Pediatric palliative care (PPC) is an integrated support program that utilizes a multidisciplinary team approach to address the physical, psychological, social, and spiritual challenges faced by patients and their families from diagnosis through the dying process and bereavement period [1]. When a family member undergoing treatment passes away, the bereaved family members experience mourning, which is a normal response to loss. Specifically, when a pediatric patient dies, the bereaved parents and siblings may face social hardships due to significant psychological trauma, which can threaten their quality of life. These families often experience intense loss and grief, and prolonged depression can lead to difficulties in interpersonal relationships and social life [2,3]. Children and adolescents may face lifelong adjustment difficulties, such as challenges in academic performance and conflicts with friends [4]. Even adults may develop post-traumatic stress disorder, substance abuse, or somatization disorder, potentially leading to personal and social problems, including family dissolution and suicidal behavior [5]. Therefore, addressing the mental health of bereaved families is crucial in PPC.

However, research on bereavement in South Korea has a relatively short history, beginning only in the 1990s, and the effectiveness of specialized psychological, social, and spiritual programs for bereaved families has not yet been verified [4]. Although terminally ill patients and their families face numerous emotional challenges from diagnosis to bereavement [6,7], the emotional support available in the medical field is quite limited [8]. According to Kristjanson and Ashcroft [9], healthcare professionals have historically neglected the emotional support of terminally ill patients and their families, believing that the emotional distress accompanying the dying process is a natural consequence that does not require professional intervention but rather is a task for patients and families to cope with on their own. However, as hospice palliative care with multidisciplinary teams has become an area of medical care, emotional support for patients and their families has gained more attention [1].

Since the bereavement of a family member is a topic with significant emotional weight that cannot be addressed lightly, art therapy has emerged as an effective counseling tool that transcends the limitations of verbal expression [10]. Art therapy programs are effective in providing psychological support to bereaved families and facilitating their adaptation. They enable the safe expression of loss, grief, and sorrow that may be difficult to verbalize and allow individuals to give a symbolic name to the work that embodies their pain, helping them to objectively perceive their experiences [10]. Through art therapy, bereaved families can stimulate communication that has been halted and project emotions they were afraid to express into art. This allows them to safely express their emotions and gain the strength to accept various feelings toward the deceased and adapt to daily life. In this way, art therapy helps bereaved families reconstruct their hope and identities for a new life and experience an adaptive mourning process [11].

Family art therapy for bereaved family members is grounded in family system theory and proves more effective in facilitating the adaptation of the entire family when provided to all members rather than just the individual patient. In family art therapy, the use of artwork, which is both visual and enduring, effectively enables families to re-examine previously unaddressed issues [12]. Malchiodi posited that family art therapy affords each family member equal opportunities for artistic expression and unlocks creative avenues for problem-solving [13]. Specifically, children, who often represent a less powerful and vocal subsystem within the family, can safely express and comprehend their diverse emotions regarding family events through participation in family art therapy.

The primary theme of family art therapy is “mourning.” Mourning theories generally focus on the stages of mourning and the tasks associated with each stage, as grieving and mourning for a deceased family member can help individuals adapt to the loss [14]. John Bowlby, a pioneer in attachment theory, discussed four stages of mourning and applied the responses of infants separated from their attachment objects to the grieving and mourning process. When individuals face the death of someone they have a strong attachment to, they experience these four stages and eventually enter the stage of reorganization and recovery (Figure 1A) [15].

Figure 1. (A) John Bowlby’s mourning stages and (B) the mourning process with the provision of art therapy.
Source A: Holmes J. John Bowlby and attachment theory. Lee GS, Translator. Seoul:Hakjisa;2005. Source B: Chang SK. A case study on art-therapy for overcoming grief with the bereaved families. Korean J Christ Couns 2010;20:227-64.

The first stage is shock and numbness, during which individuals deny and attempt to avoid the departure of their attachment objects, feeling numb in the process. The second stage, yearning and searching, involves individuals missing the deceased greatly and seeking to maintain a connection with them through photos and mementos, but ultimately experiencing frustration and grief. The third stage, despair and disorganization, occurs when individuals lose the will to live as they accept the loss of the deceased, leading to feelings of hopelessness and despair. The final stage, reorganization and recovery, involves individuals recalling positive memories with the deceased and returning to a normal life [14].

The mourning experience can be characterized by these sequential stages, which may sometimes reverse as individuals undergo cycles of change and development. Even when reversed, the intensity and depth of the impact gradually lessen compared to the initial stage of loss, and bereavement is eventually overcome through the mourning process. Additionally, each stage is not entirely distinct and may overlap with others. The stages do not necessarily occur in order, and the process is not linear or fixed, but rather irregular, resembling a wave that subsides for a while before surging again (Figure 1B) [16].

This study aimed to carry out family art therapy for family members grieving the loss of a loved one due to severe illness, and to investigate the influence of emotional support experienced during the art therapy on emotions aligned with Bowlby’s four-stage theory of mourning. This research will offer foundational data for practitioners in the field to design and implement art therapy programs that assist bereaved families in overcoming psychological challenges in palliative and end-of-life care.

1. Study design

This single-case study employed the consensual qualitative research (CQR) method to examine the mourning process of a family bereaved by the death of a terminally ill pediatric patient, using John Bowlby’s mourning stages as a framework. CQR, a widely utilized qualitative research method in counseling, is an inductive approach that draws conclusions by thoroughly analyzing a small number of cases and comprehending words, contexts, processes, and narratives within the broader context of each case. CQR aims to ensure the objectivity and validity of qualitative research, and in this study, it was used to explore the in-depth mourning process of a single family [17].

2. Participants and art therapy process

The participants in this study were the parents and a younger brother (hereinafter referred to as “child”) of a deceased patient who had been diagnosed with a mitochondrial disease immediately after birth and remained bedridden at home for approximately 10 years. To help alleviate the psychological shock experienced by the 8-year-old child who witnessed his older brother’s dying process, the child was referred to the PPC team for art therapy. During the course of the art therapy, the parents’ psychological struggles were identified, leading to the expansion of the therapy to include family art therapy.

3. Art therapy process and data collection

This study received approval from the Institutional Review Board of Seoul National University Hospital (IRB No. H-2010-112-1165). We selected a family from among the relatives of pediatric patients who had passed away while receiving palliative care. This family agreed to use their artwork for pre- and post-art therapy research in bereavement care, provided written consent, had all members participate, and demonstrated Bowlby’s mourning stages effectively. We retrospectively extracted the art therapy records for our final analysis.

The child’s art therapy consisted of eight sessions, with each session lasting 50 minutes for the child’s art therapy and 10 minutes for the parents’ interview. These eight sessions included four sessions focused on self-expression through drawing and three sessions dedicated to three-dimensional work. The mother’s art therapy comprised seven 60-minute sessions, which involved two sessions for expressing emotions through drawing and five sessions for three-dimensional work. The family art therapy consisted of four sessions. The first session, titled “Drawing Each Other’s Faces,” was a drawing session for the mother and child. The second session, “Serving a Delicious Meal to Each Other,” involved creating three-dimensional work for the father and child. The third and fourth sessions, “Inviting Your Departed Family Member and Making a Plaster Hand Frame for Them,” consisted of creating three-dimensional work for the entire family. In total, 19 family art therapy sessions took place over six months, from April 2020 to October 2020.

4. Data analysis

This study examined the records of 19 family art therapy sessions conducted for a child and their parents. The counseling records and artwork from each session were analyzed according to the stages of mourning to better understand their grieving process. Significant statements expressing mourning responses were extracted from the counseling records and categorized by the corresponding mourning stages. Statements from conversations during family art therapy sessions, as well as photocopies of nonverbally expressed artwork, were analyzed to determine which of Bowlby’s four mourning stages they represented. After reaching a consensus on the identified stages, it was confirmed whether the order of sessions and mourning stages were sequentially arranged. Furthermore, the details of art therapy sessions for each participant were analyzed to assess the overall mourning process of the family as a whole. Four researchers in this study independently and repeatedly reviewed the raw data, and a consensus was reached through cross-analysis.

5. Rigor

In order to guarantee the methodological quality and rigor of the counseling analysis results, credibility, fittingness, auditability, and confirmability were established [18]. To ensure credibility, the researchers reviewed previous studies to develop theoretical sensitivity. Moreover, the analysis data were diversified by incorporating counseling journals that documented both verbal and non-verbal expressions of the participants, as well as artwork created by the participants. Fittingness was achieved by selecting participants who adequately expressed the bereavement process through art therapy. To ensure auditability, the mourning stages were verified through a survey of 104 art therapists with master’s degrees or higher and level 2 or higher qualifications. The questionnaire did not disclose the specific counseling sequence and details to minimize bias among the respondents. After presenting 165 extracted linguistic statements from family members, the respondents were asked to identify which of Bowlby’s four mourning stages each statement corresponded to. Based on the survey results, four researchers from this study independently determined the mourning stage for each session and reached a consensus. The study’s results were reported after confirming that the mourning stages identified by both the survey respondents and the researchers were consistent. Confirmability can be ensured by achieving credibility, fittingness, and auditability [18]. Furthermore, to eliminate bias and ensure confirmability, two medical professionals from the PPC team verified the counseling process. In cases where the analysis results differed between researchers, a consensus was reached through discussion.

1. Art therapy process by session and counseling analysis according to the participants

From the art therapy records, we extracted 113 significant linguistic statements (Table 1) and 12 non-verbal artworks (Figure 2) as meaningful data.

Table 1 . Linguistic Statements and John Bowlby's Mourning Stages..

John Bowlby's Mourning Stages		Linguistic statements
Stage 1
Shock, sentiment paralysis, emotional suppression	Mother	• I had never wept so much since I let my child go. • When I visited the burial ground, I saw my child take fright due to my husband's crying, so he hid in the back. After that, he often hid his feelings and tried to read others' faces or emotions.
	Father	• I'm glad I've been busy, but I think it's hard to hold my emotions inside. • Suddenly, I'm crying, pounding, weak, and feeling a little strange. My mind tells me to quit my job, but my body says I shouldn't. It seems I'm wavering a little bit.
Stage 2
Longing, pursuit, anger, guilt	Father	• It was painful to think that my son was living in suffering. • Even if I want to talk about my son with my family, I'm worried that I might look plaintive when bringing up a sad story.
	Mother	• I had to go to the hospital a few days ago because of the paperwork, but it was so hard to remember the day my son passed away. • When I'm angry with myself, but I take my temper out on my child, it feels painful again. • I still go crazy when I think of the moment I let my son go. • I'm sad that others treat me like a useless person. • These days... Could I allow myself to live like this? but I feel like I'm just playing and eating for nothing, and I don't know how I feel. • It comes up to me for my son's smiling face, the sofa he used to live on, and I had to just leave it. • I think caring for my sick son was a way of thinking, "No one other than me." • My husband keeps trying to sort things related to my son out, but I can't. • What is death? Is my son really dead? I don't realize it. • What does it mean to die and have nothing left? Why did this happen? I resented God more when I left my child go than giving birth. • I just want to keep the surroundings white. • Sometimes, I feel antipathy toward my husband because he seems to struggle alone. • Was it a meaningful child only for me? It makes me sad that people forget my son so quickly. • I'm sorrowful when nobody seems to listen about my son. I'm sad that my son is forgotten too soon in peoplés memories. • It's also my time to look at a massive hole in my chest. • Sometimes, suddenly, it comes to mind that I want to disappear. Or, sometimes, I stay numb. • This flower is gorgeous and pretty, but it dried up before it even bloomed. So, it looks like me. It seems it couldn't bloom because of my own greed. • I want to hear my son's laughter again. • I had never seen my second child have such tantrums since birth. • These days, he often says that he wants to go back to the age of 6 or 7. He also asks me why I don't play with him.
Stage 2 and 3
Longing, guilt, confusion, perception of loss subject	Mother	• The second child often says, 'I'm sorry.' • I don't want to be angry with my child, but it doesn't work. • I want to be recognized for my time devoted to my children and family.
	Child	• Why did you burn up [cremate] my brother? I was sorry for him.
Stage 3
Confusion, despair, perception of loss subject	Mother	• I don't think I'm helping my family. I don't have to take care of my sick son anymore, so I feel like I've become superfluous. • It was my first holiday without my son. It was lonely, empty, and unfamiliar. • I feel empty a lot after my son's departure, and I don't know what to do when I wake up in the morning. • My son, who is buried in a narrow and stuffy place, I wonder if it's even right to bury loved ones underground.. • My son does not exist in this world anymore, but I feel like he was never here. • I was a little surprised when I heard my child talk about his brother. • Son, what comes to mind when I think of it is the handprint. The child used to communicate just with his hands. • Red Heart and the Sea, this is a picture of our four family members sitting on the seaside peacefully. I guess we want to rest. • In some ways, I think I had a sort of luxury in not having to worry about other things while raising my son. • Older people used to say I was on the cliff's edge while raising my son, but I think my cliff is now living without a son. • I cut my child's nails into small pieces the day he left and still keep them. • I feel like going on a picnic at his grave site, but I also think he's not really there.
	Father	• If my mind were healthier, my family would have suffered less. I feel stable during counseling sessions, but when I return to my everyday life, the anxiety comes back. • I want to talk to my wife, but she doesn't take it well. • I want to live a different life now, but I'm worried about my wife and child being anxious. • My son's departure was hard to bear, but showing my suffering to my family was even harder. It seems like my family feels burdened because of me.... • I regret it when I'm angry with myself, but I take my anger out on my child instead. • Maybe this is something everyone else goes through, and it's not a big deal.
	Child	• I think I can see peoplés sorrow. • It feels like Mom and Dad have become a little kinder during counseling. • Mom and Dad, are you crying? • I'm not enough for you, am I? • I'm fine, but I don't know how to answer.
Stage 4
Reorganization stages, reshaping the inner world, restoring ordinary life	Mother	• It's a bit surprising and so good that my child often talks about his brother naturally these days. • It was very precious and fulfilling to have time to focus on my child for the first time in a long time. • At first, I thought he described me that way because I looked disheveled, but I find it so moving to tell you that he tried to describe me in a nice way. • I feel a little relieved because I think he is doing well at school. • I'm relieved to hear that our child is included in my husband's plans. • When I was with my son, who is no longer with us, we could never go to the sandy beach even if we went to the seaside because of his wheelchair, but now I think that would no longer be a problem if we went to the sea. • It's so nice now that the three of us can go enjoy the sandy beach, but I feel sorry and strange for the child who's no longer with us. • It was so lovely to watch the super moon with my child last week and hear him say, "Mom, the Moon looks like my brother." • They were so different, but I've begun to practice seeing them as they were. • I want to tell myself not to blame myself.
Stage 4
Reorganization stages, reshaping the inner world, restoring ordinary life	Mother	• I feel a little more relaxed. • My husband and child have started talking more. • The pink in the center is the heart of the son who we lost. It's always in the center of me. • I visited my departed son on the weekend, and I realized I needed a change in my life. • After making a handprint of my son in our last session, I've been feeling strangely less suffering. • Is it possible for my family to live a balanced life? • This was a time when I realized what I needed. • I want to spend time alone when approaching the anniversary of my child's death next year. • I'm trying to talk to my husband a little more, and I'm sensing some good changes. • It[the flower] looks powerful, strong, and energetic. So, it's not going to fall down. It's not going to dry out very much. • I thought I appeared disheveled, but it didn't show on the outside. • I need some time to stop and pull myself together. • I talked confidently to people who hurt me. I'm so proud. It's cool. • The holiday I spent without my son was both heartbreaking and comfortable, and it felt so good. • Is this okay? I was sorry for my son, but it felt so good. • I am a passionate, well-educated, and energetic person. • I'm not sure now if I can achieve my dream someday. But this diamond still has room for refinement. • I want to write a book that helps people with disabilities to change their perception of the world. • I'm feeling confused now, but when I depicted my son as a tree rooted in the ground and standing, it looked like a tree that bears fruit. • I feel a lot of sadness when I think about my child who passed away, but I think the day will come when I can smile, saying, "That was then." • I don't think I should be as lethargic as I am now. • It's a story from birth to death of a child who left. It tells the story I want to tell my son. It's my son's life story. • I hope my son's not sick and smiling now. • I hope to talk to someone about my son, and I want people to remember my son for a long time. • I want to show the book to many people when it's published. • It's just that I'm crying, but it's good to talk to people about my son.
Stage 4
Reorganization stages, reshaping the inner world, restoring ordinary life	Father	• In order to grow, we need to shed our old skin and be reborn... We can just settle down, but wouldn't it be an opportunity to grow when breaking away from the framework? • Now, wouldn't it be better to let go of what I have to give up and focus on what I have in mind? This is something I often tell myself. • I think it's the role of parents to gather their courage quickly. Shouldn't we bounce back from setbacks rapidly and go for it for my child? • My second life plan is full of things for my wife and son. • You can cry when you think of your brother. You can talk and cry if you want to talk to him. • I think it would be good if this counseling could help prevent some mistakes in my future life. • It wasn't perfect, but sharing feelings and thoughts with my family was good. • It was a meaningful time because I could talk a lot with my child. • I think my son needs dad's love. We travel together, play rough games like peers, and I think we need that. • I need a change...... Because I feel like I'm weak when I want to rest. • I started counseling because I was worried about my child, but it was nice to have time to talk to all my family members. • I think I had less time to communicate with my family because of my busy work.
	Child	• I think it would be nice if my brother said thank you. He might appreciate that I played well with him. • I want to be close to my friends. • I really liked working on art with my family. • This is my big park. People here come to my garden to play. They have friends and family. • And this is a long-lived turtle. • When I met my brother, I waved my hand and said 'Hi!' • I can get along bravely. • I'm glad I went on a trip with my mom and dad last week, and I can hang out with my friends daily. I'm going to show my joy. • My wish is to have a big house. I want to live happily with my mom and dad there. • And this is a Christmas wish tree that makes my wishes come true.

Figure 2. Art therapy works and John Bowlby’s Mourning Stages.

1) Art therapy process and counseling analysis for the child

In response to the therapist’s suggestion for emotional mandala work—”think of your heart as a circle, choose a piece of paper freely, draw a circle, and express whatever you want”—the child selected a black piece of drawing paper to represent his mind and drew a large snowflake that filled the entire page, referring to it as his mind. Mandalas have been known to be created as a means to overcome inner turmoil resulting from transitional periods in life, developmental trauma, or experiences of loss. The symbols depicted in mandalas represent an attempt to reconcile and reintegrate conflicting thoughts, serving as a pathway to psychological integration for grieving families [19]. Furthermore, winter snowflakes symbolize adversity and loneliness, while the end of a season, as represented by winter, signifies a period of hardship, with the understanding that spring follows death, marking the end of life [20]. The researchers viewed the child’s artwork as a significant indicator of his feelings of loneliness and a prevailing internal state of icy numbness, corresponding to stage 1 of Bowlby’s mourning process.

In the stereoscopic piece titled “My Tree,” an alternative tool for assessing ego strength, the child conveyed a desire for protection by filling and blocking the four corners of the stereoscopic frame. The depiction of a barren tree, consisting only of trunks and branches without leaves, represented a psychological state of anxiety and fear of loss. The theme of a “tree” is frequently utilized in art therapy in connection with “self-image” and “self-concept.” The biological characteristic of a tree, which grows and extends from the earth towards the sky, is interpreted as a reflection of an individual’s desire to live and serves as a symbol of a self-portrait that demonstrates mental maturity [21]. By cycling through stages 2 and 3 of Bowlby’s mourning process, the child exhibited psychological, social, and behavioral aspects that expressed longing and guilt for his brother.

In Session 5, the activity “My Guardian Angel” was conducted to allow the child to safely project their uncomfortable and painful emotions. Despite the challenges, the child persevered and completed the task they had chosen and planned. This sense of achievement became a source of inner strength that had previously been diminished. While confronting his brother’s death, the child depicted a person without hands, symbolizing his feelings of helplessness. The researcher interpreted this as the disorganization stage of Bowlby’s mourning process, which arises from despair and the realization that nothing can be done for the deceased. In portraits, hands often represent executive function, and their absence can be seen as an indication of inadequacy, guilt, lack of confidence, and uncertainty about one’s identity [22]. The child expressed his despair and grief through statements such as “I think I could see people’s sorrow” and “you are not enough just of me, are you?”, revealing that he was struggling to understand his emotions and articulate them. However, through the subsequent sessions of “My Guardian Angel,” the child gradually developed more verbal expressions to care for his wounded inner world and build his own strength, ultimately progressing to stage 4 of the mourning process.

The final session for the child was titled “Garden of My Heart,” in which he created a three-dimensional representation of a garden he would like to cultivate in his mind. Although the child still placed symbols representing his desire for protection in the corners of the frame, he also included a stronger tree with growing leaves and fruiting jewels at the center, calling it a “wish tree.” He designed a park where family members and friends were invited to play. Moreover, he added three turtle figures to symbolize their family, completing the artwork. This piece reflected the child’s emotional withdrawal from the deceased, acceptance of the newly formed family structure, and desire to live a long life with his family. The turtle represents longevity, sincerity, stability, and the god protecting death, as well as symbolizing the recovery process [22]. Additionally, the child rapidly increased his use of positive language, such as “glad,” “nice,” and “getting along,” instead of apologetic expressions. Through this artwork, the child clearly demonstrated that he had reached stage 4 of Bowlby’s mourning process, which involves facing and confronting the reality of the deceased’s absence.

2) Mother-child art therapy process and counseling analysis

In the first family art therapy session for the mother and child, titled “Drawing Each Other’s Faces,” the mother had the opportunity to uncover and express her suppressed emotions. Self-portraits serve as a means of self-exploration, allowing individuals to affirm their existence and gain insight into their inner pain, grief, desires, values, and beliefs. This is achieved through the deep involvement of both the artist and the subject in the act of observation and drawing [23]. Furthermore, self-portraits help to confirm the existence of oneself and others, while also expressing one’s inner psychological state. During this session, as the mother and child observed and drew each other’s faces, the mother focused on the child’s incomplete drawing rather than appreciating the effort her child made to create a beautiful depiction of her. Consequently, she projected her own feelings of inadequacy onto the drawing. However, as she gradually explored the meaning behind the situation, she was able to correct her negative projection, express gratitude to her child, and experience self-awareness and integration.

3) Father-child art therapy process and counseling analysis

The second family art therapy session involved the father and child “Serving a Delicious Meal to Each Other.” During this session, the father’s language spanned stages 2 to 4. He expressed gratitude and apologized to his child, who had received comparatively less attention due to his focus on the sick child. The act of serving a meal symbolizes support and encouragement for a life lived diligently, awakening the sense of presence, which is the most basic need that empathizes with the body [22]. The father communicated his desire for his child to experience a larger world. This verbal expression revealed his own unspoken wish, as he had not expanded his horizons due to focusing on his sick child for 10 years. He finally recognized that this was his true desire.

4) Family art therapy process and counseling analysis

A total of two sessions were conducted for the entire family, during which they created a plaster hand frame together. The experience of positive interaction through physical contact and care while molding the body in plaster has a healing element. This powerful representation of real life allows individuals to express, accept, and integrate affection, regret, expectation, and disappointment for themselves or others who model the body [24]. The child had already entered stage 4, the reorganization stage, through art therapy. However, the psychological conditions of the parents remained in stages 2 and 3, cycling through confusion, despair, guilt, and anger. The father felt pressure to overcome the pain and attempted to erase the memory of the deceased by suppressing his grief. While preparing for the final family session, the researcher asked the family to discuss how to incorporate a symbol of the deceased and participate in the session. The family agreed to represent the round frame as a large “moon” symbolizing the deceased and completed the work by placing their plaster hands inside the “moon.” The symbolic meanings of the moon include fulfilling wishes, hope, birth, resurrection, life and death, rebirth, eternal life, and fullness [22]. Finally, the child created a small wooden piece representing the deceased and attached it to the center of the frame. Unlike the deceased, who lived a life with restricted movement, the symbol was designed to depict dancing and playing freely. This representation offers an opportunity for recovery and a special healing experience that consoles the life of the deceased and reshapes their memory for the family.

5) Art therapy process for the mother and counseling analysis

During the mother’s initial phase of art therapy, she experienced a complex mix of longing, guilt, and reorganization of her inner world, as she expressed her sense of loss and diminished self-worth following her child’s death. In her artwork titled “My Tree,” the pink space represented the heart of her deceased child and served as a powerful means for the mother to convey her own heart, now with a void. Subsequently, in a clay work activity designed to create a symbol for her deceased child, she crafted a hand and named it “Longing.” The hand often symbolizes various emotional expressions, such as the demonstration of handling skills, freedom, warmth, love, pain, the struggles of daily life, and fulfillment [22]. By using the hand as a symbol, the mother acknowledged her child’s death and delved into its multifaceted meaning, which encompassed her genuine desire for peace and the guilt she felt about it. This phase was characterized by recurring emotions of longing, loss, confusion, despair, guilt, and the recognition of reality, aligning with stages 2, 3, and 4 of Bowlby’s mourning process.

After creating a handprint of her deceased child, the mother experienced a sense of relief and reduced suffering. However, she continued to face psychological challenges, including feelings of longing, despair, and confusion. In Session 3, titled “Flowers That Resemble Me,” the activity served as a means for the mother to project her negative emotions and confusion, while also helping her rebuild her positivity and inner strength. The mother recalled drawing a rose to represent herself, one that was on the verge of having its stem break. A rose typically symbolizes love and beauty, but a wilting rose and its thorns can represent death and the pain of love, respectively [20]. When the researcher returned the flower with a positive image, the mother reimagined herself as a full bud and a flower capable of blooming big and strong. This allowed her to find the courage to actively confront unresolved conflicts and challenges within herself.

During the first holiday after her child’s death, the mother became aware of her ambivalent feelings of loneliness and comfort, and she began to accept the accompanying guilt. This led her to a preparatory stage where she could truly acknowledge that she had left her deceased child behind. In the “My Jewel Box” session, it was visually demonstrated that new dreams, the power of positivity, and the pain of losing a child could coexist within a person. The initial self-image of a fruitless tree from the first session was replaced and restored with a new self-image of a tree bearing both fruits and jewels. Furthermore, her diminished self-esteem gradually improved as she developed a new dream and goal of writing “Her Child’s Storybook,” which would provide comfort to both her deceased child and herself. As the mother occasionally reflected on the painful journey of her child’s illness and loss, she came to understand and accept that pain is a part of life. This inner state was mirrored in her artwork, and her verbal expressions of comfort increased. This confirmed that the mother had entered stage 4 of Bowlby’s mourning process and was in the midst of reshaping her inner world.

With a renewed goal of navigating the emotional landscape of pain and despair, the final two art therapy sessions were dedicated to creating a storybook about her child, giving form and substance to their life. The mother was responsible for the content and organization of the book. As she chronicled her child’s journey from birth to death and shared the stories she wished to tell her child, she reached the final stage of grief by acknowledging and accepting the reality of her child’s passing. Reflecting on her time with her son, she said, “It wasn’t all bad,” and completed the book, cherishing the opportunity to remember and honor her child while expressing the desire to share his story with others. Additionally, the family adapted to their new family structure and resumed their normal lives, finding more joy in their daily experiences. This signifies the final stage of mourning—adjusting to life without the deceased, detaching from the emotions tied to the deceased, and regaining the ability to form new relationships—which continues to grow throughout everyday life.

2. Mourning stages of the bereaved family according to Bowlby’s phase of mourning

As the art therapy progressed, family members were observed to engage in the process of restoring a healthy daily life by increasingly using language corresponding to stage 4 of mourning (Figure 3). The cyclical and overlapping stages that characterize the mourning process suggest that the family’s changes and processes were expressed through non-verbal artwork, accompanied by language, and evolved into the reorganization stage of overcoming the loss of bereavement. Furthermore, as the art therapy, initially intended only for the child, expanded to include the entire family, it was confirmed that the art therapy had a positive impact on helping bereaved families accept their various emotions and gain the strength to adapt to daily life and maintain hope for the future (Figure 4).

Figure 3. Mourning process of family members based on John Bowlby’s phase of mourning.
*1 month after death of the child. 1=Shock & numbness, 2=Yearning & searching, 3=Despair & disorganization, 4=Reorganization & recovery.

Figure 4. Therapeutic factors acquired in the family art therapy process.

This study involved providing family art therapy to a bereaved family referred to the PPC team and analyzing the counseling process to determine if the family’s mourning stages aligned with Bowlby’s four stages of mourning. The primary objective of this study was to examine the therapeutic effects of family art therapy in addressing the psychological, social, and spiritual challenges faced by bereaved families, which are significant concerns in PPC, and to assist them in re-establishing a healthy daily life.

An 8-year-old boy who had witnessed his older brother’s death was referred to the PPC team, experiencing emotional paralysis, which corresponds to stage 1 of Bowlby’s mourning process. Although the child gradually achieved emotional stability through art therapy intervention, the mother displayed signs of psychological distress during counseling, consistent with a study suggesting that the loss of a child can lead to marital relationship crises [5]. This aligns with previous research indicating that the pain experienced by parents after a child’s death is indescribable and can result in various difficulties in their relationships with their spouse or remaining children [25]. Consequently, the psychological hardships and conflicts that arise after a loss can be understood as unique forms of pain experienced by each family member. Therefore, the researchers structured the therapy sessions to include individual sessions, parent-child pair sessions, and whole family sessions, allowing every family member to participate in the therapy and exchange more positive healing resources with one another. This approach is consistent with a previous study that found the most effective treatment for bereavement-related pain is to provide an environment that encourages open communication about the family member’s death and the events surrounding it [26].

As the art therapy progressed, the family in this study demonstrated an increased use of linguistic statements corresponding to stage 4, which involves reshaping the inner world. This finding aligns with a previous study that showed family art therapy can facilitate understanding among family members with shared trauma, promote inner healing, and support individual growth [10]. As a result of these changes, the child exhibited fewer tantrums, improved emotional stability, and gradually reduced excessive apologetic verbal expressions.

When the art therapy was extended to the entire family, even the father, who participated for a short time, experienced positive effects. The couple’s communication improved, trust was restored, and they gained a better understanding of the different stages of mourning, ultimately helping them transition into a healthier stage of grief. Additionally, the mother’s creation of a three-dimensional “hand” of the deceased child and “my child’s storybook” through visualization of the loss scene in art therapy reaffirmed the findings of a previous study [11], which suggested that bereaved families can explore their feelings of grief more deeply by visualizing the scene of loss through art therapy. In particular, the “moon,” a symbol of the deceased expressed by the entire family, and the shape of the older brother placed in the center of the “moon” frame by the child, represented the family’s desire to comfort the deceased, who had very limited movement during his lifetime, and to bestow upon the deceased a renewed sense of meaning. These symbols served as important substitutes and indicators of healing and recovery. This symbol of restoration was also evident in the child’s final session, which depicted the remaining three family members as turtles, symbolizing longevity and stability.

The researchers of this study interpreted these artworks as the family’s declaration that they were ready to move forward in life after experiencing the waves of painful and complex emotions brought on by their loss. This is consistent with the observations of bereaved individuals in stage 4 of Bowlby’s mourning process, who reestablish the meaning of the deceased in their inner space with the scars of loss and reconstruct the cohesion of a shattered family. Thus, this study confirmed that the bereaved family was able to confront and perceive the pain of their loss through family art therapy, share inner growth through the artworks, and ultimately achieve emotional stability [11].

Since this study analyzed a single family’s experience over a six-month period, so further research is needed to continually investigate the mourning processes and recovery of bereaved family members by providing long-term family art therapy to a larger number of families. The primary aim of this study was to gain a deeper understanding of the psychological challenges faced by the bereaved family of a pediatric patient, as well as the unique language and artwork expressions used by the family to help them regain a healthy life. Additionally, this study sought to compare the healing and recovery process facilitated by the organic art therapy program, incorporating both individual and whole-family perspectives, with Bowlby’s four stages of mourning. Furthermore, the qualitative research method of art therapy used in this study was significant in establishing a foundation for the potential positive psychological, social, and spiritual impacts of family art therapy on bereaved families, who are crucial subjects in PPC. Based on the findings of this study, further research and clinical efforts are necessary to develop systematic family art therapy programs and provide bereavement care within the context of PPC.

Supplementary materials can be found via https://doi.org/10.14475/jhpc.2023.26.2.27.

^{No potential conflict of interest relevant to this article was reported.}

Conception or design of the work: all authors. Data collection: SAY. Data analysis and interpretation: SAY. Drafting the article: SAY, SHA. Critical revision of the article: all authors. Final approval of the version to be published: all authors.