Expressive Arts in End-of-Life Care & Life-Death Education in Hong Kong: Reflections for Research and Art Therapy Practice
Joshua K. M. Nan, PhD, MA, MDIV
Hong Kong
Katie, S. Y. Pang, MExpArtsTh, MA
Hong Kong
Maria Riccardi, MA, MEd, ATR-BC, Doctoral Student
Montreal, QC
Background: Challenges in End-of-Life Care, East & West
Research shows that care for dying patients in their last stage of life (End-of-Life, or EoL stage) can be costly. This mainly occurs because the patient and the family are not prepared for the rapid decline in the patient’s physical health, and have not considered the length and types of palliative care services they may need, causing the death and after-death treatment plan to become hampered (Borgstrom, 2015). In addition to needing intensive physical care, patients in the EoL stage — patients with a terminal illness or older adults in a rapidly worsening physical state — may experience tremendous psychological stress. Therefore, addition to making post-death arrangements (e.g., funeral service, legacy and assets), these individuals have specific psychological needs that should be addressed (e.g., communicating their last message to their family or answering existential questions) (Nan, Pang, Lam et al., 2018). Discussing legacy and disposal of assets is challenging in both Western societies and Chinese communities (Borgstrom, 2015; Hsu, O’Connor & Lee, 2009). Talking about death is almost taboo and may be perceived as leading to bad luck by tradition-bound Chinese elders (Hsu, O’Connor & Lee, 2009).
Wang and Chan (2015) investigated 107 sociocultural studies with an Eastern context, published between 1991 and 2014. The participants in these studies included inpatients, outpatients, healthy older adults in community settings and healthcare professionals. The issues being discussed included treatment of physical symptoms, death anxiety, spiritual issues, and training for professionals in death-related fields. A common conclusion was that more emphasis on EoL care services in primary care settings (e.g., care homes) and care for the primary care givers were essential. Moreover, there were very few studies reporting use of arts in EoL care.
In the mainstream, the work relating to Life-Death Education or LDE in community settings (e.g., in a seminar or workshop) may tend to focus on practical issues (e.g., legacies, assets and funeral preparations) (Chan, 2015). Addressing psychological and spiritual needs to people in the EoL stage can be challenging in this type of setting. Therefore, verbal communication about psychological or spiritual issues related to life and death, such as reviewing the life stories of someone who is dying or revisiting memories with love ones, may be very difficult. If the last words of a dying person to a loved one involve sensitive issues, such as legacy planning, it can be confusing or even hurtful (Borgstrom, 2015). It is especially exhausting for a lot of older adults, who may speak in dialect, to express their inner struggles in words (Nan & Man, 2017). Furthermore, many young healthcare workers find it overwhelming to respond to questions related to spirituality (Nan et al., 2016). Therefore, there may be benefits to adopting an unconventional approach to LDE that combines the benefits of verbal counselling and nonverbal media such as the arts.
Expressive Arts for EoL Care
The term expressive arts (EXA) is used to refer to the mixed use of different arts modalities (e.g., visual arts, music, dance/movement, drama, play, creative writing or a combination of the above) and formats (group vs. individual, single vs. multi-component) (Knill, Levine & Levine, 2005). According to the Person-Centered Expressive Arts Therapy approach, an individual’s creativity unleashes, and new possibilities emerge from the shift between arts modalities under a safe, empathetic and non-judgmental environment (Rogers, 2011). Being one of the humanistic approaches rooted in Carl Rogers’ Person-Centered approach, it emphasizes that every individual has the innate drive to self-actualization and creativity. According to Rogers (1993), the Creative Connection process is an interplay between different art modalities, in which the exploration using one modality opens up feelings which could further be expressed using another art modality. In this process, knowledge about ourselves unfolds and connection with the outside world strengthens (Rogers, 1993).
EXA methods have been progressively adopted as tools in EoL care to enhance an individuals’ quality of life (Bolton, 2008). Various studies have documented the benefits of EXA activities, such as symptom relief for cancer patients (Nainis, et al., 2006; Rhondali, Lasserre, & Filbet, 2012;Wood, Molassiotis, & Payne, 2011), creating meanings (Romanoff, 2006; Redhouse, 2014), fostering effective emotional expression (Nan, Pang, Lam et al., 2018), psychosocial care and communication via nonverbal means (Nan, Lau, Szeto et al., 2018). The EXA methods in EoL care use a combination of art modalities. Not only does the choice of art modalities accommodate individual differences in physical and mental abilities, but the change from one type of art creation to another enables the participants to tap into the inner creative force. The creative process allows the participants to reflect on past events, to be aware of the present mood, and then discuss their concerns about life and death issues. Through the series of EXA activities, participants develop a deeper understanding of their body, mind and spirit in the face of death, and strengthen their connection with their families and other beings.
To date, Western research investigating the use of arts in palliative care, LDE, grief work or related areas has been inadequate (Torres et al., 2014), and the same is true of research in the Hong Kong (HK) context.
Implications for Art Therapy Practitioners
In an EoL setting, talking about thoughts and feelings is often difficult. Research conducted by the first author on EoL care and LDE shows that EXA activities have various benefits when dealing with life and death issues (Nan, Lau, Szeto, et al., 2018; Nan, Pang, Lam, et al., 2018). The thematic art-making process and art products both play an important role in communicating strong emotions, touching on themes that may be threatening, and buffering interpersonal conflicts over sensitive issues. Metaphorically, the artwork is a symbol of the final message to send love, the last words, and the will, from one who is leaving to the beloved, with embodied blessings and passion (Figs. 1-3).
Figure 1 (left): Mei-lee (pseudonym) broke into tears when she shared memories of the day, she arrived in Hong Kong from mainland China decades ago. She lived in a squat and her neighbour took very good care of her and helped her get used to the new life. She was grateful for the support of her friends during those hard times. The art product contained the difficult emotions aroused during the art-making process and transformed them into positive feelings.
Figure 2 (middle): In making “Life’s Treasure Box,” Kwan (pseudonym) used images of fish and butterflies to represent her thoughts about life and her children, whom she said were the most important people in her life. She showed her love towards her children through “Life’s Treasure Box.”
Figure 3 (right): Ah Ming (pseudonym) drew himself in “the film rolls of life” that expressed his views about death. He shared the idea that when death comes, we do not need to flee; rather we should walk towards the bright light, symbolized by the sun in his picture. Ah Ming accepted death as a natural part of the life cycle and faced it with ease.
Future research should investigate the effects of these different components of art activities through both qualitative and quantitative techniques. Replication of the results using a more rigorous research design would be valuable, such as using randomized controlled trial.
EXA therapy has developed into a distinct psychotherapeutic discipline, with its own training and accreditation system (International Expressive Arts Therapy Association, 2017; Australian, New Zealand and Asian Creative Arts Therapies Association, 2018). The availability of a mixture of modalities in EXA therapy offers the freedom to use different art forms. Dillenbeck and Hammond-Meiers (2009) have documented the benefits of dance/movement therapy in alleviating the sense of disconnectedness from the bodies of individuals whilst going through the various physical and psychological transitions during the dying process. Art therapists also can learn from dance/movement therapists in their treatment on death and dying issues, regarding their professional knowledge in understanding the human body and its movement. It is noteworthy that theories of expressive therapy, such as the Expressive Therapies Continuum (ETC), also share the rationale of using other art forms, such as rhythm and body movement to facilitate the creative process of art making (Gotshall, Nan, Hinz & Riccardi, 2017; Hinz, Nan, Riccardi, & Gotshall, 2017). Consequently, the ETC incorporates the myriad therapeutic uses of art expression that explain patients’ interactions during expressive activities from a holistic point of view. This approach fosters creative expressions from simple sensory/kinesthetic activities through perceptual/affective experiences, to complex cognitive processes and multi-leveled symbols where creative expression is the overarching experience (Lusebrink, 1991). Therefore, movement, sensation, emotion, and symbol formation through the use of the expressive arts has the potential to help patients gain an awareness of life and death issues.
In the future, it would be worth exploring cross-modal use of arts to achieve various therapeutic objectives as well as strengthening the theoretical underpinnings and change mechanisms (Dillenbeck & Hammond-Meiers, 2009; Huhtinen-Hildén, 2014).
Dr. Joshua K. M. Nan is a potter, art therapist, social worker, and spiritual worker. He has many years of experiences of applying arts to work with a wide range of populations. In recent years, he has actively investigated the use of clay with adults and adolescents in treating mood disorders and other mental health challenges. Joshua is currently an Assistant Professor and the 4-Year PhD Program Director in the Department of Social Work, Hong Kong Baptist University:
Katie Pang is an expressive arts therapist graduated from the University of Hong Kong. She has extensive experiences in working with children, youth and older adults. As a fellow of thanatology, she has launched groups and conducted research in life-and-death issues with expressive arts therapy.
Maria Riccardi is a registered art therapist, a career counselor, a licensed clinical psychotherapist and the former president of the Quebec Art Therapy Association. She is an adjunct professor of art therapy at Concordia University and at l’Université du Québec in Abitibi-Témiscamingue, as well as a faculty member at Winnipeg Holistic Expressive Arts Therapy Institute. She collaborates with local non-profit organizations and mental health institutions, developing community-based art studio programs for adolescents and adults who are marginalized due to mental and physical health issues, immigration issues, and poverty.
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