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J Hosp Palliat Care 2023; 26(4): 171-184
Published online December 1, 2023 https://doi.org/10.14475/jhpc.2023.26.4.171
Copyright © Journal of Hospice and Palliative Care.
Nahyun Park 
, Im-Il Na* , Sinyoung Kwon†
Graduate School, Ewha Womans University,
*Regional Hospice Center, Korea Cancer Center, Korea Institute of Radiological and Medical Sciences, Seoul,
†Department of Nursing, Gangdong University, Eumseong, Korea
Correspondence to:Sinyoung Kwon
ORCID: https://orcid.org/0000-0001-8707-9281
E-mail: esther9324@naver.com
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Purpose: The study explored the meaning of experiences within a family art therapy process among terminal cancer patients and their families. Methods: Ten participants, including four terminal cancer patients currently admitted to the hospice ward at an inpatient hospice facility in S City and four caregiving family members, engaged in four cycles of family art therapy sessions. The sessions were conducted weekly or bi-weekly, and each lasted approximately 50 minutes. Results: Nine cross-case themes emerged: “feeling unfamiliar and intimidated by the idea of expressing my thoughts through art,” “trying to accept the present and positively overcome sadness,” “expressing hope through emotional bonds during the process of parting,” “conveying and preserving personal and family beliefs,” “feeling upset about family imbalances caused by deteriorating health,” “valuing togetherness and striving for stability amidst the current challenges,” “art as a medium of empowerment for patients and facilitator of family conversations, even amidst difficulties,” “sharing a range of emotions—not just joy, but concerns and sorrow—through art,” and “gratitude for art’s role in improving family communication and connection through artwork. Conclusion: The findings of this study lead to several conclusions. First, patients and their families faced psychological challenges when confronted with impending death, yet they strove to remain optimistic by seeking meaning in their struggles. Second, families practiced open and expressive communication, sharing a spectrum of complex emotions with one another. Third, even as the patient’s condition worsened, resulting in family fatigue, their support and cohesion strengthened.
Keywords: Hospice care, Palliative care, Art therapy, Qualitative research
In South Korea, life expectancy is on the rise, thanks to advances in medical technology and early screening efforts [1]. However, cancer remains the leading cause of death, accounting for 26.0% (n=82,688) of all fatalities [2]. This statistic underscores the urgent need for effective care for terminal cancer patients and their families [3].
The number of patients utilizing domestic hospice facilities has been on the rise, increasing from 10.6% in 2010 to 21.5% in 2021. In 2021 alone, there were 10,991 new patients (57.2%) who sought care at inpatient hospice institutions [4]. Terminal cancer patients are the primary candidates for inpatient hospice services. The goal of hospice palliative care is to develop comprehensive care plans that address the physical, psychological, social, and spiritual needs of terminal cancer patients and their families, thereby improving their quality of life [3,5].
Terminal cancer patients face an irreversible prognosis and are expected to die within several months. They endure significant physical distress, including severe pain, dyspnea, nausea, vomiting, and delirium [1]. Additionally, they suffer from emotional distress, grappling with questions about why they developed cancer and confronting the progression of their disease and the prospect of death [6]. Cancer patients encounter numerous challenges throughout their diagnosis and treatment, leading to crises and a profound sense of existential loss [7]. Consequently, terminal cancer patients require not only physical care but also psychological, existential, and spiritual support to address the psychological trauma and feelings of helplessness that arise from their fears [3].
Care is necessary not only for terminal cancer patients but also for their families. Families of terminal cancer patients often endure significant distress, grappling with the caregiving burden and the looming anxiety of death. This constant exposure can lead to them becoming “hidden patients” [8] or experiencing withdrawal or regression in response to the adversity of the patient’s impending death. To preserve family functioning, it is important to gradually imbue crises with positive meanings, thereby enhancing coping skills through the mobilization of resources at the individual, family, and community levels [9]. Consequently, there is a need to provide services that improve the quality of life and reduce the stress experienced by these families, as well as to develop interventions that bolster their ability to independently resolve problems [10].
Art therapy assists patients confronting mortality by increasing their acceptance of death anxiety and existential concerns, enhancing their sense of connectedness with others, including family members and healthcare providers, and improving self-expression and quality of life [11]. Furthermore, art therapy enables terminal cancer patients and their families to experience a sense of connectedness through the metaphorical symbolism of art, preserve their identity, and strengthen resilience by creating a lasting memento in the form of artwork [12]. It also facilitates the acceptance of the patient’s death by helping families to recollect memories and maintain stable relationships through art, even amidst the challenging period of dying [13].
Previous studies [13,14] have demonstrated that using art as a medium can lead to positive changes in terminal cancer patients and their families. These changes occur as they are provided with opportunities to understand one another better and to share their perceptions of life’s meaning. Specifically, art therapy aimed at bolstering family resilience is an effective approach for families to experience positive shifts in their belief systems. This is achieved by recognizing the strengths of individual family members and fostering positive life attitudes through the creation of supportive artwork [15]. As art therapy sessions continue, families become more aware of their existing communication patterns and any underlying issues. They naturally acquire positive communication skills, such as the ability to share thoughts and feelings, by engaging in collaborative art projects [15]. Open and constructive communication within the family unit encourages members to recognize the importance of a stable family structure. It also aids in defining clear family boundaries and roles, which includes establishing family rules and modeling appropriate behaviors [16,17]. Therefore, family art therapy offers a secure and therapeutic avenue for terminal cancer patients and their families to uncover positive family resources and improve communication. The significance of family art therapy, as applied in the current study, lies in its ability to help terminal cancer patients and their families view the end-of-life process not as a crisis but as an opportunity. It allows them to build upon their inherent strengths and cultivate positive emotions.
A family resilience approach involves the processes by which families facing crises and adversity perceive difficulties as challenges, assess the family’s resources and strengths rooted in relationships and functions, and work together to address problems [17]. Consequently, this study, guided by the factors of the belief system, communication process, and orientational pattern as proposed by Walsh [18], implemented family art therapy for terminal cancer patients and their families. The aim was to facilitate a positive and stable shift in their belief systems, promote intimate and clear communication, and help reconstruct family roles.
The purpose of this study was to gain insights into the experiences of terminal cancer patients and their families during family art therapy sessions, as well as to discern the significance of these experiences. By examining the challenges faced by patients and families amidst the crisis of impending death and separation, their adaptation to this crisis, and their engagement in family art therapy, the study sought to enhance our understanding of these individuals. Furthermore, it aimed to lay the groundwork for the development and implementation of family art therapy programs within the clinical realm of hospice palliative care.
This qualitative study utilized a multiple case study approach to explore in depth the meaning and essence of family art therapy as experienced by terminal cancer patients admitted to inpatient hospice facilities and their families.
The study participants consisted of patients admitted to the hospice ward of K General Hospital in S City, along with their families who understood the study’s purpose and provided informed consent. The researcher, an art therapist at an inpatient hospice facility, had previously discussed the study’s aims with the hospital’s manager to facilitate the recruitment of medically stable patients and their families who might benefit from psychological and emotional support. Given the nature of terminal cancer, patients whose conditions significantly deteriorated or who passed away were excluded from the study. The inclusion criteria required patients to be capable of communicating for approximately 50 minutes while in bed or in a wheelchair and to participate in at least three out of four scheduled family art therapy sessions, along with their family members.
The final number of participants was 10, comprising four patients admitted to a hospice ward and six family members. Two families out of four had three participants—one patient and two caregivers—each. The age distribution of participants was as follows: one in their teens, one in their 30s, two in their 40s, one in their 50s, one in their 60s, two in their 70s, and two in their 80s. The group included two men and eight women. The mean length of stay in the hospice was 19.3 days, and seven of the 10 participants were religious (Table 1).
Table 1 Characteristics of Participants (N=10).
| Category | Sex | Age (yr) | Religion | Diagnosis | |
|---|---|---|---|---|---|
| Family A | A1 | Female | 82 | Buddhist | Pancreatic cancer |
| A2 | Female | 46 | Buddhist | - | |
| A3 | Female | 12 | Buddhist | - | |
| Family B | B1 | Female | 76 | Atheist | Oral cancer |
| B2 | Female | 42 | Atheist | - | |
| B3 | Male | 83 | Atheist | - | |
| Family C | C1 | Male | 70 | Protestant | Pancreatic cancer |
| C2 | Female | 68 | Protestant | - | |
| Family D | D1 | Female | 36 | Protestant | Breast cancer |
| D2 | Female | 59 | Protestant | - | |
The content and methodology of this study received approval from the Institutional Review Board of K Hospital (KIRAMS 2020-03-018-002). Data collection took place from July 8, 2020 to February 5, 2021. Researchers clearly communicated the study’s purpose and methods to the participants, ensuring they understood that there were no disadvantages to non-participation, that they could withdraw at any time, and that their personal information would remain confidential. The data compiled included voice recordings and verbatim transcripts of family art therapy sessions, clinical notes from each session, photographs of artwork, and in-depth interviews. Following each session, individual in-depth interviews with patients were conducted, lasting approximately 30 minutes, contingent upon their medical conditions. In cases where a patient’s condition deteriorated to the point where they could not participate in an in-depth interview, family interviews were conducted, focusing on their experiences with art therapy. Observations of participants’ facial expressions, tones, and behaviors, as well as photographs of artwork and the researcher’s reflections, were meticulously documented in field notes during the art therapy sessions and interviews.
In this study, the family art therapy program was conducted either in a hospital room or a designated program room, taking into account the preferences and convenience of the participants. The therapy was provided on an individual family basis. If a patient experienced pain or discomfort during the session, the art therapist promptly informed the attending nurse, and the session was adjusted to accommodate the patient’s condition. The family art therapy approach utilized in this research drew upon methods designed to enhance family resilience [17], as well as a program developed for patients in an inpatient hospice and their families [13]. Considering that the maximum stay in an inpatient hospice is typically three weeks, the therapy comprised four sessions, each lasting approximately 50 minutes, and was scheduled once or twice weekly.
One of the researchers in this study conducted the art therapy program. This individual holds a bachelor’s degree in Western painting and a master’s degree in art therapy, and had completed all coursework for a doctoral program at the time of this study. Certified as an art psychotherapist, the researcher has been practicing as an art therapist at a hospice institution since 2018. The family art therapy approach utilized in this study was grounded in the concept of family resilience, as outlined in Table 2. Each session (Table 3) was structured according to the Psychocybernetic Model of Art Therapy (PMAT) developed by Nucho [19]. The PMAT framework is divided into four phases. Initially, during the unfreezing phase, participants were briefed on the goals of visual expression and the therapeutic process. They were also encouraged to unwind through discussions about the day’s theme, exploration of art materials, and sharing their current feelings. Next, in the doing phase, the researcher fostered an environment conducive to concentration and encouraged participants to express their emotions freely and to recognize these emotions in their artwork. In the dialoguing phase, patients and their families presented and discussed their visual creations. Finally, the ending phase provided an opportunity for participants to share their overall impressions of the artwork and reflect on the meaning of their experiences. For this program, a variety of materials were made available to accommodate the needs and preferences of the families, including paper for painting, as well as clay, threads, and fibers—chosen for their ease of use and gentle texture suitable for terminal cancer patients. Additionally, photographs and collage materials were provided to cater to the diverse interests of the participants.
Table 2 Family Art Therapy Intervention Program.
| Session | Elements of family resilience | Aim | Theme | Activities |
|---|---|---|---|---|
| 1 | Belief system: Explore family beliefs | 1. Comprehend the concept and significance of family resilience 2. Establish a therapeutic relationship 3. Discover familial beliefs | Describe my family through an object | Initial orientation Identifying a symbolic family object |
| 2 | Belief system: Discover the meaning within difficulties Communication: Facilitate clear expression and communication | 1. Uncover lessons from overcoming past difficulties 2. Enhance effective and authentic communication | Our treasured memories | Sharing and expressing family memories Utilizing various materials |
| 3 | Organizational patterns: Explore and harness available family resources Communication: Foster openness in emotional expression | 1. Share emotions and acquire effective communication skills 2. Discover social and economic resources | Connective heart of the family | Exploring family resources and support Sharing and expressing feelings and thoughts through preferred art mediums |
| 4 | Organizational patterns: Promote family connectedness | 1. Facilitate the sharing of emotions while also promoting reconciliation and support | Create gifts for each other | Creating gifts for family using a variety of materials |
Table 3 The Approach to Family Art Therapy Based on the Psychocybernetic Model of Art Therapy (PMAT).
| Phase | Time | Contents |
|---|---|---|
| Unfreezing phase | 10 min | Guiding the client on the purpose of visual expression and the therapeutic process Spending time with the therapist and participant to share topics, explore mediums, and discuss current feelings, aiming to relax and release tension |
| Doing phase | 15~20 min | Creating an atmosphere that allows participants to concentrate and freely express emotions Facilitating opportunities for perception through the creative process |
| Dialoguing phase | 20~25 min | Having the opportunity to introduce and communicate about the visual outcomes (i.e., the artwork) |
| Ending phase | 5 min | Sharing overall impressions of the art-making process and discussing the significance of the experience |
The collected data were analyzed using the multiple case study method proposed by Creswell and Poch [20]. The within-case analysis was designed to explore the key issues encountered by participants throughout the family art therapy sessions. To achieve this, photographs of artwork, verbatim transcripts, and clinical notes gathered during the therapy were meticulously documented. Verbatim transcripts from in-depth interviews were also transcribed and cross-referenced with clinical notes to ensure data consistency. Furthermore, to grasp the holistic significance of the family art therapy experience, the data were repeatedly reviewed by listening to the recordings. Cross-case analysis facilitated the identification of themes by examining the similarities and differences across cases. The research team, consisting of all three study authors, regularly exchanged and deliberated on the analyzed data. Additionally, two art therapists with extensive experience in qualitative research reviewed the data to enhance the study’s validity and reliability. The within-case analysis followed the approach of a prior study [21], which involved analyzing multiple case phenomena to identify themes through case comparisons. The content of the family art therapy sessions and interviews was derived from both within-case and cross-case analyses. The artworks produced during the sessions were also examined to deepen the understanding of the cases (Figure 1).
Figure 1.Family art therapy works.
In this study, the criteria of truth value, applicability, consistency, and neutrality, as proposed by Lincoln and Guba [22], were employed to enhance the reliability and validity of our findings. To ensure truth value, the researchers repeatedly read, analyzed, and summarized the collected data sources. For applicability, the team engaged in discussions to confirm the meanings of the participants’ themes and continued to collect data until saturation was reached, ensuring the data was rich with experience-oriented information. To achieve consistency, all three researchers were involved in every step of data collection and analysis, categorizing interview content through ongoing dialogue. Lastly, to maintain neutrality, the researchers meticulously reviewed the data to check for any inclusion of their own biases or claims, striving to keep a value-neutral stance while carefully avoiding the influence of their subjective perspectives.
Family A consisted of a pancreatic cancer patient (A1) and her cohabitating family members. Her daughter (A2) and granddaughter (A3) engaged in art therapy sessions. Participant A1, who had pancreatic cancer, was admitted to a hospice ward, while Participant A2, her daughter, was her primary caregiver. With the grandmother hospitalized, Participant A3 resided alone at home and joined a family art therapy session once during a visit to the hospital, at the request of Participants A1 and A2.
In the first session, Participant A1 referred to cancer as “my friend,” indicating an acceptance of living with the disease and acknowledging its role in the end of her life. She conveyed to the therapist a complex mix of regret and gratitude: regret for the burden placed on her child, who was caring for her, and gratitude for their care, despite the sorrow of leaving them behind. Participant A2 wept consistently during the program, expressing deep concern for Participant A1’s cancer-related pain and the anxiety and sadness stemming from her end-of-life circumstances.
In the second and third sessions, the participants reflected on their family’s memories and explored aspects they cherished about their family life. This contrasted with the first session, during which Participant A2 expressed apprehension about art, saying, “I haven’t done art,” and “I don’t know how to do it, Mom, you try it.” However, as the sessions progressed, they began to communicate and collaborate, making concerted efforts to complete their projects using a variety of materials within the frame. Initially burdened and lacking confidence in their artistic abilities, they gradually became more engaged, actively creating their own artwork and experimenting with different materials. As the sessions allowed family members to share feelings and thoughts that are not typically expressed, they found themselves able to articulate their emotions and communicate with one another more openly and comfortably.
In the fourth session, Family A engaged in a creative activity where they made gifts for one another using their preferred materials. Participant A1 chose to represent A2 and A3 as animals, using metaphor to communicate her feelings to her family. Participant A2 crafted trophies from felt and wood as tokens of love and appreciation for his family members. Participant A3 drew a family portrait in which the figures appeared sad, seemingly reflecting their current circumstances, yet they also seemed to be attempting to smile. Additionally, she shared that although she initially feared hospital visits, the sessions provided a valuable opportunity to spend time with her family.
2) Family BThe patient from Family B, along with her daughter and spouse, engaged in art therapy. Participant B1, a female patient diagnosed with oral cancer, and Participant B2, her only daughter, who had resided in Canada but returned to Korea to assist in B1’s care, were involved in the sessions. Participant B3, B1’s husband, alternated with B2 in providing care for B1. Despite B1’s restricted verbal communication abilities due to hearing loss, she was able to communicate non-verbally through eye contact and gestures like nodding or shaking her head.
The first session (crafting) was designed with Participant B1’s fondness for knitting in mind. Participant B1 quickly grasped the techniques demonstrated by the therapist and proceeded to work independently. Observing her intense concentration on the task, Participant B2 expressed surprise and admiration for the beautiful finished product. During the session, Participant B2 became emotional and shed tears while composing a message card as part of her artwork. In a gesture of comfort, Participant B1 responded by writing words of love to B2 in her own message card. Participant B1, who was previously observed to be helpless, started to actively participate in making artwork. Participant B2 found a new avenue for interacting with her mother through their shared artistic endeavor, fostering a deeper familiarity between the mother and daughter, and promoting positive support between them.
The second and third sessions centered around family photographs to facilitate positive reminiscence and encourage the sharing of family memories, fostering open emotional expression. Participant B1 was reluctant to trim photos that included family members’ faces, displaying affection by holding them close or kissing the images. Participant B2, with a sentiment of preserving joyful recollections, remarked, “Mom, keep only happy memories,” and aptly titled the artwork “Grandmother’s Hope.” Participant B1 reflected on how the restrictions on family visits during the COVID-19 pandemic led her to reminisce about her youth and family, which helped her feel reconnected with her loved ones. During the art-making process, Participants B1 and B3 experienced a disagreement over the choice of materials and colors. Despite this, Participant B1 was able to articulate her preferences succinctly, using just one or two words. Participant B3, in turn, provided functional support and respect for Participant B1’s choices, ensuring that Participant B1 could express what she wanted.
The fourth session focused on fostering a range of emotional expressions and promoting clear communication within the family. Participants B2 and B3 were given time to reflect on how to preserve their familial bonds. They set a definitive goal to show their affection for Participant B1 by crafting a bracelet and a necklace as tokens of their love. Despite Participant B1’s increased sleeping hours, B2 and B3 remained hopeful that they could connect with her upon her awakening by presenting their handmade gifts. Their commitment to the art therapy sessions persisted even as Participant B1’s condition worsened. The family utilized art therapy to demonstrate support, foster reconciliation, and affirm their love for one another in the face of hardship, choosing to engage and confront issues rather than diminishing communication and avoiding problems.
3) Family CThe patient and his spouse engaged in art therapy. Participant C1, a male patient diagnosed with pancreatic cancer, was accompanied by Participant C2, his caregiving spouse. Despite experiencing symptoms of general weakness, Participant C1 consistently attended each art therapy session alongside Participant C2. Participant C2 experienced confusion and expressed deep sadness regarding Participant C1’s terminal illness and the prospect of their impending separation. Through their involvement in family art therapy, Participants C1 and C2 openly communicated their emotions and thoughts, conveying their feelings through their artwork to family members who were unable to attend the sessions.
In the first session, Participants C1 and C2 were not familiar with creating artwork, having not engaged in such activities since childhood. Participant C1, who had recently been admitted to a hospital ward, reported experiencing both physical and psychological challenges. He conveyed his aspirations for health and recovery with the metaphor, “I want to revive like a potted plant that has lived for a long time.” Meanwhile, Participant C2 expressed profound sorrow regarding the abrupt decline in Participant C1’s health.
In the second and third sessions, as Participant C1’s condition deteriorated, both C1 and C2 spent time sharing memories and conveying emotions they had longed to express to one another. Participant C1 affectionately referred to C2 as “an angel,” admitting, with some embarrassment, that this was their first time expressing such affection, which deeply moved Participant C2. Initially, upon admission to the hospice ward, their communication was marked by sharpness and irritability, likely due to the abrupt nature of the admission. However, as they reflected on their shared life and discussed previously unvoiced feelings of regret and guilt, they found opportunities to articulate a range of emotions, including those that were negative.
Due to Participant C1’s pain, the fourth session took place in a hospital room. Both Participants C1 and C2 remarked that they became distracted from their pain while engaged in the art-making process. Participant C2 observed that although Participant C1 is typically confined to bed because of pain, the shared art activity in the otherwise stark hospital environment provided a sense of relaxation. When asked by the therapist what message he wished to convey to his family, Participant C1 asked, “You mean writing a will?” He then created an artwork depicting a tree with leaves, symbolizing the values and beliefs he wanted to communicate to his loved ones. Previously, Participant C1 had been uncomfortable with expressing himself either verbally or through art, but he began to view family time more positively and started to gradually come to terms with the prospect of separation.
4) Family DIn Family D, both the patient and her mother engaged in art therapy. Participant D1, a female patient with breast cancer, and Participant D2, her mother, were involved in the sessions. Participant D1 endeavored to come to terms with her terminal diagnosis, revealing that her primary worry was for the well-being of Participant D2, who would be left behind, rather than her own impending death.
In the initial session, Participant D1 created a painting inspired by memories of past family moments, while Participant D2 reflected on her daughter’s impending absence, expressing feelings of sadness and despair. Participant D1 engaged enthusiastically in the painting activity and encouraged Participant D2 to join in the art therapy.
In the second and third sessions, Participant D1 reminisced about a family trip and expressed the desire to leave behind the phrase, “Be happy and do not get sick.” Meanwhile, Participant D2 began drawing a house where she envisioned living with her daughter. However, she eventually abandoned the artwork, stating that creating the painting no longer held meaning for her. The anticipated sadness of Participant D2, stemming from their impending separation, persisted throughout. Despite this, Participant D1 consistently provided support, helping Participant D2 feel stable and encouraging her to create lasting memories through her artwork.
In the fourth session, participants D1 and D2 demonstrated increased levels of active communication compared to previous sessions. Participant D2 shared her desire to live in the countryside with her family by creating a collage, and she managed to safely navigate her emotions, including regret, sadness, chagrin, and remorse, associated with the anticipated separation and loss. Notably, they both expressed previously unvoiced regrets to one another, leading to a profound moment of mutual empathy and forgiveness. While Participant D2 consistently expressed negative emotions such as anger and sadness about the impending separation in each session, she was able to maintain stability and prepare for the forthcoming grieving process by engaging in artwork alongside Participant D1.
Based on the analysis of the collected data, this study derived three categories and nine subcategories (Table 4).
Table 4 Experience of Art Therapy in Patients with Terminal Cancer and their Families.
| Categories | Subcategories |
|---|---|
| Belief systems evolve as individuals transform their understanding of illness and death into a positive outlook, discovering meaning in the process | Feeling unfamiliar and intimidated by the idea of expressing my thoughts through art |
| Trying to accept the present and positively overcome sadness | |
| Expressing hope through emotional bonds during the process of parting | |
| Conveying and preserving personal and family beliefs | |
| Within the crisis, a sense of family bonding is strengthened and cohesion is formed | Feeling upset about family imbalances caused by deteriorating health |
| Valuing togetherness and striving for stability amidst the current challenges | |
| Experiencing art therapy that aids in clear communication and open emotional expression, the family overcomes crisis and moves forward | Art as a medium of empowerment for patients and facilitator of family conversations, even amidst difficulties |
| Sharing a range of emotions, not just joy, but concerns and sorrow, through art | |
| Gratitude for art's role in improving family communication and connection through artwork |
At the start of family art therapy, participants were initially uncomfortable with creating artwork and hesitant to convey their memories through this medium. Nevertheless, as they engaged in process-oriented art activities, patients and their families began to communicate and express a range of emotions. This interaction led to a positive shift in their attitudes toward their circumstances. In addition, the participants shared important things in their lives with their families through artwork.
This study employed a multiple case study method to explore the experiences of terminal cancer patients and their families with family art therapy in a hospice ward, as well as the meanings they derived from these experiences. Nine themes were derived: “feeling unfamiliar and intimidated by the idea of expressing my thoughts through art,” “trying to accept the present and positively overcome sadness,” “expressing hope through emotional bonds during the process of parting,” “conveying and preserving personal and family beliefs,” “feeling upset about family imbalances caused by deteriorating health,” “valuing togetherness and striving for stability amidst the current challenges,” “art as a medium of empowerment for patients and facilitator of family conversations, even amidst difficulties,” “sharing a range of emotions—not just joy, but concerns and sorrow—through art,” and “gratitude for art’s role in improving family communication and connection through artwork.”
Through family art therapy, the belief systems of the participants in this study changed as they found meaning in the face of death and separation. The concept of family resilience emerged within these belief systems, framing adversity as meaningful and fostering a positive outlook characterized by hope and proactive behavior [23]. Initially, some participants were uncomfortable and hesitant to express their emotions through art. Over time, however, they began to reflect on meaningful experiences, embraced the present with a positive attitude, and expressed hope while navigating the emotional journey of separation. Furthermore, their artwork became a symbolic representation of their feelings about death, with motifs such as “sunflowers, heaven, angels, and revival,” enabling them to ascribe new meaning to their lives and find stability amidst the anticipation of death and separation. The process of creating art allowed patients to metaphorically express their intuitions and feelings, helping them to adopt a more accepting and flexible perspective on the dying process, even in the midst of anxiety and existential fear [11]. Additionally, the theme of “conveying and preserving personal and family beliefs” identified in this study echoes the findings of another [12], which observed that patients in an inpatient hospice setting produced tangible artifacts during art therapy sessions, some of which became cherished keepsakes. This study also corroborates research [24] indicating that family art therapy significantly enhances hope and quality of life for terminally ill patients. It suggests that a resilience-based approach, which can evolve over time, should be implemented as early as possible for both cancer and non-cancer patients by the hospice palliative care team.
In this study, participants became more open in their communication styles, sharing their innermost truths with one another through repeated interactions. They expressed a range of complex emotions beyond just positive feelings like gratitude and love; they also shared feelings of regret, sorrow, and sadness, which they empathized with. This suggests that despite the patients’ worsening conditions and the difficulty in accepting their terminal diagnoses, art therapy enabled them to express a variety of normally concealed emotions. Artworks served as a conduit for communication, acting as a window through which they could connect. This observation aligns with previous research indicating that terminal cancer patients in an inpatient hospice were better able to articulate their emotions while engaging with images and creating paintings in an art therapy program [25]. Similarly, family members were able to rebuild intimate connections, and there was an increase in positive communication through the creation of artwork [13]. Additionally, this study’s findings resonate with those of another study [26], where families who received praise and support during family art therapy experienced healing from their emotional wounds, gained a sense of stability, and engaged in more open communication. Participants noted that the artworks produced during art therapy sessions not only facilitated family communication and strengthened bonds but also served as a medium for connection, especially when visits were restricted due to COVID-19 and interactions were limited by the patients’ declining health. The artworks became a testament to the patients’ and families’ messages, symbolizing promises and conveying their sentiments.
In this study, participants maintained supportive and friendly relationships despite the deterioration of patients’ conditions or experiences of burnout among family members. Family cohesion, which refers to the emotional connection, commitment, and mutual support among family members, has a direct impact on the unity of the family [27]. Initially, art therapy sessions were challenging for participants, as they grappled with the upset caused by the worsening health of patients and the resulting family imbalance. Over time, however, they began to strengthen their family bonds through the shared experience of creating art amidst the adversity of impending death—a situation that can be both confusing and overwhelming. Furthermore, by engaging in art and conversation, family members were able to share memories and strive for stability during the crisis, viewing the terminal conditions not merely as problems but as opportunities to find meaning in life by valuing their time together. This observation aligns with findings from another study [28], which reported that participants could gain a deeper understanding of themselves and their family members through family art therapy, and that positive feedback could transform their perceptions.
In this study, we found that participants were able to reconstruct family dynamics and maintain stability even under challenging circumstances. This included selecting art materials that reflected the preferences of family members and creating gifts for those unable to attend family art therapy sessions. These behaviors align with findings from a previous study [29], which indicated that family art therapy supports the emotional stability of family members experiencing shared trauma, and fosters inner healing and personal growth. The significance of this study lies in its demonstration of how patients and their families can collectively rediscover life’s meaning, engage in healthy communication, and strengthen their bond, even when confronted with the crisis of end-of-life issues and death.
The limitations of this study, along with suggestions for future research, are outlined below. First, the case studies included in this research were limited to fewer than five sessions for patients in a hospice ward. Patients who died after attending only one or two sessions were not included. Furthermore, due to the short duration of the study, there was a limitation in exploring the profound significance of resilience for terminal cancer patients and their families. Future research should consider longer-term interventions and include patients utilizing a variety of services, such as consultative care or advisory services, along with their families. Second, while this study provided an in-depth look at the experiences of art therapy among terminal cancer patients in a hospice setting and their families, it is important for future research to include non-cancer patients at the end of life and their families as well.
Supplementary materials can be found via https://doi.org/10.14475/jhpc.2023.26.4.171.
No potential conflict of interest relevant to this article was reported.
Conception or design of the work: all authors. Data collection: NP, SK. Data analysis and interpretation: NP, SK. Drafting the article: NP, SK. Critical revision of the article: NP, SK. Final approval of the version to be published: all authors.
J Hosp Palliat Care 2023; 26(4): 171-184
Published online December 1, 2023 https://doi.org/10.14475/jhpc.2023.26.4.171
Copyright © Journal of Hospice and Palliative Care.
Nahyun Park , Im-Il Na* , Sinyoung Kwon†
Graduate School, Ewha Womans University,
*Regional Hospice Center, Korea Cancer Center, Korea Institute of Radiological and Medical Sciences, Seoul,
†Department of Nursing, Gangdong University, Eumseong, Korea
Correspondence to:Sinyoung Kwon
ORCID: https://orcid.org/0000-0001-8707-9281
E-mail: esther9324@naver.com
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Purpose: The study explored the meaning of experiences within a family art therapy process among terminal cancer patients and their families. Methods: Ten participants, including four terminal cancer patients currently admitted to the hospice ward at an inpatient hospice facility in S City and four caregiving family members, engaged in four cycles of family art therapy sessions. The sessions were conducted weekly or bi-weekly, and each lasted approximately 50 minutes. Results: Nine cross-case themes emerged: “feeling unfamiliar and intimidated by the idea of expressing my thoughts through art,” “trying to accept the present and positively overcome sadness,” “expressing hope through emotional bonds during the process of parting,” “conveying and preserving personal and family beliefs,” “feeling upset about family imbalances caused by deteriorating health,” “valuing togetherness and striving for stability amidst the current challenges,” “art as a medium of empowerment for patients and facilitator of family conversations, even amidst difficulties,” “sharing a range of emotions—not just joy, but concerns and sorrow—through art,” and “gratitude for art’s role in improving family communication and connection through artwork. Conclusion: The findings of this study lead to several conclusions. First, patients and their families faced psychological challenges when confronted with impending death, yet they strove to remain optimistic by seeking meaning in their struggles. Second, families practiced open and expressive communication, sharing a spectrum of complex emotions with one another. Third, even as the patient’s condition worsened, resulting in family fatigue, their support and cohesion strengthened.
Keywords: Hospice care, Palliative care, Art therapy, Qualitative research
In South Korea, life expectancy is on the rise, thanks to advances in medical technology and early screening efforts [1]. However, cancer remains the leading cause of death, accounting for 26.0% (n=82,688) of all fatalities [2]. This statistic underscores the urgent need for effective care for terminal cancer patients and their families [3].
The number of patients utilizing domestic hospice facilities has been on the rise, increasing from 10.6% in 2010 to 21.5% in 2021. In 2021 alone, there were 10,991 new patients (57.2%) who sought care at inpatient hospice institutions [4]. Terminal cancer patients are the primary candidates for inpatient hospice services. The goal of hospice palliative care is to develop comprehensive care plans that address the physical, psychological, social, and spiritual needs of terminal cancer patients and their families, thereby improving their quality of life [3,5].
Terminal cancer patients face an irreversible prognosis and are expected to die within several months. They endure significant physical distress, including severe pain, dyspnea, nausea, vomiting, and delirium [1]. Additionally, they suffer from emotional distress, grappling with questions about why they developed cancer and confronting the progression of their disease and the prospect of death [6]. Cancer patients encounter numerous challenges throughout their diagnosis and treatment, leading to crises and a profound sense of existential loss [7]. Consequently, terminal cancer patients require not only physical care but also psychological, existential, and spiritual support to address the psychological trauma and feelings of helplessness that arise from their fears [3].
Care is necessary not only for terminal cancer patients but also for their families. Families of terminal cancer patients often endure significant distress, grappling with the caregiving burden and the looming anxiety of death. This constant exposure can lead to them becoming “hidden patients” [8] or experiencing withdrawal or regression in response to the adversity of the patient’s impending death. To preserve family functioning, it is important to gradually imbue crises with positive meanings, thereby enhancing coping skills through the mobilization of resources at the individual, family, and community levels [9]. Consequently, there is a need to provide services that improve the quality of life and reduce the stress experienced by these families, as well as to develop interventions that bolster their ability to independently resolve problems [10].
Art therapy assists patients confronting mortality by increasing their acceptance of death anxiety and existential concerns, enhancing their sense of connectedness with others, including family members and healthcare providers, and improving self-expression and quality of life [11]. Furthermore, art therapy enables terminal cancer patients and their families to experience a sense of connectedness through the metaphorical symbolism of art, preserve their identity, and strengthen resilience by creating a lasting memento in the form of artwork [12]. It also facilitates the acceptance of the patient’s death by helping families to recollect memories and maintain stable relationships through art, even amidst the challenging period of dying [13].
Previous studies [13,14] have demonstrated that using art as a medium can lead to positive changes in terminal cancer patients and their families. These changes occur as they are provided with opportunities to understand one another better and to share their perceptions of life’s meaning. Specifically, art therapy aimed at bolstering family resilience is an effective approach for families to experience positive shifts in their belief systems. This is achieved by recognizing the strengths of individual family members and fostering positive life attitudes through the creation of supportive artwork [15]. As art therapy sessions continue, families become more aware of their existing communication patterns and any underlying issues. They naturally acquire positive communication skills, such as the ability to share thoughts and feelings, by engaging in collaborative art projects [15]. Open and constructive communication within the family unit encourages members to recognize the importance of a stable family structure. It also aids in defining clear family boundaries and roles, which includes establishing family rules and modeling appropriate behaviors [16,17]. Therefore, family art therapy offers a secure and therapeutic avenue for terminal cancer patients and their families to uncover positive family resources and improve communication. The significance of family art therapy, as applied in the current study, lies in its ability to help terminal cancer patients and their families view the end-of-life process not as a crisis but as an opportunity. It allows them to build upon their inherent strengths and cultivate positive emotions.
A family resilience approach involves the processes by which families facing crises and adversity perceive difficulties as challenges, assess the family’s resources and strengths rooted in relationships and functions, and work together to address problems [17]. Consequently, this study, guided by the factors of the belief system, communication process, and orientational pattern as proposed by Walsh [18], implemented family art therapy for terminal cancer patients and their families. The aim was to facilitate a positive and stable shift in their belief systems, promote intimate and clear communication, and help reconstruct family roles.
The purpose of this study was to gain insights into the experiences of terminal cancer patients and their families during family art therapy sessions, as well as to discern the significance of these experiences. By examining the challenges faced by patients and families amidst the crisis of impending death and separation, their adaptation to this crisis, and their engagement in family art therapy, the study sought to enhance our understanding of these individuals. Furthermore, it aimed to lay the groundwork for the development and implementation of family art therapy programs within the clinical realm of hospice palliative care.
This qualitative study utilized a multiple case study approach to explore in depth the meaning and essence of family art therapy as experienced by terminal cancer patients admitted to inpatient hospice facilities and their families.
The study participants consisted of patients admitted to the hospice ward of K General Hospital in S City, along with their families who understood the study’s purpose and provided informed consent. The researcher, an art therapist at an inpatient hospice facility, had previously discussed the study’s aims with the hospital’s manager to facilitate the recruitment of medically stable patients and their families who might benefit from psychological and emotional support. Given the nature of terminal cancer, patients whose conditions significantly deteriorated or who passed away were excluded from the study. The inclusion criteria required patients to be capable of communicating for approximately 50 minutes while in bed or in a wheelchair and to participate in at least three out of four scheduled family art therapy sessions, along with their family members.
The final number of participants was 10, comprising four patients admitted to a hospice ward and six family members. Two families out of four had three participants—one patient and two caregivers—each. The age distribution of participants was as follows: one in their teens, one in their 30s, two in their 40s, one in their 50s, one in their 60s, two in their 70s, and two in their 80s. The group included two men and eight women. The mean length of stay in the hospice was 19.3 days, and seven of the 10 participants were religious (Table 1).
Table 1 . Characteristics of Participants (N=10)..
| Category | Sex | Age (yr) | Religion | Diagnosis | |
|---|---|---|---|---|---|
| Family A | A1 | Female | 82 | Buddhist | Pancreatic cancer |
| A2 | Female | 46 | Buddhist | - | |
| A3 | Female | 12 | Buddhist | - | |
| Family B | B1 | Female | 76 | Atheist | Oral cancer |
| B2 | Female | 42 | Atheist | - | |
| B3 | Male | 83 | Atheist | - | |
| Family C | C1 | Male | 70 | Protestant | Pancreatic cancer |
| C2 | Female | 68 | Protestant | - | |
| Family D | D1 | Female | 36 | Protestant | Breast cancer |
| D2 | Female | 59 | Protestant | - | |
The content and methodology of this study received approval from the Institutional Review Board of K Hospital (KIRAMS 2020-03-018-002). Data collection took place from July 8, 2020 to February 5, 2021. Researchers clearly communicated the study’s purpose and methods to the participants, ensuring they understood that there were no disadvantages to non-participation, that they could withdraw at any time, and that their personal information would remain confidential. The data compiled included voice recordings and verbatim transcripts of family art therapy sessions, clinical notes from each session, photographs of artwork, and in-depth interviews. Following each session, individual in-depth interviews with patients were conducted, lasting approximately 30 minutes, contingent upon their medical conditions. In cases where a patient’s condition deteriorated to the point where they could not participate in an in-depth interview, family interviews were conducted, focusing on their experiences with art therapy. Observations of participants’ facial expressions, tones, and behaviors, as well as photographs of artwork and the researcher’s reflections, were meticulously documented in field notes during the art therapy sessions and interviews.
In this study, the family art therapy program was conducted either in a hospital room or a designated program room, taking into account the preferences and convenience of the participants. The therapy was provided on an individual family basis. If a patient experienced pain or discomfort during the session, the art therapist promptly informed the attending nurse, and the session was adjusted to accommodate the patient’s condition. The family art therapy approach utilized in this research drew upon methods designed to enhance family resilience [17], as well as a program developed for patients in an inpatient hospice and their families [13]. Considering that the maximum stay in an inpatient hospice is typically three weeks, the therapy comprised four sessions, each lasting approximately 50 minutes, and was scheduled once or twice weekly.
One of the researchers in this study conducted the art therapy program. This individual holds a bachelor’s degree in Western painting and a master’s degree in art therapy, and had completed all coursework for a doctoral program at the time of this study. Certified as an art psychotherapist, the researcher has been practicing as an art therapist at a hospice institution since 2018. The family art therapy approach utilized in this study was grounded in the concept of family resilience, as outlined in Table 2. Each session (Table 3) was structured according to the Psychocybernetic Model of Art Therapy (PMAT) developed by Nucho [19]. The PMAT framework is divided into four phases. Initially, during the unfreezing phase, participants were briefed on the goals of visual expression and the therapeutic process. They were also encouraged to unwind through discussions about the day’s theme, exploration of art materials, and sharing their current feelings. Next, in the doing phase, the researcher fostered an environment conducive to concentration and encouraged participants to express their emotions freely and to recognize these emotions in their artwork. In the dialoguing phase, patients and their families presented and discussed their visual creations. Finally, the ending phase provided an opportunity for participants to share their overall impressions of the artwork and reflect on the meaning of their experiences. For this program, a variety of materials were made available to accommodate the needs and preferences of the families, including paper for painting, as well as clay, threads, and fibers—chosen for their ease of use and gentle texture suitable for terminal cancer patients. Additionally, photographs and collage materials were provided to cater to the diverse interests of the participants.
Table 2 . Family Art Therapy Intervention Program..
| Session | Elements of family resilience | Aim | Theme | Activities |
|---|---|---|---|---|
| 1 | Belief system: Explore family beliefs | 1. Comprehend the concept and significance of family resilience 2. Establish a therapeutic relationship 3. Discover familial beliefs | Describe my family through an object | Initial orientation Identifying a symbolic family object |
| 2 | Belief system: Discover the meaning within difficulties Communication: Facilitate clear expression and communication | 1. Uncover lessons from overcoming past difficulties 2. Enhance effective and authentic communication | Our treasured memories | Sharing and expressing family memories Utilizing various materials |
| 3 | Organizational patterns: Explore and harness available family resources Communication: Foster openness in emotional expression | 1. Share emotions and acquire effective communication skills 2. Discover social and economic resources | Connective heart of the family | Exploring family resources and support Sharing and expressing feelings and thoughts through preferred art mediums |
| 4 | Organizational patterns: Promote family connectedness | 1. Facilitate the sharing of emotions while also promoting reconciliation and support | Create gifts for each other | Creating gifts for family using a variety of materials |
Table 3 . The Approach to Family Art Therapy Based on the Psychocybernetic Model of Art Therapy (PMAT)..
| Phase | Time | Contents |
|---|---|---|
| Unfreezing phase | 10 min | Guiding the client on the purpose of visual expression and the therapeutic process Spending time with the therapist and participant to share topics, explore mediums, and discuss current feelings, aiming to relax and release tension |
| Doing phase | 15~20 min | Creating an atmosphere that allows participants to concentrate and freely express emotions Facilitating opportunities for perception through the creative process |
| Dialoguing phase | 20~25 min | Having the opportunity to introduce and communicate about the visual outcomes (i.e., the artwork) |
| Ending phase | 5 min | Sharing overall impressions of the art-making process and discussing the significance of the experience |
The collected data were analyzed using the multiple case study method proposed by Creswell and Poch [20]. The within-case analysis was designed to explore the key issues encountered by participants throughout the family art therapy sessions. To achieve this, photographs of artwork, verbatim transcripts, and clinical notes gathered during the therapy were meticulously documented. Verbatim transcripts from in-depth interviews were also transcribed and cross-referenced with clinical notes to ensure data consistency. Furthermore, to grasp the holistic significance of the family art therapy experience, the data were repeatedly reviewed by listening to the recordings. Cross-case analysis facilitated the identification of themes by examining the similarities and differences across cases. The research team, consisting of all three study authors, regularly exchanged and deliberated on the analyzed data. Additionally, two art therapists with extensive experience in qualitative research reviewed the data to enhance the study’s validity and reliability. The within-case analysis followed the approach of a prior study [21], which involved analyzing multiple case phenomena to identify themes through case comparisons. The content of the family art therapy sessions and interviews was derived from both within-case and cross-case analyses. The artworks produced during the sessions were also examined to deepen the understanding of the cases (Figure 1).
Figure 1. Family art therapy works.
In this study, the criteria of truth value, applicability, consistency, and neutrality, as proposed by Lincoln and Guba [22], were employed to enhance the reliability and validity of our findings. To ensure truth value, the researchers repeatedly read, analyzed, and summarized the collected data sources. For applicability, the team engaged in discussions to confirm the meanings of the participants’ themes and continued to collect data until saturation was reached, ensuring the data was rich with experience-oriented information. To achieve consistency, all three researchers were involved in every step of data collection and analysis, categorizing interview content through ongoing dialogue. Lastly, to maintain neutrality, the researchers meticulously reviewed the data to check for any inclusion of their own biases or claims, striving to keep a value-neutral stance while carefully avoiding the influence of their subjective perspectives.
Family A consisted of a pancreatic cancer patient (A1) and her cohabitating family members. Her daughter (A2) and granddaughter (A3) engaged in art therapy sessions. Participant A1, who had pancreatic cancer, was admitted to a hospice ward, while Participant A2, her daughter, was her primary caregiver. With the grandmother hospitalized, Participant A3 resided alone at home and joined a family art therapy session once during a visit to the hospital, at the request of Participants A1 and A2.
In the first session, Participant A1 referred to cancer as “my friend,” indicating an acceptance of living with the disease and acknowledging its role in the end of her life. She conveyed to the therapist a complex mix of regret and gratitude: regret for the burden placed on her child, who was caring for her, and gratitude for their care, despite the sorrow of leaving them behind. Participant A2 wept consistently during the program, expressing deep concern for Participant A1’s cancer-related pain and the anxiety and sadness stemming from her end-of-life circumstances.
In the second and third sessions, the participants reflected on their family’s memories and explored aspects they cherished about their family life. This contrasted with the first session, during which Participant A2 expressed apprehension about art, saying, “I haven’t done art,” and “I don’t know how to do it, Mom, you try it.” However, as the sessions progressed, they began to communicate and collaborate, making concerted efforts to complete their projects using a variety of materials within the frame. Initially burdened and lacking confidence in their artistic abilities, they gradually became more engaged, actively creating their own artwork and experimenting with different materials. As the sessions allowed family members to share feelings and thoughts that are not typically expressed, they found themselves able to articulate their emotions and communicate with one another more openly and comfortably.
In the fourth session, Family A engaged in a creative activity where they made gifts for one another using their preferred materials. Participant A1 chose to represent A2 and A3 as animals, using metaphor to communicate her feelings to her family. Participant A2 crafted trophies from felt and wood as tokens of love and appreciation for his family members. Participant A3 drew a family portrait in which the figures appeared sad, seemingly reflecting their current circumstances, yet they also seemed to be attempting to smile. Additionally, she shared that although she initially feared hospital visits, the sessions provided a valuable opportunity to spend time with her family.
2) Family BThe patient from Family B, along with her daughter and spouse, engaged in art therapy. Participant B1, a female patient diagnosed with oral cancer, and Participant B2, her only daughter, who had resided in Canada but returned to Korea to assist in B1’s care, were involved in the sessions. Participant B3, B1’s husband, alternated with B2 in providing care for B1. Despite B1’s restricted verbal communication abilities due to hearing loss, she was able to communicate non-verbally through eye contact and gestures like nodding or shaking her head.
The first session (crafting) was designed with Participant B1’s fondness for knitting in mind. Participant B1 quickly grasped the techniques demonstrated by the therapist and proceeded to work independently. Observing her intense concentration on the task, Participant B2 expressed surprise and admiration for the beautiful finished product. During the session, Participant B2 became emotional and shed tears while composing a message card as part of her artwork. In a gesture of comfort, Participant B1 responded by writing words of love to B2 in her own message card. Participant B1, who was previously observed to be helpless, started to actively participate in making artwork. Participant B2 found a new avenue for interacting with her mother through their shared artistic endeavor, fostering a deeper familiarity between the mother and daughter, and promoting positive support between them.
The second and third sessions centered around family photographs to facilitate positive reminiscence and encourage the sharing of family memories, fostering open emotional expression. Participant B1 was reluctant to trim photos that included family members’ faces, displaying affection by holding them close or kissing the images. Participant B2, with a sentiment of preserving joyful recollections, remarked, “Mom, keep only happy memories,” and aptly titled the artwork “Grandmother’s Hope.” Participant B1 reflected on how the restrictions on family visits during the COVID-19 pandemic led her to reminisce about her youth and family, which helped her feel reconnected with her loved ones. During the art-making process, Participants B1 and B3 experienced a disagreement over the choice of materials and colors. Despite this, Participant B1 was able to articulate her preferences succinctly, using just one or two words. Participant B3, in turn, provided functional support and respect for Participant B1’s choices, ensuring that Participant B1 could express what she wanted.
The fourth session focused on fostering a range of emotional expressions and promoting clear communication within the family. Participants B2 and B3 were given time to reflect on how to preserve their familial bonds. They set a definitive goal to show their affection for Participant B1 by crafting a bracelet and a necklace as tokens of their love. Despite Participant B1’s increased sleeping hours, B2 and B3 remained hopeful that they could connect with her upon her awakening by presenting their handmade gifts. Their commitment to the art therapy sessions persisted even as Participant B1’s condition worsened. The family utilized art therapy to demonstrate support, foster reconciliation, and affirm their love for one another in the face of hardship, choosing to engage and confront issues rather than diminishing communication and avoiding problems.
3) Family CThe patient and his spouse engaged in art therapy. Participant C1, a male patient diagnosed with pancreatic cancer, was accompanied by Participant C2, his caregiving spouse. Despite experiencing symptoms of general weakness, Participant C1 consistently attended each art therapy session alongside Participant C2. Participant C2 experienced confusion and expressed deep sadness regarding Participant C1’s terminal illness and the prospect of their impending separation. Through their involvement in family art therapy, Participants C1 and C2 openly communicated their emotions and thoughts, conveying their feelings through their artwork to family members who were unable to attend the sessions.
In the first session, Participants C1 and C2 were not familiar with creating artwork, having not engaged in such activities since childhood. Participant C1, who had recently been admitted to a hospital ward, reported experiencing both physical and psychological challenges. He conveyed his aspirations for health and recovery with the metaphor, “I want to revive like a potted plant that has lived for a long time.” Meanwhile, Participant C2 expressed profound sorrow regarding the abrupt decline in Participant C1’s health.
In the second and third sessions, as Participant C1’s condition deteriorated, both C1 and C2 spent time sharing memories and conveying emotions they had longed to express to one another. Participant C1 affectionately referred to C2 as “an angel,” admitting, with some embarrassment, that this was their first time expressing such affection, which deeply moved Participant C2. Initially, upon admission to the hospice ward, their communication was marked by sharpness and irritability, likely due to the abrupt nature of the admission. However, as they reflected on their shared life and discussed previously unvoiced feelings of regret and guilt, they found opportunities to articulate a range of emotions, including those that were negative.
Due to Participant C1’s pain, the fourth session took place in a hospital room. Both Participants C1 and C2 remarked that they became distracted from their pain while engaged in the art-making process. Participant C2 observed that although Participant C1 is typically confined to bed because of pain, the shared art activity in the otherwise stark hospital environment provided a sense of relaxation. When asked by the therapist what message he wished to convey to his family, Participant C1 asked, “You mean writing a will?” He then created an artwork depicting a tree with leaves, symbolizing the values and beliefs he wanted to communicate to his loved ones. Previously, Participant C1 had been uncomfortable with expressing himself either verbally or through art, but he began to view family time more positively and started to gradually come to terms with the prospect of separation.
4) Family DIn Family D, both the patient and her mother engaged in art therapy. Participant D1, a female patient with breast cancer, and Participant D2, her mother, were involved in the sessions. Participant D1 endeavored to come to terms with her terminal diagnosis, revealing that her primary worry was for the well-being of Participant D2, who would be left behind, rather than her own impending death.
In the initial session, Participant D1 created a painting inspired by memories of past family moments, while Participant D2 reflected on her daughter’s impending absence, expressing feelings of sadness and despair. Participant D1 engaged enthusiastically in the painting activity and encouraged Participant D2 to join in the art therapy.
In the second and third sessions, Participant D1 reminisced about a family trip and expressed the desire to leave behind the phrase, “Be happy and do not get sick.” Meanwhile, Participant D2 began drawing a house where she envisioned living with her daughter. However, she eventually abandoned the artwork, stating that creating the painting no longer held meaning for her. The anticipated sadness of Participant D2, stemming from their impending separation, persisted throughout. Despite this, Participant D1 consistently provided support, helping Participant D2 feel stable and encouraging her to create lasting memories through her artwork.
In the fourth session, participants D1 and D2 demonstrated increased levels of active communication compared to previous sessions. Participant D2 shared her desire to live in the countryside with her family by creating a collage, and she managed to safely navigate her emotions, including regret, sadness, chagrin, and remorse, associated with the anticipated separation and loss. Notably, they both expressed previously unvoiced regrets to one another, leading to a profound moment of mutual empathy and forgiveness. While Participant D2 consistently expressed negative emotions such as anger and sadness about the impending separation in each session, she was able to maintain stability and prepare for the forthcoming grieving process by engaging in artwork alongside Participant D1.
Based on the analysis of the collected data, this study derived three categories and nine subcategories (Table 4).
Table 4 . Experience of Art Therapy in Patients with Terminal Cancer and their Families..
| Categories | Subcategories |
|---|---|
| Belief systems evolve as individuals transform their understanding of illness and death into a positive outlook, discovering meaning in the process | Feeling unfamiliar and intimidated by the idea of expressing my thoughts through art |
| Trying to accept the present and positively overcome sadness | |
| Expressing hope through emotional bonds during the process of parting | |
| Conveying and preserving personal and family beliefs | |
| Within the crisis, a sense of family bonding is strengthened and cohesion is formed | Feeling upset about family imbalances caused by deteriorating health |
| Valuing togetherness and striving for stability amidst the current challenges | |
| Experiencing art therapy that aids in clear communication and open emotional expression, the family overcomes crisis and moves forward | Art as a medium of empowerment for patients and facilitator of family conversations, even amidst difficulties |
| Sharing a range of emotions, not just joy, but concerns and sorrow, through art | |
| Gratitude for art's role in improving family communication and connection through artwork |
At the start of family art therapy, participants were initially uncomfortable with creating artwork and hesitant to convey their memories through this medium. Nevertheless, as they engaged in process-oriented art activities, patients and their families began to communicate and express a range of emotions. This interaction led to a positive shift in their attitudes toward their circumstances. In addition, the participants shared important things in their lives with their families through artwork.
This study employed a multiple case study method to explore the experiences of terminal cancer patients and their families with family art therapy in a hospice ward, as well as the meanings they derived from these experiences. Nine themes were derived: “feeling unfamiliar and intimidated by the idea of expressing my thoughts through art,” “trying to accept the present and positively overcome sadness,” “expressing hope through emotional bonds during the process of parting,” “conveying and preserving personal and family beliefs,” “feeling upset about family imbalances caused by deteriorating health,” “valuing togetherness and striving for stability amidst the current challenges,” “art as a medium of empowerment for patients and facilitator of family conversations, even amidst difficulties,” “sharing a range of emotions—not just joy, but concerns and sorrow—through art,” and “gratitude for art’s role in improving family communication and connection through artwork.”
Through family art therapy, the belief systems of the participants in this study changed as they found meaning in the face of death and separation. The concept of family resilience emerged within these belief systems, framing adversity as meaningful and fostering a positive outlook characterized by hope and proactive behavior [23]. Initially, some participants were uncomfortable and hesitant to express their emotions through art. Over time, however, they began to reflect on meaningful experiences, embraced the present with a positive attitude, and expressed hope while navigating the emotional journey of separation. Furthermore, their artwork became a symbolic representation of their feelings about death, with motifs such as “sunflowers, heaven, angels, and revival,” enabling them to ascribe new meaning to their lives and find stability amidst the anticipation of death and separation. The process of creating art allowed patients to metaphorically express their intuitions and feelings, helping them to adopt a more accepting and flexible perspective on the dying process, even in the midst of anxiety and existential fear [11]. Additionally, the theme of “conveying and preserving personal and family beliefs” identified in this study echoes the findings of another [12], which observed that patients in an inpatient hospice setting produced tangible artifacts during art therapy sessions, some of which became cherished keepsakes. This study also corroborates research [24] indicating that family art therapy significantly enhances hope and quality of life for terminally ill patients. It suggests that a resilience-based approach, which can evolve over time, should be implemented as early as possible for both cancer and non-cancer patients by the hospice palliative care team.
In this study, participants became more open in their communication styles, sharing their innermost truths with one another through repeated interactions. They expressed a range of complex emotions beyond just positive feelings like gratitude and love; they also shared feelings of regret, sorrow, and sadness, which they empathized with. This suggests that despite the patients’ worsening conditions and the difficulty in accepting their terminal diagnoses, art therapy enabled them to express a variety of normally concealed emotions. Artworks served as a conduit for communication, acting as a window through which they could connect. This observation aligns with previous research indicating that terminal cancer patients in an inpatient hospice were better able to articulate their emotions while engaging with images and creating paintings in an art therapy program [25]. Similarly, family members were able to rebuild intimate connections, and there was an increase in positive communication through the creation of artwork [13]. Additionally, this study’s findings resonate with those of another study [26], where families who received praise and support during family art therapy experienced healing from their emotional wounds, gained a sense of stability, and engaged in more open communication. Participants noted that the artworks produced during art therapy sessions not only facilitated family communication and strengthened bonds but also served as a medium for connection, especially when visits were restricted due to COVID-19 and interactions were limited by the patients’ declining health. The artworks became a testament to the patients’ and families’ messages, symbolizing promises and conveying their sentiments.
In this study, participants maintained supportive and friendly relationships despite the deterioration of patients’ conditions or experiences of burnout among family members. Family cohesion, which refers to the emotional connection, commitment, and mutual support among family members, has a direct impact on the unity of the family [27]. Initially, art therapy sessions were challenging for participants, as they grappled with the upset caused by the worsening health of patients and the resulting family imbalance. Over time, however, they began to strengthen their family bonds through the shared experience of creating art amidst the adversity of impending death—a situation that can be both confusing and overwhelming. Furthermore, by engaging in art and conversation, family members were able to share memories and strive for stability during the crisis, viewing the terminal conditions not merely as problems but as opportunities to find meaning in life by valuing their time together. This observation aligns with findings from another study [28], which reported that participants could gain a deeper understanding of themselves and their family members through family art therapy, and that positive feedback could transform their perceptions.
In this study, we found that participants were able to reconstruct family dynamics and maintain stability even under challenging circumstances. This included selecting art materials that reflected the preferences of family members and creating gifts for those unable to attend family art therapy sessions. These behaviors align with findings from a previous study [29], which indicated that family art therapy supports the emotional stability of family members experiencing shared trauma, and fosters inner healing and personal growth. The significance of this study lies in its demonstration of how patients and their families can collectively rediscover life’s meaning, engage in healthy communication, and strengthen their bond, even when confronted with the crisis of end-of-life issues and death.
The limitations of this study, along with suggestions for future research, are outlined below. First, the case studies included in this research were limited to fewer than five sessions for patients in a hospice ward. Patients who died after attending only one or two sessions were not included. Furthermore, due to the short duration of the study, there was a limitation in exploring the profound significance of resilience for terminal cancer patients and their families. Future research should consider longer-term interventions and include patients utilizing a variety of services, such as consultative care or advisory services, along with their families. Second, while this study provided an in-depth look at the experiences of art therapy among terminal cancer patients in a hospice setting and their families, it is important for future research to include non-cancer patients at the end of life and their families as well.
Supplementary materials can be found via https://doi.org/10.14475/jhpc.2023.26.4.171.
No potential conflict of interest relevant to this article was reported.
Conception or design of the work: all authors. Data collection: NP, SK. Data analysis and interpretation: NP, SK. Drafting the article: NP, SK. Critical revision of the article: NP, SK. Final approval of the version to be published: all authors.
Table 1 Characteristics of Participants (N=10).
| Category | Sex | Age (yr) | Religion | Diagnosis | |
|---|---|---|---|---|---|
| Family A | A1 | Female | 82 | Buddhist | Pancreatic cancer |
| A2 | Female | 46 | Buddhist | - | |
| A3 | Female | 12 | Buddhist | - | |
| Family B | B1 | Female | 76 | Atheist | Oral cancer |
| B2 | Female | 42 | Atheist | - | |
| B3 | Male | 83 | Atheist | - | |
| Family C | C1 | Male | 70 | Protestant | Pancreatic cancer |
| C2 | Female | 68 | Protestant | - | |
| Family D | D1 | Female | 36 | Protestant | Breast cancer |
| D2 | Female | 59 | Protestant | - | |
Table 2 Family Art Therapy Intervention Program.
| Session | Elements of family resilience | Aim | Theme | Activities |
|---|---|---|---|---|
| 1 | Belief system: Explore family beliefs | 1. Comprehend the concept and significance of family resilience 2. Establish a therapeutic relationship 3. Discover familial beliefs | Describe my family through an object | Initial orientation Identifying a symbolic family object |
| 2 | Belief system: Discover the meaning within difficulties Communication: Facilitate clear expression and communication | 1. Uncover lessons from overcoming past difficulties 2. Enhance effective and authentic communication | Our treasured memories | Sharing and expressing family memories Utilizing various materials |
| 3 | Organizational patterns: Explore and harness available family resources Communication: Foster openness in emotional expression | 1. Share emotions and acquire effective communication skills 2. Discover social and economic resources | Connective heart of the family | Exploring family resources and support Sharing and expressing feelings and thoughts through preferred art mediums |
| 4 | Organizational patterns: Promote family connectedness | 1. Facilitate the sharing of emotions while also promoting reconciliation and support | Create gifts for each other | Creating gifts for family using a variety of materials |
Table 3 The Approach to Family Art Therapy Based on the Psychocybernetic Model of Art Therapy (PMAT).
| Phase | Time | Contents |
|---|---|---|
| Unfreezing phase | 10 min | Guiding the client on the purpose of visual expression and the therapeutic process Spending time with the therapist and participant to share topics, explore mediums, and discuss current feelings, aiming to relax and release tension |
| Doing phase | 15~20 min | Creating an atmosphere that allows participants to concentrate and freely express emotions Facilitating opportunities for perception through the creative process |
| Dialoguing phase | 20~25 min | Having the opportunity to introduce and communicate about the visual outcomes (i.e., the artwork) |
| Ending phase | 5 min | Sharing overall impressions of the art-making process and discussing the significance of the experience |
Table 4 Experience of Art Therapy in Patients with Terminal Cancer and their Families.
| Categories | Subcategories |
|---|---|
| Belief systems evolve as individuals transform their understanding of illness and death into a positive outlook, discovering meaning in the process | Feeling unfamiliar and intimidated by the idea of expressing my thoughts through art |
| Trying to accept the present and positively overcome sadness | |
| Expressing hope through emotional bonds during the process of parting | |
| Conveying and preserving personal and family beliefs | |
| Within the crisis, a sense of family bonding is strengthened and cohesion is formed | Feeling upset about family imbalances caused by deteriorating health |
| Valuing togetherness and striving for stability amidst the current challenges | |
| Experiencing art therapy that aids in clear communication and open emotional expression, the family overcomes crisis and moves forward | Art as a medium of empowerment for patients and facilitator of family conversations, even amidst difficulties |
| Sharing a range of emotions, not just joy, but concerns and sorrow, through art | |
| Gratitude for art's role in improving family communication and connection through artwork |
2024; 27(3): 103-106
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