Exploring the Impacts of an Art and Narrative Therapy Program on Participants’ Grief and Bereavement Experiences

Abstract

Grief and bereavement impact nearly every individual at some point of their lives, often having short or long-term physical and psychosocial impacts. Yet, these issues are rarely the focus of discussion, intensive therapy programs, or policy initiatives (Corr, 2002; Doka, 2002). This research explores the impacts of a closed group art and narrative therapy program in Ontario for individuals experiencing a grief or bereavement process following the loss of a loved one. It explores the grief experiences of art therapy participants during their time in the program, the nature, extent, and impacts of social and community connections that were made, how the program influenced grief over time, and the overall effectiveness of the program. This study suggests that art and narrative therapy hold great therapeutic potential as a tool to help individuals going through a grief or bereavement process.

Background

Grief and Bereavement

When an individual suffers a loss of any sort in their lives, Corr, 2002; Doka, 2002 they are in a state of bereavement (Rando, 2012). Related to bereavement is “grief”, which refers to the typical emotional and cognitive responses to an instance of bereavement (Kutner, 2002). While the effects of grief may vary, there are some commonly shared symptoms which can be considered typical of bereavement experiences, (Parkes, 1990) including nausea, chest tightness, crying spells, insomnia and fatigue (Kutner, 2002; Raphael & Middleton, 1990). From an affective perspective, the bereaved’s experience can often shift from a sense of numbed disbelief into one of intense sadness; feelings of helplessness or feeling ‘stunned’ are also common (Attig, 2011; Kutner, 2002). The individual’s cognitive tendencies during bereavement are generally characterized by a fixation on memories of the deceased, often focusing on any unresolved dealings with the deceased, such as lingering perceptions of conflict or guilt (Attig, 2011; Kutner, 2002).

Bereavement can be separated into the categories of physical loss and psychosocial loss; physical loss referring to the perceptible forfeiture of a tangible thing (such as the death of a loved one or the loss of a limb), and psychosocial loss referring to the less palpable losses of intangible belongings, such as roles, relationships, goals, or states of mind (Rando, 2012). Furthermore, bereavement can involve dealing with secondary loss, which refer to the peripheral losses that are suffered in addition to, and because of, the initial loss; for example, the forfeiture of income and financial security experienced alongside the death of a working spouse (Parkes & Prigerson, 2009; Rando, 2012).

From our theoretical positioning, a particularly pertinent form of secondary loss is that of the individual’s assumptive world. A person’s assumptive world refers to the framework of suppositions and expectancies that the individual has developed through their previous lived experience, and by which they now perceive the world (Parkes & Prigerson, 2009; Rando, 2012; Russell, 2012). The loss of a prominent figure in one’s life can have major ramifications for that person’s assumptive world (Attig, 2011); by contradicting the assumptions that had previously depended on the prominent figure’s ongoing existence, that figure’s loss changes the way the bereaved individual perceives and interprets their own existence (Bryant, 2003; Hibberd et al., 2011; Parkes & Prigerson, 2009; Rando, 2012; Russell, 2012). The overall accumulation of the experiences from all sources of grief (physical and psychosocial, initial and secondary) contribute collectively to the individual’s full experience of mourning, referred to as a person’s Total Bereavement Experience (TBE) (Rando, 2012).

Art Therapy

One of the earliest known uses of the term ‘Art Therapy’ (AT) was by British artist and author Adrian Hill in 1942, used to describe the therapeutic application of producing images and immersing oneself in the creative process (Edwards, 2014). Since then, AT has developed as a means of addressing various forms of bereavement. During the late 1990’s, Lachman-Chapin et al. (1997) observed that fields offering psychotherapeutic services to clients had become increasingly interested in the use of artistic-based therapies for recovery. Case and Dalley (2014) conceptualize AT as a form of psychotherapy that uses art as the primary medium of communication. Today, different practitioners have adapted the ideologies and practices of AT to fit the frameworks of their theoretical foundations and the unique needs of their clients.

The use of AT offers valuable insights that continue to be implemented by professionals in both clinical and health care settings (Malchiodi, 2013). These sentiments leverage the healing and life-enhancing properties of art creation (Malchiodi, 2013), helping clients to reestablish a sense of worth and empowerment through their engagement with art. Samuels and Rockwood (1998) [in Malchiodi, 2013] differentiate between AT and other forms of artistic creation by noting that AT is focused on the acts of interpretation and analysis in relation to the artistic process, rather than the artistic process or output. By taking this position, these researchers identify that the meaning and empowerment that individuals create for themselves during AT comes from how they perceive their artistic process and the words they use to describe their relation to it, rather than the subjective quality of the piece of art created.

Accordingly, there is a notable difference between art created in a therapeutic setting and art that is created for one’s own leisure or employment. Specifically, there is a healing element that is centered in the artistic process of AT. Edwards (2014) highlights this position by noting the particular significance of the relationship between the client and the therapist in the healing process. Case and Dalley (2014) extend this position, and note that there is a three-way relationship formed and leveraged in AT contexts: the relationship between the client, therapist, and piece of art. The role of the Art Therapist is central in this relationship (Bat-Or & Garti, 2019) because they provide opportunities for grief stories to be heard and appreciated, help establish an environment of safety (Moon, 2007; Moon, 2010), and help elicit meaning from experiences of grief.

Systematic reviews of the literature have found that art therapy can gradually and successfully be used for patients with mental symptoms and disorders, including individuals coping with trauma (Regev & Cohen-Yatziv, 2018). One study by Slayton et al. (2011) found that when isolated as a specific intervention, a small body of quantifiable data supports the claim that art therapy is an effective treatment for a variety of symptoms and disorders in diverse age groups.

Narrative Therapy

Narrative therapy within the grieving process is understood as the (re)storying of loss or traumatic experiences (White & Epston, 1990). The practice of creating narratives or stories that help to make sense of trauma enables individuals in situating difficult circumstances, problems, or unresolved traumas within the larger stories of their life journeys (Pennebaker & Chung, 2007). Narrative therapies operate using a social constructionist approach, meaning that the individual is centered within their process of meaning-making and storytelling (Neimeyer, 1999; for a more complete review of the social constructionist approach see McLeod, 1997). When individuals are given the opportunity to conceptualize and share their stories in their own way, the narrative therapy process becomes reflexive (White & Epston, 1990), empowering (Neimeyer, 1999; Pizzaro, 2004), intersectional, and diverse (McLeod, 1997) by virtue of the space held for the unique experiences and perspectives possessed by each person.

There are several recognized benefits to engaging in narrative-based therapies. For example, the opportunity for a bereaved person to narrate their grief experience provides an opportunity for others to form a deeper understanding of the loss that person has gone through. Similarly, Pennebaker and Chung (2007) acknowledge that the opportunity to create a story allows individuals to understand their own emotional traumas in a more coherent manner. The ability to use language and conversation in narrating experiences of grief and loss allow for emotions to be understood and recognized comprehensibly by someone trying to make sense of their past trauma (Pennebaker & Chung, 2007). Additionally, the use of language and conversation helps to externalize diverse emotions and allows opportunities for the bereaved to reframe their grief experiences (Rafealy, 2020). When externalizing emotions or utilizing a self-distanced approach (Kross & Ayduk, 2011), an individual can not only better understand their traumas but can also reconstruct them to include components of hope, empowerment, and growth, helping the individual to reintegrate back into daily life in meaningful ways (Hedtke, 2014).

Hospice Wellington’s Art Therapy Program

Hospice Wellington (HW) was established in 1980 by a group of residents in the Guelph/Wellington community who identified a need for the provision of compassionate care, emotional support, and practical assistance to those with life-threatening illnesses, those caring for people with life threatening illnesses, and clients experiencing bereavement. A range of programs, from one-on-one support to community workshops and wellness programs, are provided to the community at no cost to the client. As a part of these services, HW hosts a 12-week long group-based AT program facilitated by a trained Art Therapist for the bereaved individuals from the community who face a state of bereavement following the loss of a loved one.

Several different theoretical and artistic perspectives have combined to give shape to the current form of AT that is offered by HW. Specifically, the program derives much of its theoretical orientation from the Meaning Reconstruction approach (Niemeyer, 1999). According to this perspective, the primary focus of bereavement is the search for meaning, and “the perceived relationship with the deceased is the key component to be explored on the journey through meaning reconstruction” (Hospice Wellington, 2019). This approach emphasizes the connection to the personal identity of the person in grief (Niemeyer 1999). AT uses dialogue from traditional psychotherapy combined with creative art production in its pursuit towards rehabilitation.

At HW, the AT program is a 12-week closed group program, that engages participants in the act of creating a piece of art. The process for each group (cohort) is vetted by community artist with a specialization in the medium employed during each cycle, and is support by HW’s Art Therapist. Examples of previous mediums used have included stone-carving, wood working, and oil painting. Program participants receive ongoing assistance in the use of the medium they are using from the associated community artist. The art intervention is accompanied by the Art Therapist, who employs narrative therapy techniques to expand the participants engagement with the material and externalize difficult emotions and potentially find meaning from their experience. At the end of the twelfth week, participants have completed their artwork accompanied by a narrative artist statement.

The group component of the program is designed to provide participants with a safe social environment wherein they can find support during the grieving process, including a safe space to engage in adaptive forms of risk-taking. Likewise, the community-accessible location of the service is meant to provide insulation for vulnerable populations from potentially stressful or damaging environments (Fantin, 2014).

Enrollment in HW’s AT program is available at no cost to the client and prospective participants are typically made aware of the program through independent research, community connections, or previous experience with HW. The use of AT as a therapeutic medium is particularly valuable given the wide demographic range of participants the program supports. As stated on HW’s website, “for individuals who do not have the words to express how they feel, AT can provide an alternative to traditional talk therapies” (2019). As an equally accessible medium of grief management regardless of age, language barrier, socioeconomic status, or most other discerning factors between engaging participants, AT at HW strives to reach the greatest number of people possible.

The Present Study

In 2020, HW’s Art Therapist approached the Research Shop, part of the Community Engaged Scholarship Institute (CESI) at the University of Guelph, to explore the value and impact that HW’s AT program had on existing clients. The Research Shop works with local and regional organizations to carry out high impact community engaged research. It provides a cost-free program model and typically collaborates with organizations from non-profit sectors. This project was carried out by a team of students and staff from CESI/The Research Shop.

Purpose

The purpose of this research project was to explore the experiences of individuals who participated in HW’s Closed Group AT between the year 2015 to the last program prior to the start of the COVID 19 pandemic (March 2020). Specifically, it sought to describe the grief experience of individual participants in the AT program by understanding how the art and narrative therapy process impacted the grief experience; how participants experienced the combination of art and narrative therapy; what community connections were created; and how the program influenced the grieving process over time.

Methods Recruitment

Participants invited to participate in this study included those who participated in the HW Closed Group AT Program between April 2015 and the last program prior to the COVID 19 pandemic closure in March 2020 (which ended the program early). Participants meeting these criteria (n = 62) were contacted by a staff member at HW to consent to being contacted by a member of the research team. Those who gave consent (n = 38) were contacted by members of the research team from CESI by phone or email, sent a letter of information, and were scheduled for an in-depth, semi-structured interview. Consent forms were sent to participants in advance of the interview; participants were offered the option of giving either electronic or verbal consent. A total of 31 participants agreed to be interviewed when contacted by researchers and were scheduled for an interview. Data from two participants were later removed from the study, as it was determined the participants fell outside of the inclusion criteria, resulting in a final study population of 29 participants.

Data Collection

Data collection for this study comprised of in-depth, semi-structured interviews (n = 29). The research team, along with HW’s Art Therapist, developed a qualitative interview guide for participants. The interview guide consisted of eight questions structured around four topics:

• The participant’s overall experience of grief during the AT program, and reasons for engaging.

• The participant’s experience of the combined AT and narrative processing.

• The social and community connections the participants made.

• The influence of the AT program on the participant’s grief over time.

Each interview was conducted by two members of the research team from CESI, from April to June 2021. As a result of distancing requirements related to the ongoing COVID-19 pandemic, all interviews were held by phone or virtual meeting (Microsoft Teams or Zoom). One member of the research team facilitated the interview, while the other took notes. Verbal consent was ongoing throughout the interview, with the participants being reminded that they could skip questions, take a break, or withdraw from the interview at any point.

Data Analysis

Qualitative data were analyzed through a thematic analysis process, whereby researchers identified major themes following Tech’s (1990) eight step coding process. Transcripts were divided between researchers, reviewed, and given initial codes. Following this step, the research team worked together to refine the research codes and categorize them into general themes. A final codebook with themes was developed, and transcripts were re-coded for final analysis. To provide additional context, the team also tracked the number of responses within each theme, which are reflected in the results.

Results

Participant Background

Of the 29 participants, nine were from Cohort 1 (2015-2016), ten were from Cohort 2 (2017-2018) and ten were from Cohort 3 (2019-2020). Most participants (19/29) were introduced to the program by word of mouth – through friends and family, or through prior experience with HW. Eight of the 29 participants sought out the program independently (using the HW website or visiting HW directly) and two were referred to the program by a practitioner. Nearly half of participants (14/29) expressed explicitly seeking alternatives to talk therapy – they were drawn to diverse ways of expressing their emotions outside of just talking. As one participant explained, “I was in talk therapy, but I couldn’t talk about my experience. Art therapy allowed me to process in a way I didn’t know existed.” Given that experience with artistic modalities was not a requirement of the program, participants had varying levels of prior experience with art and narrative modalities. Some of the participants self-identified as experienced artists and others as had no previous experience with art.

Beginning the Program

“Art therapy is for when you cannot grasp the words to explain outwardly the feelings you have, the art speaks for you.”

- HW AT Participant

Participants in the AT program entered during various stages of their grief journey and had varying levels of openness to engaging in the program. While not directly asked, some participants self-expressed having initially faced entry barriers related to their grief. One participant reported that they were in a “dark place” going into the program, while another reported they were “in a hole and couldn’t function at all.” Some participants reported that they initially experienced fear or distrust of the program, although this receded overtime. As described by one participant, “I didn’t think making art would really hel…. As time went on, I began to feel differently. I was surprised about the power the art piece had…I was very, very surprised that I got into it.” As their time in the program began, some participants (8/29) stated that the program gave them something to look forward to and that they enjoyed the structure of participating in a weekly program, especially during a period of, as described by one participant, “sadness and loneliness.” “My whole focus was getting up and going to this place once a week. And I was able to do that, which was big progress. I wasn't doing anything before,” reported one participant.

Program Structure

“The merging of therapy with art was remarkable.”

‐ HW AT Participant

HW’s AT program is designed to integrate both art and narrative therapies, and many participants described how the combination of these had an impact on their grief journey. As one participant reported, “Talking work speaks to one part of your brain, whereas working with your hands and using visual approaches speaks to another part. By taking a more holistic approach to therapy it addresses the whole picture.” Another participant noted that they appreciated the variety of approaches that were available, reporting they felt that the combination allowed the participant agency to choose where and how they participated in AT programming.

Over one third of participants (12/29) spoke specifically about the positive role of the narrative component in the program. One participant reported that the writing gave them the context, or lens, to process their grief and further described “The art was good, but the writing was what did it. The prompts were poignant, and they helped you dig deeper and process your experience of grief.” Two participants felt the narrative components were specifically helpful in creating a strong group dynamic, with participants noting that the narrative component helped to center the group and create a sense of community.

Most participants (21/29) also reported a connection between the art making process and their own grief, explaining that it allowed them to connect with, and express, their grief. As one participant stated, “It asked you to take your grief and do something with it. I could sit there and look at all the problems, and I could turn it around and pick at it. This asked me to do something different; it asked me to try and change the shape of it – it was almost a physical experience.” Others found that AT was a useful tool to support personal reflection and expression. Art helped with the grief journey, but more than that, it also served as a reflective practice, or tool, to help deal with anything in life - not just grief.

Social and Community Connections

“As great as the physical space was, being in the presence of people [going through a] similar experience was just as, maybe more, important.”

- HW AT Participant

As an integral part of the AT program’s intended design, the social and community connections made during the program influenced participants’ experiences in several ways. Many of the participants interviewed (21/29) spoke directly to the benefits of simply being in a shared space with others going through a similar experience. “I think the most important thing the Art Therapy program did to help me begin to move forward was that it put me with a group of people who understood – we all experienced the same thing. There is huge, huge power in being with other people whose experiences have been similar to yours,” stated one participant. A similar sentiment was shared by others (19/29), who noted the positive influence of not just sharing space with those in a similar experience, but also of the actual interactions and connections formed during the program. As one participant noted, “it allowed me to listen to other people’s stories and experience secondhand some of their growth, which made me realize things within myself.”

Some participants (16/29) expressed having been reluctant or nervous to participate fully in a social group setting yet were comforted by the assurance that they would not have to share their feelings with the group involuntarily. While participants are never required by the program to share their experiences, two participants expressed that they developed a sense of responsibility to reciprocate the openness demonstrated by their peers after hearing them share their experiences. As one participant explained, “at first I was guarded, but I could see the other participants’ vulnerability as well and thought to myself ‘if I can’t open up and be as vulnerable as they are, I shouldn’t be here, it’s unfair.”

Most participants (25/29) either expressed a desire or reported an attempt to stay in contact with their fellow participants from AT following the program’s conclusion. These attempts were met with mixed success. While some participants (11/29) reported forming ongoing and deep friendships with peers from their program, others (6/29) recalled attempts to organize informal gatherings of the group which “fizzled out”, largely due to lack of assistance in coordination, or as a result of social restrictions during the COVID-19 pandemic. Despite some of the apparent barriers to the formation of long-term connections within the group, some participants (5/29) expressed the value of the program in strengthening existing relationships with friends and family, either through the sharing of created art, or through more open communication spurred by the program and its curriculum.

Grief Experience and Personal Growth

“It was a loss of my identity. Who am I if I’m not a mom? I didn’t know, and now I’m starting to know.”

- HW AT Participant

Some participants (6/29) spoke directly about how the program was able to strengthen their perceived relationship with the person they had lost, often through a re-examining of that relationship while planning or creating art. For example, during the program’s “Objects We Have Left” seminar, participants were asked to think of physical objects related to the person they had lost, which could then be used as the basis of the artwork they created. One participant spoke to how they were able to connect more deeply with the person they had lost through the consideration of the physical things which still connected them to that person. Another participant spoke to the feeling of connection with their loss fostered by the painting of a nature scene close to the heart of the person they had lost.

In addition to a deepening sense of connection with the person who was lost, nearly half (13/29) of participants also reported a deeper understanding of and connection with themselves and their relationship with grief, including unresolved grief. For example, one participant recalled how the program helped not just with the presenting loss that brought them to the program, but also with unresolved feelings of grief from the death of a family member over 20 years prior: “Feelings that I thought were resolved or handled, but in actuality were not, came out during art therapy.” The notion of transforming grief into a persistent yet manageable companion was expressed in some way by most participants (26/29), with one participant sharing: “The grief isn’t gone. Christmases and anniversaries still happen, it’s never gone – grief is a part of life. But it changes from simply pain to a gift, of being able to appreciate what you had with that person and being able to celebrate them…The relationship doesn’t die, grief is a part of life, but it changes the way you experience that grief.”

Furthermore, many participants expressed that AT helped them understand some of the complex and overlapping emotions experienced during a state of bereavement. As recalled by one participant: “I was very angry in my grief, and I didn’t really know why. I’ve really found that Art Therapy helped me understand that anger was my safe emotion, and that I was actually really sad. That understanding was just ground-breaking for me.” Another participant mentioned the way the program addressed unexpected losses; “Art Therapy helped me grieve all the things I didn’t realize I had given up; my sense of self, loss of identity, my own life and agency.” This sentiment was shared by many participants (23/29), who recalled how the program assisted in the navigation of self-identity post loss, and the reintegration back into a fulfilling life. As one participant explained; “I was experiencing the loss of two different roles: I was no longer a daughter, and I was no longer a wife. The hard part was finding out who I was outside of these roles. Art Therapy helped me understand this in a better way.”

Continuing Impacts, Growth, or Challenges Following the Program

Nearly half of the participants (14/29) reported that they held on to the art pieces they produced throughout the program and found importance and value in them. Many participants discussed the connection of their art pieces to the person/people they were grieving, with some connecting the final piece to memories of their loved one(s), as well as it being an outlet for externalization of their grief. As one participant said, the art piece created “almost gives you a container to house your grief, so that it does not have to live with you anymore.” Nearly one third of the participants reported keeping their art object(s) in their home or office.

The AT program typically concludes with a public exhibition, inviting friends and family of participants, as well as the general public, to view the art and written works on display by program participants. Over half of the participants (16/29) reported positive experiences from participating in the exhibition. Seven participants felt it was a positive way to share their grief experience with the broader community, honour a lost one, and share the impact that the AT program had on them. As one participant reported: “Grieving can be isolating, and the exhibition was a way of placing that grief within a larger community.” Some participants noted they felt a sense of pride in sharing their art with the public – they were proud of their work and were happy with how the final exhibition turned out.

Many participants expressed that the skills they developed in the AT program helped to build their resilience and ability to cope with losses that occurred following their primary loss. For instance, participants expressed that the program helped them to later deal with personal crises, such as diagnosis of personal illness, other losses of family members and friends, and the impacts of COVID-19. As one participant explained, they were more prepared for the loss of their mother after having entered the AT program to deal with the loss of their partner, acknowledging that this would be a different kind of grief for them now that they had the skills and knowledge to navigate such complex emotions.

When asked about their grieving processes over time, many participants noted that the COVID-19 pandemic presented new forms of grief, with major impacts on their daily lives and experiences of well-being. Participants expressed experiencing isolation and loneliness, as well as direct impacts on their experience of AT, such as having their public exhibition cancelled or being unable to connect with HW through other ongoing opportunities such as volunteering. While these impacts were experienced negatively by a significant number of participants (11/29), many expressed that the skills and teachings they obtained during the AT program have enabled them to better cope with the pandemic. Some participants explained that they now do art in their own homes and continue to use the AT teachings to get through bad days. As one participant stated, “I think if I hadn’t gone through major grief, [the pandemic] would have been a lot harder for me.”

Challenges, Considerations and Opportunities

Throughout the interview process many participants made observations or comments about the program that, while peripheral to the aims and objectives of this study, provided valuable insights worthy of consideration. The most common and relevant of those observations are outlined below:

Accessibility

Several participants provided feedback related to the accessibility of the program. A few participants felt that the cost-free model was of great benefit to people who might not otherwise have access to therapy. Participants also felt that the physical setting in which AT took place was an environment that was friendly, welcoming, and accessible to individuals of all skill levels. However, participants expressed some frustration that the program was only offered in Guelph, ON. While HW offers services to a wide geographic area (City of Guelph and County of Wellington), the single location of the program posed challenges to those living in the smaller cities or more rural areas in Wellington County.

Program Orientation and Scope

Although most participants held positive views regarding the value of the AT program, individuals sometimes struggled with certain aspects of the program. This depended largely on personal preferences, experiences and characteristics and is not as much a reflection of the program itself. For instance, one participant said that the AT program often felt too metaphorical for them, being themselves a very literal person. This caused the participant to contemplate leaving the program, although they eventually found value in it. Another participant expressed that although AT helped to address their grief, it did not engage with or support them in overcoming the trauma they had faced, which they saw as a gap in programming.

Timing

Several participants stated that the timing of when a participant starts the program, in relation to their loss, is critical to the value they can obtain from AT. For example, many participants expressed feeling like they were not thinking clearly or were ‘in a fog’ immediately following their loss, and that this may not have been the best time to start the AT journey. While the grieving process occurs at different speeds for different people, it is worth noting that HW’s AT program does make use of guidelines throughout the intake process which are specifically geared towards ensuring an appropriate fit between the participant and program prior to service provision. In the interests of ensuring this fit, the program’s intake procedures include a verbal agreement between the AT and the participant on the program’s theoretical framework, approach, and objectives.

Program Delivery

A few participants expressed that the face-to-face aspect and the physical environment - i.e., the layout of the space, having art supplies readily available, or being able to get up and make tea, for example, were critical aspects of the program. Participants felt that the physical environment and being present amongst one another created a safe, inclusive atmosphere. Although this was not explicitly addressed by interview questions, some participants were doubtful about whether the program could be delivered in alternative formats, such as online, and expressed their preference for face-to-face delivery. As one participant stated, they did not believe that the program could be done remotely, as it “really needed the physical space to work in the intended way.”

Leadership

Many participants in the study referenced the importance of having a trained, skilled and experienced Art Therapist and volunteers for the AT program. With a couple of exceptions, participants largely felt that the Art Therapist and volunteers at the HW AT program were a large part of what made the program so valuable for participants. Many of the participants (20/29) expressed praise for the Art Therapist, stating that they embodied characteristics such as kindness, compassion, good humour and understanding. As one participant stated, “[the Art Therapist] provided assistance that was beyond the realms of art therapy.” Many participants also gave praise to the volunteers for their assistance in the program, explaining that they were informative and showed compassion and care throughout the AT experience. Considerations to note were that a high turnover of volunteers could be challenging, and some participants stressed the necessity of having volunteers who had gone through a bereavement experience themselves in order to be able to offer shared understanding.

Program Replicability

Participants felt that whether the HW AT program could be effectively replicated elsewhere was contingent on several factors. While participants felt the program was unique and highly dependent on the expertise of current leadership, they also felt that under the right conditions it would be possible to expand the program and/or create new programs in other regions. All participants interviewed expressed that the program had value, and many participants felt very strongly that more institutional support, such as increased funding, policy infrastructure, facilitator training programs, and endorsement from primary healthcare providers; was needed to support the expansion of the program to other regions in a manner that is reflective of the thoughtful and high-quality AT programming offered by HW.

Discussion

This study has built on previous work demonstrating the use of art and narrative therapy as a therapeutic tool for individuals going through a grief or bereavement process (Case and Dalley, 2014). In general participants felt strongly about the efficacy of the therapeutic AT program in helping them cope with their grief both during the program and afterwards.

Upon entering the program, many participants reported being mentally fixated on memories of the deceased, as consistent in the literature (Attig, 2011 and Kutner, 2002). Furthermore, some participants distinguished between physical and psychosocial losses (Rando, 2012), identifying the impacts of both the primary loss, as well as the loss of their role, or relationship with that person. The common participant recollection of being “in a fog” or “lost” at the start of the program seems to be reflective of the notion of loss resulting in disruptions to the assumptive world, as described by Attig (2011). Most participants experienced a stabilization of these feelings while participating in the AT program and learned new skills and self-care practices that helped them cope with their grief in new ways and move forward with their loss.

Evidence of the stabilization of self-concept can be heard in many participant responses; as described by one participant: “I was really tired of carrying all of these negative emotions, it’s exhausting. The process of producing art while in a place of grief helped you to reassert your own ego, so that you were not overwhelmed by grief.” The rejuvenation of a future-orientation seemed to reliably coincide with reports of a stabilization of self-concept. For example, as one participant stated, “I got into that [relationship] when I was 27, and I lived in it for 35 years. Now that experience of 35 years I had to forget and discover who I was in the first 27 years of my life. That’s what the program helped me find.” Reports of the adoption and/or enhancement of self-care practices tended to be centered around artistic or narrative exercises similar to those engaged in as part of the AT program. For example, as one participant recalled: “I regularly journal now. I used to on and off, but it is more regular now.” The acceptance of the reality of the loss and the search for meaning from the grief experience appear to be ongoing processes for many of the interviewed participants. In the words of one interviewee, “It slowed down the grieving process and made me feel… The art therapy program provided support in being able to truly experience my grief process the way I needed to.”

Furthermore, AT’s three-way relationship involving the client, therapist, and art, as described by Case and Dalley (2014), was also reflected in participant interviews, with many participants noting the importance of the Art Therapist’s role during AT, particularly in the prompting of creative reflection, artistic expression, and the eliciting of meaning from grief experiences. Along this vein, participants felt that a strength of the program was its melding (by the Art Therapist) of art and narrative therapeutic modalities, which granted participants agency in choosing how to participate in the program and offered a more holistic therapeutic experience. Many participants found value specifically in the narrative aspect of the program – participants used language to narrate their grief stories, which acted as a tool to help externalize emotion and allow participants to understand their grief in a more contextual and cohesive way.

Participants consistently expressed that the social and community connections made during the AT program had a significant therapeutic impact on their grief and bereavement experiences. Some participants reported value in hearing stories shared by others, and felt it helped with their own grief journey. As expressed by one participant, it [was] helpful to not walk the journey alone.” One participant spoke specifically to the idea of the group as an “intentional space to share, grieve and learn” as well as an “intense and intimate shared journey.” Others echoed this sentiment, noting the power of being with a group of people who they felt understood them, and therefore, could provide the type of support they need. A few participants noted that they were encouraged to share their stories with others, because of the intimacy and trust built within the group. Many participants reported they would not have been able to share their stories with others in their life in the same way, suggesting that the group component contributed to the narrative aspect of their healing.

Finally, we found that the AT program was able to influence the participants experience of grief over time, often influencing how the approached later grief-related experiences, such as loss of another loved one or grief experienced during the COVID-19 pandemic. Participants gained tools through the art and narrative components of their integrated therapy experience which they were able to carry with them and use well after the program had ended. For instance, many participants stated that they regularly used journaling, written prompts and art exercises later in life to help them cope with difficult times. Many participants also commented on how the skills they learned during the AT program helped them to cope with the challenges of the COVID-19 pandemic, indicating that the AT program may have helped them develop long-term, resilient strategies for dealing with grief experiences.

With these considerations in mind, we conclude with two central recommendations for practice based on our findings.

The accessibility of the AT program was in large part what made it appealing to many individuals, and what made it possible for participants to participate in the first place. The program was offered at no cost, and it did not require previous experience with art and narrative modalities. It provided a safe, inclusive environment where individuals could learn together, explore, create, and perhaps most importantly, grieve. For future program development, consideration should be given to making sure programs are accessible to individuals in terms of their cost, physical accessibility considerations, art and narrative therapy experience requirements, access to supplies, etc…

Secondly, given that most participants learned about the program through word of mouth, it would be worth exploring how to best increase awareness this type of programming in order to reach a wider audience. Many of the participants indicated that they sought out the program as an alternative to talk therapy, indicating that wider awareness is also needed regarding sound alternatives to traditional forms of therapy for grief and loss. We recommend that practitioners and participants of the art and narrative therapies increase awareness of its utility in practice by engaging in further research, outreach and engagement with policy and decision-making.

We see the HW as a replicable model for art and narrative therapy for grieving individuals and recommend that other hospices and aligned organizations consider a similar model as part of their therapeutic offerings. As participants in the program repeatedly expressed, there was a desire for the program to be expanded across a wider jurisdiction and that it be made available to a larger audience. “I hope, more than anything, that the program stays viable, and I hope that it can expand. It can be life changing” mentioned one participant; “Art therapy is such a valuable program. Anyone who is fortunate enough to participate in it is going to take a lot from it. I hope it continues on,” continued another. Any program wishing to replicate or follow the practices laid out by HW would need to take into consideration many of the factors mentioned in this paper that led to its perceived success by participants, including adopting a group based therapeutic model that can benefit from the social and community connections which our research has shown to be pivotal to the healing experience. It also includes having trained, experienced practitioners running the art and narrative therapy program who can carefully guide volunteers and participants through the integrated therapy experience, integrating different modalities, and teaching participants tools that they can carry with them well after the program has ended.

Conclusion

Using the case study of HW’s AT program, this research supports the use of art and narrative therapies as effective therapeutic models for helping participants who are going through a grieving or bereavement experience. The art and narrative therapy program offered by HW enabled participants to make strong connections with other participants and the community; to learn new skills and coping mechanisms through the integrated offerings of art and narrative therapies; to develop a stronger self-concept and to learn new self-care tools and management strategies; and to obtain skills that supported their resilience when facing future grief experiences, such as the COVID-19 pandemic. The unique theoretical orientation and methodological approach of HW’s AT program offers a valuable example for other programs or organizations wishing to adapt or expand their bereavement services. Accordingly, we suggest that practitioners interested in adopting these methods begin the process of embracing many aspects of the HW model, by creating programs that are accessible and by more broadly, raising community awareness of available alternatives to traditional talk therapy approaches. By providing participants the tools to change their relationship with grief, rather than only addressing the presenting loss, HW’s AT program is able to holistically address its participants’ bereavement experience, helping to pave the road to an adaptive and fulfilling life post-loss. As summarized by one participant, “Grief has to be expressed. It cannot be something that just lives inside you, or it will destroy you. Art therapy helped me do that.”

Limitations and Future Research

This study did not have a comparison group between individuals in traditional group therapy versus group art therapy. This meant that conclusions could not be drawn specifically between outcomes for those in traditional group programming versus those involving art as an intervention within the programming. Further, there is a gap in the literature when it comes to comparing the outcomes of these two different therapeutic approaches.

A significant limitations of the present study involve the sample of participants interviewed. Firstly, only 29 of the 62 past participants were included in the study. The Research team was given contact information for 38 participants, with the remaining 24 either not consenting to be contacted or were unable to be reached. Of those 38, only 31 were available to be interviewed, two of whom were eventually excluded from analyses based on their program cohort, leaving 29 participants eligible for analyses. As most responses were overwhelmingly supportive of the program, it is possible there may have been some form of self-selection bias by our participants, whereby participants who had an exceptionally positive experience with the program were more likely to respond to and participate in the survey than participants who may have had a more mediocre or negative experience. However, it is unclear how many (if any) of our participants this bias may have influenced, and it is also worth noting that at least one participant did provide strong critiques of the program, indicating some diversity in opinion and impressions of the program.

Another limitation of the study involved the length of time between the earlier cohorts’ participation in program (2015-2016) and our interviews with them. Understandably, some participants of the earlier cohorts had difficulties remembering specific details or interactions from their time in the AT program some five years previously. Despite some uncertainty in details, most participants from this cohort were still able to clearly recall the overall impacts and effects of the program and had a more nuanced understanding of the longitudinal influences of the program than their more recently participating counterparts. Additionally, two of our interviewed cohorts had their programming impacted by the COVID-19 pandemic, either cutting short their program or cancelling their planned public exhibition. While this provided an interesting opportunity to assess how the program was able to provide support and coping mechanisms for participants throughout the pandemic and related lockdowns, it nonetheless represented an atypical delivery of the AT programming.

A further limitation of this study is that it took place during the global COVID-19 pandemic and was conducted entirely online. It was clear that some participants struggled with the online nature of the study and were not entirely comfortable using phone conversations or zoom to convey their experiences of art and narrative therapy. It is also possible that the pandemic influenced participants' current emotional state, which might have influenced our findings.

Finally, a possible limitation of the study involves the disregard of participants’ demographic information. Demographics were intentionally ignored in this study for two reasons, 1) the ensured confidentiality of participants given the small sample size and unique population being interviewed, and 2) to reflect the openness of the program intended to be effective and welcoming regardless of age, gender, socioeconomic status, ethnicity, or language.

To overcome some of these limitations, future research should explore the demographics and personal characteristics of those who engage in, and benefit from, the program as compared to those who do not. Specifically, future research should seek to understand how different identities and systemic factors may exclude some participants from this type of programming, or present different benefits and challenges. As well, a formal program evaluation of the AT program, which includes measures of participants’ progress throughout different check points, would help to capture more participant data on an ongoing basis and reduce errors in participant recall.