundağ et al., 2017; Eratay et al., 2017; Maral, 2018; Morais et al., 2014; Rahmani & Moheb, 2010; Sherwood, 2004). Four experts were consulted to develop the booklet. In the activity program, methods such as narration, sharing experiences, group practice, question–answer, learning by doing, and imagining were used.

The physical, psychological, social, and mental characteristics of older adults were considered when selecting these methods. The duration of the activity program was determined by taking into account that art therapy using clay intervention programs had been carried out for 5–8 weeks, as described in the literature ( Kim et al., 2017 a; Morais et al., 2014).

The group leader received regular supervision from an experienced ceramic (clay) artist. The content and objectives of each session in the clay-based group art therapy program were as follows;

Session 1

The first session started with the activity called “Introduce yourself, familiarize with clay” to enable group members to get to know each other and meet, using clay. Group members were first asked to identify themselves by setting a nickname. The dry, plastic, and baked stages of clay were then shown, and the stages of transformation into ceramic were explained. Later, clay was given to each participant and they were asked to make objects suitable for their nicknames.

Session 2

This session was conducted with the title “I know my feelings” for the participants to recognize and express their emotions and realize the effects of their emotions on their behavior. They were informed about positive and negative emotions and asked to give examples of their feelings. Participants were enabled to transform the emotions they experienced the most into objects through clay. At the end of the activity, the volunteer participants were encouraged to think about this issue by asking questions such as “How did you act because of this feeling? What did you do? What would you do now? What do you think would be better to do? Did you tell the other person about your feeling? How can you express your feeling to the other person?

Session 3

The third session was conducted under the name of “My Emotion Flowers” for the participants to recognize and express their feelings. Participants were asked how they felt that day. Their emotions were matched with colors based on their responses (For example, blue for sadness, red for anger, yellow for happiness, etc.). Different colored clays were given to the participants. The participants were asked to choose a color suitable for their mood of that day and make flowers. When they were completed, the objects were removed for drying.

Session 4

This session was conducted under the title of “My Past Life and My Feelings.” The participant was asked to remember his feelings about his “past” life. Later, the whole group was asked to make an object out of clay about the emotion that most affected them in the past. The session ended after the elders were asked if they had anything to ask about the activity.

Session 5

The fifth session was conducted under the title of “My Life and Feelings Today” to increase the emotional awareness of the individual and to enable them to express their feelings of “today.” Participants were helped to realize their feelings about “home, work, me and my loved ones,” the most important areas of life. For this purpose, they were asked to close their eyes during the application and think about their home, their work-life, themselves, and finally their loved ones, and the emotions that all of these aroused in them. After making sure that everyone completed the activity, they were asked to reflect on the emotion regarding each area of life and project it into an object using clay.

Session 6

This session was conducted under the title of “My Future Life and Feelings” to enable the participants to express their feelings about their “future” life. Participants were asked to express their goals and hopes for the future with the help of clay. In addition, a “love bombing” activity was performed to end the group process and receive feedback. Finally, the participants shared their feelings for the group work and the study was concluded.

The CG was also divided into three subgroups of 10 participants (group 1: 3 men, 7 women; group 2: 3 men, 7 women; group 3: 10 women). During the 6 weeks, two 30-minute face-to-face interviews were conducted with the older adults in the CG. In the face-to-face interviews with the CG, health, social life, and financial issues were discussed with older adults. After the research findings were reported to the CG members, the group art therapy using clay was performed.

Statistical Analysis

All analyses were conducted using Statistical Package for the Social Sciences statistical software, Version 23 (IBM SPSS Corp., Armonk, NY, USA). Cronbach’s alpha was used to assess the internal consistency of the scales. For the analysis of individual characteristics, descriptive statistics (percentile, arithmetic mean, standard deviation, min–max), nominal values in the intergroup comparison, and chi-square test were used. In addition, independent t-tests and paired series t-tests were used to compare the measurement values and scale scores, and ANOVA analysis was used to determine the effectiveness of the intervention. In the study, all findings were tested at a significance level of p = .05.

Ethical Considerations

Ethics committee approval was received for this study from the ethics committee of Karadeniz Techinical University (Date: April 16, 2018 No: 2018/51). Participants were informed of the study objectives, duration, content, group processes, and other ethical considerations before signing the consent forms for joining this study. Written consent included the agreement that allowed the researchers to use the demographic data of participants, scores obtained from the outcome measures, and digital copies of the artworks created by participants during the treatment process, for research purposes.

Results

The individual characteristics of the IG and CG are shown in Table 1 and , both groups were found to be similar (p > .05, Table 1). The lifestyle characteristics of the IG and CG are shown in Table 3 and were also found to be similar (p > .05, Table 2).

Table 1.

Individual Characteristics of Older Adults (N = 60)

Characteristics Total (n=60) IG (n = 30) CG (n = 30) Test and p
X ± SD Min–Max X ± SD Min–Max X ± SD Min–Max
Age 72.56 ± 1.01 65–95 72.60 ± 8.10 65–95 72.53 ± 7.75 65–95 .033*>.05
Number of children 3.23 ± .15 1–6 3.39 ± 1.10 2–6 3.07 ± 1.20 1–5 1.025*>.05
n % n % n %
Gender
 Female 47 78.3 23 76.7 24 80.0 .001**>.05
 Male 13 21.7 7 23.3 6 20.0
Education level
 Illiterate 13 21.7 5 16.7 8 26.7 .910**>.05
 Literate 17 28.3 9 30.0 8 26.7
 Elementary school 21 35.0 11 36.7 10 33.3
 High school 9 15.0 5 16.7 4 13.3
The place where you have lived the longest
 Village 15 25.0 9 30.0 6 20 .910**>.05
 District 16 26.7 8 26.7 8 26.7
 City 29 48.3 13 43.3 16 53.3
Occupation
 Housewife 43 71.7 21 70.0 22 73.3 .134**>.05
 Civil servant 9 15.0 5 16.7 4 13.3
 Worker 4 6.7 2 6.7 2 6.7
 Self-employed 4 6.7 2 6.7 2 6.7
Employment status
 Retired 14 23.3 8 26.7 6 20.0 .642**>.05
 Still employed 3 5.0 1 3.3 2 6.7
 No job experience 43 71.7 21 70.0 22 73.3
Having children
 Yes 55 91.7 28 93.3 27 90.0 .218**p>.05
 No 5 8.3 2 6.7 3 10.0
Perception of social-economic level
 Low 18 30.0 8 26.7 10 33.3 1.748**>.05
 Moderate 27 45.0 16 53.3 11 36.7
 High 15 25.0 6 20 9 30
Having a chronic disease
 Yes 42 70.0 19 63.3 23 76.7 .714**>.05
 No 18 30.0 11 36.7 7 23.3
Use of regular medication
 Yes 42 70.0 19 63.3 23 76.7 .714**>.05
 No 18 30.0 11 36.7 7 23.3
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Note: *Independent Samples t-tests; **Chi-Square test statistics

Table 3.

Comparison of Sociodemographic Characteristics of Older Adults with the UCLA-LS and BHS Pre-test Scores (N = 60)

Characteristics UCLA-LS BHS
X ± SD Min–Max Test p X±SD Min–Max Test p
Gender
 Female 55.29 ± 11.21 33–75 .58* >.05 11.46 ± 2.59 5–16 1.58* >.05
 Male 53.30 ± 9.17 34–67 10.15 ± 2.85 6–14
Education level
 Illiterate 51.92 ± 12.01 33–73 1.64** >.05 10.46 ± 3.07 5–16 1.005** >.05
 Literate 59.47 ± 8.84 43–75 12.00 ± 2.06 8–16
 Elementary school 52.90 ± 11.44 33–70 11.23 ± 2.71 6–16
 High school 55.00 ± 9.20 45–72 10.55 ± 3.04 6–16
Place of residence
 Village 56.33 ± 8.68 43–70 .19** >.05 12.13 ± 2.13 8–16 2.34** >.05
 District 54.68 ± 11.06 33–75 11.62 ± 2.65 6–16
 City 54.20 ± 11.80 33–73 10.44±2.82 5–16
Occupation
 Housewife 55.37 ± 11.17 33–75 .16** >.05 11.60±2.55 5–16 1.47** >.05
 Civil servant 52.88 ± 11.81 34–72 9.88±2.71 6–14
 Worker 53.25 ± 8.30 43–60 11.00±3.46 6–14
 Self-employed 55.50 ± 8.42 43–61 9.75±2.87 8–14
Employment status
 Retired 53.07 ± 10.66 34–71 .25** >.05 10.64 ± 2.73 6–14 3.69** <.05
 Still employed 56.00 ± 5.29 50–60 7.66 ± 1.52 6–9
 No job experience 55.37 ± 11.17 33–75 11.60 ± 2.55 5–16
Having children
 Yes 55.94 ± 10.33 33–75 2.70* <.05 11.23 ± 2.58 5–16 .50* >.05
 No 43.00 ± 8.77 34–56 10.60 ± 3.97 6–16
Perception of Socio-economic level
 Low 55.72 ± 9.88 33–73 2.98** >.05 11.38 ± 2.00 8–16 .11** >.05
 Moderate 54.14 ± 11.76 33–75 11.81 ± 2.64 6–16
 High 55.13 ± 10.52 36–72 9.80 ± 3.09 5–16
Having a chronic disease
 Yes 53.80 ± 11.03 33–75 1.16* >.05 11.35 ± 2.79 5–16 .76* >.05
 No 57.33 ± 9.95 33–73 10.77 ± 2.43 6–14
Use of regular medication
 Yes 53.80 ± 11.03 33–75 1.16* >.05 11.35 ± 2.79 5–16 .76* >.05
 No 57.33 ± 9.95 33–73 10.77 ± 2.43 6–14
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Note: *Independent samples t-test; **Variance analysis.

Table 2.

Lifestyle Characteristics of Older Adults (N = 60)

Characteristics Total (n = 60) IG (n = 30) CG (n = 30) Test and
p
X ± SD Min–Max X ± SD Min–Max X ± SD Min–Max
Duration of living alone (months) 94.80 ± 108.06 5–420 84.1 ± 102.5 5–420 105.5 ± 114.0 5–420 .764* >.05
n % n % n %
Frequency of spending time with family members
 Everyday 12 20.0 6 20.0 6 20.0 .083**>.05
 Once or several times a week 25 41.7 12 40.0 13 43.3
 Once or several times a month 23 38.3 12 40.0 11 36.7
Frequency of spending time with neighbors
 Everyday 17 28.3 11 36.7 6 20.0 3.511**>.05
 Once or several times a week 25 41.7 13 43.3 12 40.0
 Once or several times a month 18 30.0 6 20.0 12 40.0
Leisure activities
 Relaxing 11 18.3 7 23.3 4 13.3 ---
 Gardening 19 31.7 9 30.0 10 33.3
 Doing knitting/handicraft 9 15.0 4 13.3 5 16.7
 Watching TV 11 18.3 5 16.7 6 20.0
 Solving puzzles 1 1.7 1 3.3 0 0
 Performing religious practices 9 15.0 4 13.3 5 16.7
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Note: *Independent samples t-tests; **Chi-square test statistics.

When the individual characteristics of participants (n = 60) and the mean scores of the UCLA-LS and BHS pre-test were compared, a significant difference was found between the parental status (t = 2.70, p < .05) and the mean scores of the UCLA-LS pre-test. A significant difference was also found between working status (t = 3.69, p < .05) and the BHS pre-test mean scores (Table 3).

The comparison of the pre-test and post-test total scores of the UCLA-LS and BHS in the IG and CGs are shown in Table 4. While there was no significant difference between the IG and CG (t = .765, p > .05 and t = .239, p > .05, respectively) before the group art therapy using clay, a significant difference was found between the groups after the group art therapy using clay, in favor of the IG (t = −3.579, p < .05; t = −7.919, p < .05).

Table 4.

Intragroup and Intergroup Comparison of Older Adults’ UCLA-LS and BHS Pre-test–Post-test Mean Scores (N = 60)

IG (n = 30) CG (n = 30) Test Statistics p
The UCLA-LS
 Pre-test 55.93 ± 10.84 53.80 ± 10.77 .765** .448
 Post-test 41.03 ± 10.33 50.87 ± 10.94 −3.579** <.001
 Test statistics 23.468* 5.889*
 p <.001 <.001
The BHS
 Pre-test 11.27 ± 2.77 11.10 ± 2.64 .239** .812
 Post-test 5.10 ± 2.32 10.03 ± 2.50 −7.919** <.001
 Test statistics 30.245* 7.899*
 p <.001 <.001
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Note: *Paired samples t-test; **Independent samples t-test.

There was a significant difference between the UCLA-LS pre-test and post-test in the IG (t = 23.468, p < .05). Similarly, there was a significant difference between the UCLA-LS pre-test and post-test in the CG (t = 5.889, p < .05). In the IG, a significant difference was also found between the BHS pre-test and post-test (t = 30.245, p < .05). Similarly, a significant difference was seen between the BHS pre-test and post-test in the CG (t = 7.899, p < .05) (Table 4). According to these results, H1 and H2 were confirmed.

Discussion

When the individual characteristics of participants and the UCLA-LS and BHS scores were compared before the intervention, the UCLA-LS total scores of older adults having children were found to be higher, whereas the BHS total scores of employed older adults were lower (p < .05). According to the Disabled and Elderly Statistics Bulletin published by the General Directorate of Disabled and Elderly Services (2019), 14.4% of older adults considered their children as a source of happiness, and 51.3% reported that they wanted to live with their children. In Turkish society, having children has three values: economic, psychological, and social. The economic value indicates “the financial benefit of children when they are both young and adults, and the assurance of care at old age.” The psychological value indicates “happiness, joy, friendship, and pride,” and social value refers to “being socially accepted by society and the continuation of surname and family traditions when having a boy” (Erol & Aloğlu, 2017). The fact that these older adults of Trabzon province had to live alone despite having children in Trabzon province, which is not consistent with the traditional social structure, is likely to increase their sense of loneliness. In this study, there were also statistically significant differences between the BHS mean scores according to the employment status of older adults. The average BHS score of employed older adults was lower than that of unemployed ones. Consistent with this study, Akdemir and Açan (2017) found that employed individuals have higher levels of hope. Aydın and Karaoğlu (2012) reported that employed older adults have a higher ability to live on their own and a better quality of life, are more open to social interaction and communication, and have lower anxiety about death and dying than the others. The reasons for this may be that employed older individuals can still use their talents and potentials, feel that they have a place in society, and are able to express their presence as individuals.

After comparing the UCLA-LS and BHS pre-test scores of the IG and CG, the difference between them was not found to be statistically significant (p > .05). This result shows that this research sample was suitable for interventional research.

The comparison of the UCLA-LS post-test mean scores between the IG and CG revealed that the difference was statistically significant, and the mean scores for loneliness decreased significantly in the IG compared to the CG (p < .001). The fact that this decrease in loneliness score averages was higher and statistically significant in the IG in this study may indicate that the group art therapy using clay was effective. No studies have examined the effect of group art therapy using clay on loneliness among older adults living alone. However, some studies have demonstrated the effects of art activities on the health of older adults (DiNapoli et al., 2016; Elkis-Abuhoff et al., 2008; Kim et al., 2017 a; Martinec, 2018; Ueda et al., 2013). According to the literature and current research results, engaging in art promotes better physical and psychosocial health status ( Kim et al., 2017 a), reduces functional impairment (Masika et al., 2021), increases life satisfaction and quality of life (DiNapoli et al., 2016), and improves self-confidence (Ching-Teng et al., 2019). Kim et al. (2017b) highlighted that physical activity as a leisure activity reduces loneliness and increases life quality and psychological well-being. Garcia et al. (2004), in their study with 122 older adults who were assigned into groups for aerobics, handicrafts, computers, and painting, noted that these activities reduced levels of depression and loneliness, besides improving life satisfaction in this population. Doric-Henry (1997) found a decrease in the depression and anxiety levels of the participants and an increase in their self-esteem, in the clay art therapy study which they conducted with the older adults living in a nursing home.

After comparing the BHS post-test mean scores of the IG and CG, it was determined that the difference between them was statistically significant and that the mean BHS score in the IG decreased significantly compared to the CG (p < .001). In this study, the fact that the decrease in BHS mean scores were higher and statistically significant in the IG showed that the group art therapy using clay was effective. In the literature, no studies investigating the effect of group art therapy using clay on hopelessness have been carried out with older adults living alone. “Instillation of hope,” included in the category of nursing interventions, is recommended for alleviating hopelessness. Instillation of hope is an initiative comprised of activities to increase self-esteem, talk about past achievements, remember loved ones, ensure life review, and join support groups (Bulechek et al., 2017). Thus, clay-based group art therapy with this approach aimed at providing emotional expression and reducing hopelessness levels in older adults by helping them express their past, present, and future experiences verbally and transform them into objects through clay.

Group art therapy practices are reported to be more effective than individual practices (Davidson & Rossall, 2014). Those participating in group work can benefit from the mirroring and supporting functions of the group (Çıtakbaş & Üçok, 2019), and as the process progresses, they can feel like an important part of a valuable, useful, and meaningful whole (Yalom, 2018). Gardiner et al. (2018) pointed out that group activities can be effective in alleviating loneliness and social isolation in older adults, and further evidence-based studies are required in this regard. Results from this randomized controlled study suggest that the participation of older adults in the group art therapy using clay enhances interaction, offers the opportunity to verbally express emotions and thoughts, and introduces an art form that reduces loneliness. Mishra et al. (2021) reported that expressive group art therapy increases subjective happiness and decreases the feeling of loneliness in older women. In their synthesis studies in which they reviewed 119 group artworks, Gabel and Robb (2017) argued that participating in group art therapy provided a therapeutic effect, with self-awareness and psychosocial growth. During the clay-based group work in this study, it was observed that older adults were shy and hesitant to speak in the first sessions. However, in the following sessions, they started to express themselves, and they liked being with the group. For individuals living alone, meeting new people can be challenging due to feelings such as shyness or fear. However, in art activities with the group, it may be easier for them to make eye contact, have verbal communication, and start friendships (Crockett, 2020). Some of the statements of the individuals participating in this study about belonging to a group are as follows; “… I never went to school, but I really wanted to. This workshop has become my school, and the people here are my classmates…,” “… It is very nice to be with my peers, apparently, they feel what I feel. It relieved me to see that others also have similar feelings…,” “… If they compare loneliness and death, loneliness will be worse. I look forward to coming here…” Depending on the statements of the elderly individuals, it can be said that they are happy to belong to a group. Social acceptance and being a member of a group facilitates adaptation to the environment and provides a normative basis for an individual’s behavior (Aydın et al., 2013). The sense of belonging meets the individual’s needs of belonging to a group, being important to each other, and having a shared purpose, and unity. It also has a protective function for the possible pain and loneliness that may be experienced due the alienation, social isolation, and the lack of a sense of belonging, (Ersanlı & Koçyiğit, 2013). In this study, in addition to the positive effects of the clay art therapy method by itself, on the loneliness and hopelessness levels when applied to the older adults living alone, it is thought that performing the therapy together with the group was even more effective.

Conclusion and Recommendations

After the clay-based group art therapy, a significant decrease was seen in the loneliness and hopelessness levels of older adults in the IG, compared to those in the CG, when the outcomes of the face-to-face interviews of both groups were compared. Therefore, it can be concluded that intervention with group art therapy using clay was effective in reducing the levels of loneliness and hopelessness in older adults living alone.

Loneliness and hopelessness are negative emotions that affect millions of older adults. Short-term, cost-effective, and community-based treatments are urgently needed. Clay-based group art therapy has emerged as an interventional art therapy model that achieved a rapid reduction in the loneliness and hopelessness levels of older adults living alone, within a short period. However, the study has some limitations. One of the major limitations was that the assessment of the intervention outcomes included only self-report measures. Besides, most of the participants in the present study were women (71.6%), which may affect the generalizability of the study findings. Finally, the long-term effect of clay-based group art therapy is yet unknown. It is recommended that further comprehensive research is conducted to evaluate the effects of clay-based group art therapy on the levels of loneliness and hopelessness of older adults living alone, through follow-up studies.

Ethics Committee Approval

Ethics committee approval was received for this study from the ethics committee of Karadeniz Techinical University (Date: April 16, 2018 No: 2018/51).

Author Contributions

Concept – M.A., F.Y.K.; Design – M.A., F.Y.K.; Supervision – F.Y.K.; Resources – M.A.; Materials – M.A.; Data Collection and/or Processing – M.A.; Analysis and/or Interpretation – M.A., F.Y.K.; Literature Search – M.A., F.Y.K.; Writing Manuscript – M.A., F.Y.K.; Critical Review – F.Y.K.

Figure 1.

Figure 1.

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CONSORT Flow Diagram.

Funding Statement

The authors declared that this study has received no financial support.

Footnotes

Peer-Review: Written informed consent was obtained from the participants who participated in this study.

Peer-Review: Externally peer-reviewed.

Conflict of Interest: The authors have no conflicts of interest to declare.

References

  1. Akdemir B., Açan A. (2017). A research on determining psychological capital and job satisfaction. Journal of Academic Approaches, 8(2), 57–79. [Google Scholar]
  2. Akgül H., Yeşilyaprak B. (2018). The effect of psychoeducation program for reducing lonelinesson loneliness level of the elderly. International Journal of Society Researches, 8(14), 11–52. 10.26466/opus.401331 [Google Scholar]
  3. Akhan L. U., Kurtuncu M., Çelik S. (2017). The effect of art therapy with clay on hopelessness levels among neurology patients. Rehabilitation Nursing, 42(1), 39–45. 10.1002/rnj.215). [DOI] [PubMed] [Google Scholar]
  4. Altundağ M., Ural M., Eratay E., Aydoğan Y. (2017). Evaluation of ceramic training and applications given to preschool children with and without disability. Abant İzzet Baysal University, Faculty of Education Journal, 17(1). 10.17240/aibuefd.2017.17.28551-304617) [DOI] [Google Scholar]
  5. Aydın Ö. S., Karaoğlu L. (2012). The quality of life and the influencing factors among the population over 65 living in Gaziantep city center. Turkish Journal of Geriatrics, 15(4), 424–433. [Google Scholar]
  6. Aydın O., Sahin D., Güzel H. Y., Abayhan Y., Kaya A. G., Ceylan S. (2013). The effects of the need to belong and being informed on reactions to ostracism. Turkish Journal of Psychology, 28(72), 21. [Google Scholar]
  7. Bahar G., Bahar A., Savaş H. A. (2009). Elderly and social services for the elderly. Fırat Sağlık Hizmetleri Dergisi, 4(12), 85–98. [Google Scholar]
  8. Beck A. T., Ward C. H., Mendelson M., Mock J., Erbaugh J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4(6), 561–571. 10.1001/archpsyc.1961.01710120031004 [DOI] [PubMed] [Google Scholar]
  9. Beck A. T., Weissman A., Lester D., Trexler L. (1974). The measurement of pessimism: The hopelessness scale. Journal of Consulting and Clinical Psychology, 42(6), 861–865. 10.1037/h0037562 [DOI] [PubMed] [Google Scholar]
  10. Bulechek, M. G, Butcher H. K., Dochterman, J. M., & Wagner, C (2017). Sanat Terapisi, In Erdemir F., Kav, S., Yılmaz, A.A. (Ed.), Hemşirelik Girişimleri Sınıflaması (NIC) (pp. 331). Nobel Tıp Kitapevleri. [Google Scholar]
  11. Çam O., Altınköprü H. (2013). The effect of music upon the emotional status and styles to cope with stress of ­university students. Motif Academy Journal of Folklore, 11, 262–272. [Google Scholar]
  12. Ching-Teng Y., Ya-Ping Y., Yu-Chia C. (2019). Positive effects of art therapy on depression and self-esteem of older adults in nursing homes. Social Work in Health Care, 58(3), 324–338. 10.1080/00981389.2018.1564108 [DOI] [PubMed] [Google Scholar]
  13. Ciasca E. C., Ferreira R. C., Santana C. L. A., Forlenza O. V., Dos Santos G. D., Brum P. S., Nunes P. V. (2018). Art therapy as an adjuvant treatment for depression in elderly women: A randomized controlled trial. Revista Brasileira de Psiquiatria, 40(3), 256–263. 10.1590/1516-4446-2017-2250 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Çıtakbaş A., Üçok V. A. (2019). İmgeden simgeye dönüşüm: Psikotik bozukluklarda resimle çalışma. In Eren N.(Ed.) Ruhsal bozuklukların tedavi ve rehabilitasyonunda yaratıcı sanat psikoterapileri, pp. 29–33. Ankara. Türkiye Klinikleri. Retrieved from http://dijitalakademi.turkiyeklinikleri.com/flippage/psikiyatri-hemsireligi-ozel/5-2/tr-index.html#p=39. [Google Scholar]
  15. Crewdson J. A.2016). The effect of loneliness in the elderly population: A review. Healthy Aging and Clinical Care in the Elderly, 8, 1–8. 10.4137/HACCE.S35890. [Google Scholar]
  16. Crockett T.2020). Expressive arts therapy and the loneliness epidemic - A critical review of literature. Expressive. Expressive Therapies Capstone Theses. 325. Retrieved from https://digitalcommons.lesley.edu/cgi/viewcontent.cgi?article=1329&context=expressive_theses [Google Scholar]
  17. Davidson S., & Rossall, P. (2014). Evidence review: loneliness in later life. Retrieved from https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/reports-and-briefings/health--wellbeing/rb_june15_lonelines_in_later_life_evidence_review.pdf [Google Scholar]
  18. Demir, A. (1989). UCLA yalnızlık ölçeğinin geçerlik ve güvenirliği. Psikoloji Dergisi, 7(23), 14-18.
  19. Demirel O. N., Yılmaz Y., Üngüren E. (2015). A research of burnout levels on vocational school students. Ekev Akademi Dergisi, 19(62), 173–184. [Google Scholar]
  20. Dereli F., Koca B., Demircan S., Tor N. (2010). The evaluation of loneliness level of elderly individuals residing in rest homes. Yeni Tıp Dergisi, 27, 93–97. [Google Scholar]
  21. DiNapoli E. A., Scogin F., Bryant A. N., Sebastian S., Mundy M. J. (2016). Effect of individualized social activities on quality of life among older adults with mild to moderate cognitive impairment in a geriatric psychiatry facility. Aging and Mental Health, 20(3), 262–270. 10.1080/13607863.2015.1008990 [DOI] [PubMed] [Google Scholar]
  22. Dossey L.2020). Loneliness and health. Explore, 16(2), 75–78. 10.1016/j.explore.2019.12.005 [DOI] [PubMed] [Google Scholar]
  23. Durak A., Palabıyıkoğlu R. (1994). Beck Hopelessness Scale validity study. Crisis Magazine, 2, 311–319. [Google Scholar]
  24. Elkis-Abuhoff D. L., Goldblatt R. B., Gaydos M., Corrato S. (2008). Effects of clay manipulation on somatic dysfunction and emotional distress in patients with Parkinson’s disease. Art Therapy, 25(3), 122–128. 10.1080/07421656.2008.10129596 [Google Scholar]
  25. Eratay E., Aydoğan Y., Altundağ M., Ural M. (2017). Effectiveness of ceramic training given to preschool children with and without mental disability. Trakya University Journal of Social Sciences, 19(1), 351–369. [Google Scholar]
  26. Eren N.2019). Sanat psikoterapisinde etik ilkeler. In İçinde Eren N.(Ed.) Ruhsal bozuklukların tedavi ve rehabilitasyonunda yaratıcı sanat psikoterapiler, 1(1) (pp. 1–6). Ankara: Türkiye Klinikleri, [Google Scholar]
  27. Erol, P. Ö., & Aloğlu, E. (2017). Çocuğun değeri ve aile değişimi: Türkiye’den otuz yıllık bir portre. Sosyoloji Dergisi, 35, 77-101.
  28. Erol S., Sezer Balcı A., Şişman F. N., Öztürk S. (2016). The perception of loneliness and life satisfaction at older ­people. Gümüşhane University Journal of Health Sciences, 5, 60–69. [Google Scholar]
  29. Ersanlı K., Koçyiğit M. (2013). Psychometric properties of the belonging scale. Electronic Turkish Studies, 8(12), 751-764. [Google Scholar]
  30. Eskin M.2001). Adolescent loneliness, coping methods and the relationship of loneliness to suicidal behavior. Clinical Psychiatry, 4, 5–11. [Google Scholar]
  31. Foster F.1997). Fear of three-dimensionality, clay and plasticine as experimental bodies. In Killick K., Schaverien J. (Eds.) Art, psychotherapy and Phychosis (pp. 52–72). London: Routledge. [Google Scholar]
  32. Gabel, A., & Robb, M. A. (2017). (Re)considering psychological constructs: A thematic synthesis defining five therapeutic factors in group art therapy. The Arts in Psychotherapy, 55, 126-135.
  33. García M. Á, Gómez L. (2003). Psychosocial effects of leisure workshops on the subjective well-being and loneliness in the elderly. Revista de Psicología Social, 18(1), 35–47. 10.1174/02134740360521769 [Google Scholar]
  34. García, M. E., Gomez, L., & Martimportugués, C. (2004). A structural model of the effects of organized leisure activities on the well-being of elder adults in Spain. Activities, Adaptation & Aging, 28(3), 19-24.
  35. Gardiner C., Geldenhuys G., Gott M. (2018). Interventions to reduce social isolation and loneliness among older people: An integrative review. Health and Social Care in the Community, 26(2), 147–157. 10.1111/hsc.12367 [DOI] [PubMed] [Google Scholar]
  36. Gökbunar A. R., Uğur A., Duramaz S. (2016). The importance of public policies of the decreasing in health spending for elderly population. International Journal of Economic and Social Research, 12(1), 109–122. [Google Scholar]
  37. Hamamcı Z., Duy B. (2005). The effect of social skill training based oncognitive behavioral approach on loneliness levels and dysfunctional attitudes of university students. Eğitim Bilimleri ve Uygulama, 4(7), 3–20. [Google Scholar]
  38. Jang H., Choi S. (2012). Increasing ego-resilience using clay with low SES (Social Economic Status) adolescents in group art therapy. Arts in Psychotherapy, 39(4), 245–250. 10.1016/j.aip.2012.04.001 [Google Scholar]
  39. Julsing J. E., Kromhout D., Geleijnse J. M., Giltay E. J. (2016). Loneliness and all-cause, cardiovascular, and noncardiovascular mortality in older men: The Zutphen Elderly Study. American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 24(6), 475–484. 10.1016/j.jagp.2016.01.136 [DOI] [PubMed] [Google Scholar]
  40. Kar Ö., Toros F. (2015). Aile içi şiddet ve çocuk istismarı olgularında sanat terapisi. Hacettepe University Faculty of Health Sciences Journal, 1(2), 192–211. [Google Scholar]
  41. Kim D. H., Bae Y. S., Kim S. H. (2017. a). Effects of clay and drawing art program on self-expression and depression in elderly patients at a long-term care hospital. Journal of Korean Academy of Community Health Nursing, 28(2), 196–205. 10.12799/jkachn.2017.28.2.196 [Google Scholar]
  42. Kim J., Lee S., Chun S., Han A., Heo J. (2017. b). The effects of leisure-time physical activity for optimism, life satisfaction, psychological well-being, and positive affect among older adults with loneliness. Annals of Leisure Research, 20(4), 406–415. 10.1080/11745398.2016.1238308 [Google Scholar]
  43. Kimport, E. R., & Robbins, S. J. (2012). Efficacy of creative clay work for reducing negative mood: A randomized controlled trial. Art. therapy. Journal of the American Art Therapy Association, 29(2), 74–79.
  44. Kimport E. R., Hartzell E. (2015). Clay and anxiety reduction: A one-group, pretest/posttest design with patients on a psychiatric unit. Art Therapy, 32(4), 184–189. 10.1080/07421656.2015.1092802 [Google Scholar]
  45. Mann F., Bone J. K., Lloyd-Evans B., Frerichs J., Pinfold V., Ma R., Wang J., Johnson S. (2017). A life less lonely: The state of the art in interventions to reduce loneliness in people with mental health problems. Social Psychiatry and Psychiatric Epidemiology, 52(6), 627–638. 10.1007/s00127-017-1392-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Maral, N. C. (2018) Dışavurumcu resim teknikleri. İçinde Kaduson, H; Schaefer, C. (Ed.). En popüler 101 oyun terapisi Ankara. Nobel Yaşam, 1, 96-102.
  47. Martinec R.2018). Complementary and art-therapies as a supportive approach in gerontology and geriatrics. Gerontology and Geriatrics Studies, 3(1), 1–4. 10.31031/GGS.2018.03.000554 [Google Scholar]
  48. Masika G. M., Yu D. S. F., Li P. W. C. (2021). Can visual art therapy be implemented with illiterate older adults with mild cognitive impairment? A pilot mixed-method randomized controlled trial. Journal of Geriatric Psychiatry and Neurology, 34(1), 76–86. 10.1177/0891988720901789 [DOI] [PubMed] [Google Scholar]
  49. McWhirter B. T., Horan J. J. (1996). Construct validity of cognitive-behavioral treatments for intimate and social loneliness. Current Psychology, 15(1), 42–52. 10.1007/BF02686933 [Google Scholar]
  50. Mishra K., Misra N., Chaube N. (2021). Expressive arts therapy for subjective happiness and loneliness feelings in institutionalized elderly women: A pilot study. Asia Pacific Journal of Counselling and Psychotherapy, 12(1), 38–57. 10.1080/21507686.2021.1876116 [Google Scholar]
  51. Morais, A. H., Dalécio, M. A. N., Vizmann, S., de Carvalho Bueno, V. L. R., Roecker, S., Salvagioni, D. A. J. & Eler, G. J. (2014). Effect on scores of depression and anxiety in psychiatric patients after clay work in a day hospital. The Arts in Psychotherapy, 41(2), 205-210. 10.1016/j.aip.2014.02.002
  52. Özmen D., Dündar P. E., Çetinkaya A. Ç., Taşkın O., Özmen E. (2008). Hopelessness and factors affecting hopelessness in high school students. Anadolu Psikiyatri Dergisi, 9(1), 8–15. [Google Scholar]
  53. Rahmani P., Moheb N. (2010). The effectiveness of clay therapy and narrative therapy on anxiety of pre-school children: A comparative study. Procedia - Social and Behavioral Sciences, 5, 23–27. 10.1016/j.sbspro.2010.07.044 [Google Scholar]
  54. Rook K. S.1984). Promoting social bonding: strategies for helping the lonely and socially isolated. American Psychologist, 39(12), 1389–1407. 10.1037/0003-066X.39.12.1389 [Google Scholar]
  55. Rubin J. A.2010). Introduction to art therapy (2nd ed). New York: Routledge. [Google Scholar]
  56. Russell D. W.1996). UCLA Loneliness Scale (Version 3): reliability, validity, and factor structure. Journal of Personality Assessment (3rd version), 66(1), 20–40. 10.1207/s15327752jpa6601_2 [DOI] [PubMed] [Google Scholar]
  57. Russell D., Peplau L. A., Ferguson M. L. (1978). Developing a measure of loneliness. Journal of Personality Assessment, 42(3), 290–294. 10.1207/s15327752jpa4203_11 [DOI] [PubMed] [Google Scholar]
  58. Seber, G., Dilbaz, N., Kaptanoğlu, C., & Tekin, D. (1993) Umutsuzluk ölçeği: Geçerlik ve güvenirlik. Kriz Dergisi, 1(3), 139-142.
  59. Schoenmakers E. C., van Tilburg T. G., Fokkema T. (2012). Coping with loneliness: What do older adults suggest? Aging and Mental Health, 16(3), 353–360. 10.1080/13607863.2011.630373 [DOI] [PubMed] [Google Scholar]
  60. Sherwood P.2004). Healing Art of Clay Therapy, 120. Camberwell, Vic. Australian Council Educational Research (ACER) [Google Scholar]
  61. Sholt M., Gavron T. (2006). Therapeutic qualities of clay-work in art therapy and psychotherapy: A review. Art Therapy, 23(2), 66–72. 10.1080/07421656.2006.10129647 [Google Scholar]
  62. Steptoe A., Shankar A., Demakakos P., Wardle J. (2013). Social isolation, loneliness, and all-cause mortality in older men and women. Proceedings of the National Academy of Sciences of the United States of America, 110(15), 5797–5801. 10.1073/pnas.1219686110 [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. T. C. Aile, Çalışma ve sosyal Hizmetler Bakanlığı, Engelli ve yaşlı Genel Müdürlüğü (2019). İstatistiklerle yaşlı nüfus. Engelli ve Yaşlı İstatistik Bülteni. Ankara. Accessed:13.06.2019.
  64. Tercanlı N., Demir V. (2012). The assesment of beck hopelessness scale in terms of several variables (the sample of Gümüşhane province). Gümüşhane Üniversitesi Sağlık Bilimleri Dergisi, 1(1), 29-40. 10.1080/13607863.2011.630373 [Google Scholar]
  65. Tufan İ., Kılavuz A., Özgür Ö., Ayan S., Gürdal F. Y., Engin B. (2019). Gerontology Atlas in Turkey: Results an old age poverty and loneliness. Geriatrik Bilimler Dergisi, 2(1), 1–7. [Google Scholar]
  66. Ueda T., Suzukamo Y., Sato M., Izumi S. (2013). Effects of music therapy on behavioral and psychological symptoms of dementia: A systematic review and meta-analysis. Ageing Research Reviews, 12(2), 628–641. 10.1016/j.arr.2013.02.003 [DOI] [PubMed] [Google Scholar]
  67. World Health Organization (2015). World report on ageing and health. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/186463/9789240694811_eng.pdf;jsessionid=5F32EA35064B77AAEEFA67998148C54F?sequence=1 [Google Scholar]
  68. Yalom I. D.2018). Kısa süreli grup terapileri. 1 baskı, (pp 49–93). İstanbul: Pegasus Yayınları. [Google Scholar]
  69. Yıldız, S., & Yıldız, K (2016). The relationship between academic procrastination and hopelessness perceptions of primary school teaching department students. International Online Journal of Educational Sciences, 8(3), 234-251. 10.15345/iojes.2016.03.018 [Google Scholar]

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