HEALING GRIEF THROUGH ART:
ART THERAPY BEREAVEMENT GROUP WORKSHOPS
Malinda Ann Hill, M.A.

ABSTRACT

"Healing from grief is not the process of forgetting,
it is the process of remembering with less pain and more joy."

In recent years, professionals in the fields of grief counseling and art therapy have done much to address the value of non-verbal therapeutic approaches, such as drawing and guided visualization, to deal with the emotional stress arising from terminal illness and grief. In fact, the number of articles about art therapy with the dying and bereaved has steadily risen in the hospice and art therapy literature over the past ten years (Birnbaum,1991; Crenshaw, 1990 Goldstein Alter & Axelrod, 1996; Levi, Gilad & Friedman-Kalmovitca, 1996).

Grieving individuals are faced with overwhelming feelings and without proper support these intense feelings can lead to low self-esteem, depression, suicidal ideation and/or physical illness (Stroebe & Stroebe, 1987; Vachon, Sheldon, Lancee, Lyall, Rogers & Freeman, 1982; Windholz, Marmar & Horowitz, 1985). It has been found that many grieving individuals respond more quickly using creative arts therapies than through traditional verbal therapy (Irwin, 1991; Junge, 1985; McIntyre, 1990; Simon 1981).

Generally, in today's fast-paced society there is little time, space or support available for the grieving individual (Rosenblatt, 1988). During the period of grief, the physical and emotional well-being of the bereaved individual may be threatened (Carey, 1977; Clayton & Darvish, 1979; Parkes and Weiss, 1983; Osterweis, Solomon & Green, 1984; Rogers & Reich, 1988; Parkes, 1990). Health risks and psychological problems can be lessened and/or avoided if proper support and help is made available (Leick & David-Nielsen, 1990; Lieberman & Videka-Sherman, 1986; Nerken, 1993; Sanders, 1992; Rando, 1984; Reif, Patton, & Gold, 1995). Therefore, it is important to provide grieving individuals with emotionally supportive interventions in order to prevent long-term problems.

In the past, communities came together to support and help those who experienced a death in the family (Rosenblatt, Walsh & Jackson, 1976). Today, individuals are often isolated from extended family members and the community (Platt & Persico, 1992). As a result, grieving individuals feel alone in the grief process and often experience a lack of adequate support (Rodgers & Cowles, 1991). Bereavement support groups offer individuals the opportunity to share thoughts and feelings with others. Sharing within a supportive network can be of great help during this difficult time (McCallum, Piper & Morin, 1993).

Many researchers and practitioners have found that some type of involvement or participation in bereavement support groups is beneficial, useful or meaningful to this high-risk population (Levine, Toro & Perkins, 1993; Levy & Derby, 1992; Longmann, 1993; Marquis, 1996). Benefits from support group involvement include increased emotional, mental and physical stability during and after participation (McCallum, Piper & Morin, 1993; Thuen, 1994; Zimpfer, 1990; Yalom & Vinogradov, 1988). More specific benefits of group participation include: 1) feeling that one has a better understanding of the grief process; 2) feeling that one has a safe place in which to express one's emotions, developing better stress management skills; 3) being better able to cope with loneliness, developing support systems; and 4) improved self-esteem (Souter & Moore, 1989; Rognile, 1989). According to Worden (1991), bereavement support groups can provide one of the most efficient ways possible to work on or resolve incomplete mourning and to prepare the person to move forward with life.

The benefits of group support can be increased substantially with the addition of art therapy (Raymer & McIntyre, 1987; Schimmel & Kornreich, 1993; Schut, de Keijeser, van den Bout & Stroebe, 1997; Speert, 1993). Art therapy is a modality well-suited to the needs of grieving individuals (Aldridge, 1993; Malchiodi, 1991). Since many individuals are unable to fully express their feelings of grief through words, art therapy offers them a unique opportunity to express their feelings non-verbally through the use of art materials (Simon, 1981; Borden, 1992; Zambelli & DeRosa, 1992). Through art making and sharing in a group setting, individuals begin to understand their own difficulties and their individual strengths as well as discover new possibilities to cope with their loss (Grant, 1995; Graves, 1994).

LITERATURE REVIEW

The literature review will address issues related to grief counseling and art therapy. In particular, the usefulness of art therapy as an effective mode of expression and means of coping for the bereaved will be addressed. The review is organized in two sections, which will focus on 1) issues of the grief counseling and 2) art therapy with grieving individuals.

Complications of Unresolved Grief
Over the past twenty years, health care professionals have showed an increased interest in the issues related to death and dying. People often seek counseling support when they feel stuck in their grieving (Deits, 1992; Dershimer, 1990; Elders, 1995). In addition, grief often surfaces as the underlying cause of various physical and mental conditions (Souter & Moore, 1990; Zissook & Schucter, 1991). Lindermann (1944) was the first to postulate that avoiding or delaying the grief process in an effort to avoid intense distress led to morbid grief reactions. Similarly, Bowlby (1980) proposed the hypothesis that much psychiatric illness is an expression of pathological mourning. Crenshaw (1990) agrees that if the grief process is "skipped, avoided or interrupted before closure, the person is at risk for manifestation either delayed or distorted grief reaction" (p.26). He predicted that symptoms of unresolved grief would be manifested psychosomatically or interpersonally and states "as we attempt to go forward in life, sooner or later an event occurs that brings the unresolved grief into focus, sometimes with startling intensity" (p. 27).

Many clinical studies lend support to these hypotheses that unresolved grief is associated with substantial mental health hazards, including an increased incidence of mental health problems of clinical magnitude (Averill, 1968; Barrett & Scott, 1989; Carey, 1977; Clayton & Darvish, 1979; Parkes & Weiss, 1983). Zisook (1985) found that 17 percent of people seeking mental health counseling have, underneath their particular psychological condition, an unresolved grief reaction. After evaluating several studies, Rando (1991) concluded that 15-21% of the outpatients at mental health clinics are suffering from unresolved grief and that grief is the basis for their presenting symptoms of anxiety or depression.

Additionally, there are a number of studies in the literature that point to the impact of grief on morbidity and mortality (Helsing & Szklo, 1981; Jones, 1987; Kaprio & Koskenvuo, 1987; Osterweis, Solomon, & Green, 1984; Parkes, 1986; Stroebe & Stroebe, 1987). Investigators such as Yalom and Vinogradov (1988) and Lieberman and Videka-Sherman (1986) have stated that the recently widowed are prone to increased incidence of poor physical health for a year or more after a loss.

In conclusion, the recently bereaved represent an at-risk population. Unresolved grief can precipitate depression and low self-esteem in many people, and over time this could lead to substance abuse and suicidal ideation, which will require more extensive, long-term therapy (McCrae & Costa, 1988; Yalom and Vinogradov, 1988; Leick & Daivdson-Nielsen, 1990; Worden, 1991). In addition, unresolved grief can lead to increased physical health problems and ultimately death (Helsing & Szklo, 1981; Windhotz, Marmar & Horowitz, 1985). With timely therapeutic intervention many of these psychiatric, psycho-social and somatic complications could be reduced.

Normal Grief Reactions

The term "normal grief" sometimes referred to as uncomplicated grief, encompasses a broad range of feelings and behaviors that are common after a loss (Worden, 1991). One of the earliest and most influential study complete to describe normal grief reactions was done Lindermann (1944) who discovered similar patterns in his bereaved patients and described the characteristics as: somatic or bodily distress of some type; preoccupation with the image of the deceased; guilt relating to the deceased or the circumstances of the death; and the inability to function as one had before the loss.

Because the list of normal grief behaviors is so extensive and varied, there is no complete list of the experiences that comprise grief. These most common ones can be described under four categories: 1) feelings; 2) physical sensations; 3) cognitions, and 4) behaviors (Fitzgerald, 1994).

1. Feelings: Experts describe the process of grieving and the emotions of grief in various ways. A person feels several of these emotions at the same time, perhaps in different degrees. Feelings that exist in abnormally long periods of time and at excessive intensity may indicate a complicated grief reaction (Worden, 1993). Some of the more common feelings experienced include: loneliness, fatigue, helplessness, yearning, emancipation, relief, and numbness.

2. Physical Sensations: Physical sensations are often overlooked, but they play a significant role in the grieving process. The following a list of the most commonly reported sensations experienced by those who are grieving: hollowness in stomach; heavy and repeated sighing ; tightness in the throat ; tightness or heaviness in the chest; aching; overeating or loss of appetite; fatigue or insomnia; muscular weakness ; tension and irritability.

3. Cognitions: There are many different thought patterns that mark the experience of grief including: disbelief, confusion, preoccupation with the deceased, a sense of presence of the deceased, and hallucinations. These thought patterns are common in the early stages of grieving and usually disappear after a short time, however sometimes the thoughts persist and trigger feelings that can lead to depression or anxiety.

4. Behaviors: Behaviors during this period may include: sleep disturbances, appetite disturbances, absent-minded behavior, social withdrawal, searching and calling out, sighing, restless over-activity, crying, visiting places or carrying objects that remind the survivor of the deceased.

Determinants of Grief

When assessing a large number of grieving people, a wide range of behaviors and individual differences will be observed. For some, grief is a very intense experience, and for others it is rather mild. According to Parker & Weiss (1983), Walter (1996) and Worden (1991), the intensity and longevity of grief may be determined due to the variety of situational, social, and personal variables affecting each individual's grieving process.
The experience of grief is related to the developmental level and conflict issues of the individual involved, the most important determinants seem to fall into the following categories: identification to the deceased; origin or nature of the attachment; mode of death; historical issues; personality variables; and social variables.

The Mourning Process

Central to the discussion of the mourning process is an understanding of grief as a necessary normal and universal response, as well as a time for healing, adaptation and growth (Melges & DeMaso, 1980; Moos, 1995; Viney, 1991). Worden (1991) states that the process of mourning is necessary after one sustains a loss, and views it similarly to the process of healing, a course that takes time until restoration of function can take place. He states that there are certain tasks of mourning that must be accomplished for equilibrium to be reestablished. Furthermore, the process of mourning needs to be completed since uncompleted grief tasks can impair further growth and development.

Mourning is a long-term process, and the culmination will not be the pre-grief state (Worden, 1991). The mourning process is completed when a person is able to: reinvest his or her emotions back into life and in the living; think of the deceased without intense pain; integrate their experience of loss into their life; and move toward investing in a new life without the lost loved one (Worden, Leick and Davidsen-Nielson, 1991). Worden (1993) refers to the term "mourning" to indicate the process which occurs after a loss, while "grief" refers to the personal experience of the loss. For the bereaved, the models of grief work can serve both as compasses which show the direction of their path at a particular time, and as topographical maps revealing the landscape of grief's highs and lows. Bereavement is a normal process during which people mourn the loss of their loved ones and heal sufficiently to continue life without them.

Grief Models

Grief Work, Stages, and Phases - are all terms that refer to the several models about grief that have been proposed. Models regarding the process of grief abound and depending on the writer, 3 to 12 stages or phases of grief are described (Attig, 1991; Bowlby, 1980; Corr, 1991; Rando, 1984). Sigmund Freud (1957) began with the concept of having to do 'grief work', that is, a specific job should be finished before the next job begins.

According to Kubler-Ross, the stages of denial, anger, bargaining, depression, and acceptance as described in On Death and Dying (1969) are experienced not only by those dying, but by families and friends while grieving. Emotional reactions may also involve shock, numbness, and pain. Allowing time and space to externalize such feelings facilitates dealing with loss and moving on with life's activities. In the course of bereavement, these stages often acts as defense mechanisms helping the bereaved cope with extremely difficult situations. Kubler-Ross lists the stages of grief in a specific order, however, in the normal process of grief, they last for different periods of time, will replace each other, overlap or exist at times simultaneously.

As an antidote to what many came to perceive as a kind of passivity inherent in the stage model of grief, Worden (1991) developed a more active grieving model which defined four tasks necessary for the individual to complete. Worden states: "Phases imply a certain passivity, something the mourner must pass through. Tasks, on the other hand are much more consonant with Freud's concept of grief work and imply that the mourner needs to take action and can do something" (p.35). Each person will react differently to loss, but in general, the work of bereavement entails the following developmental tasks:

1. To accept the reality of the loss. At first, people may react to the death of their loved
one with numbness, shock and denial. The first task of grieving is to come to acknowledge and realize that the person is dead. This task takes time because it involves an intellectual acceptance as well as an emotional one. Traditional rituals, such as the funeral, help many bereaved people move toward acceptance.

2. To work through to the pain of grief. It is necessary to acknowledge and work
through the pain associated with loss or it will manifest itself through others symptoms
or behaviors. Not everyone will experience the same intensity of pain or feel it in the
same way. One of the aims of grief counseling is to help facilitate people through this
difficult second task so they don't carry the intense pain with them throughout their life.

3. To adjust to an environment in which the deceased is missing. Adjusting to a new
environment means different things to different people depending on what the
relationship was with the deceased. The bereaved may feel lonely and uncertain about
a new identity without the person who has died. This loss confronts them with the
challenge of adjusting to their own sense of self.

4. To emotionally relocate the deceased and move on with life. Individuals never lose
memories of a significant relationship, yet eventually grieving individuals need to look forward and continue with their lives. They may need help in letting go of the emotional energy that used to be invested in the person who has died, and they may need help in finding an appropriate place for the deceased in their emotional lives. Completing the necessary grief work enables them to focus less on the loss and connect with other people by investing new energy in ongoing relationships.

In summary, models of the grief process can be viewed as "generalized maps", in that each theory is an attempt by an investigator to understand and guide the grieving individual through their pain. However, humans are unique and cannot be forced into particular patterns of behavior. Each individual will travel through grief at his/her own speed using an appropriate route.

Grief Counseling

When a loved one dies, those left behind often need help getting through the pain and need support to encourage healing. The bereaved are at-risk for future physical, emotional and social problems, especially if they have difficulty coming to terms with their grief and reinvesting in the future. Counseling can help to offset the detachment, isolation and depression so often experienced by people who have lost a loved one (Bayer, 1984). Because of the loneliness often associated with bereavement, this work is particularly suited to groups (Burke and Gerraoughty, 1991).

Lattanzi and Coffelt (1979) and Worden (1991) have identified certain principles that help make grief counseling more effective. These include:

1. Acknowledge the Loss. Assist the individual in acknowledging and accepting the loss by finding time to grieve and share feelings with others.

2. Identify and Express Feelings. This discussion should involve a balance between expressing "positive" and "negative" feelings toward the deceased. Regret, anger, guilt, helplessness, sadness and existential questions are all part of normal bereavement.

3. Facilitate Emotional Relocation of the Deceased. Assist individuals to overcome obstacles that prevent them from letting go of the loss and readjusting to life. Assist individual in gaining skills for living without the loss relationship by helping them to focus on life without the deceased. This entails reconstructing new life meaning and accepting a new identity as well as filling the void in their lives by exploring new activities and recognizing that life can have meaning again.

4. Identify the Normal Continuum of Grief. Educate grieving individuals about typical grief reactions in an effort to normalize their experience.

5. Allow for Individual Differences. Bereavement is an individual experience, with no right or wrong way and no set time for completion. It is essential to acknowledge and value the individual differences during the grief process.

6. Access to Ongoing Support. Ideally, grief counseling should be available for a full year following the loss. The most difficult transitions during that year are likely to be holidays, birthdays and anniversaries. Helping the bereaved to get through these milestones can greatly assist their future adjustment.

7. Exploration of Coping Skills. With an expanded repertoire of coping skills (i.e. meditation, relaxation, art making), grieving individuals will be able to more effectively deal with the stress of bereavement.

8. Recognition of Extreme Difficulties and Make Referrals.

Creative and Useful Approaches to Grief Counseling

Many grief counselors have identified certain approaches that are useful in grief counseling (Bolton & Camp, 1989; Dean, 1991; Eaton-Heegard, 1988; Hammer, Nichols & Armstrong, 1992; Worden, 1991 ). The purpose of the utilization of these approaches is to encourage the fullest expression of thoughts and feelings regarding the loss. Listed below are several of the recommended approaches that will be incorporated into the structure of the art therapy workshops.

1. Use of Symbols and Analogies - Helping the mourner bring photos, letters, tapes, articles of clothing or significant objects from the deceased. This can help the counselor and others get clearer sense of which the person was and creates a concrete focus for sharing.

2. Writing - Writing letters to the deceased can help express thoughts and feelings regarding any unfinished business. Keeping a journal and writing poetry can also facilitate the expression of feelings.

3. Art Making - Art helps reflect one's feelings as well as expressing experiences with the deceased.

4. Commemoration - Creating a book of stories, pictures, memorabilia, poems and drawings can help the bereaved reminisce and eventually mourn a more realistic image of the deceased.

5. Guided Imagery - Helping the person imagine the deceased and then encouraging them to say what they need to say to the deceased can be a very powerful technique.

6. Healing Rituals - Individual or group rituals can help ease the pain of grief and encourage memorialization and healing.

Rationale for Grief Counseling in Groups

Grief counseling can be done in the context of a group, which is not only very efficient, but can also be an effective way to offer the emotional support the bereaved person is seeking (Harding & Southern, 1991; Lagrand, 1991; Price, Dinas, Dunn & Winterowd, 1995; Worden, 1991). Bereavement groups can provide emotional support and an introduction to the grief process, while allowing participants to interact with others in a similar situation, all of which helps individuals recognize their feelings and put them in perspective (Weiss, 1988). The experience of sharing with others who are in a similar situation can be comforting and reassuring, alleviating the feeling that they are alone (Yalom & Vinogradov, 1988).

Researchers and practitioners have agreed that bereavement groups are helpful to this high-risk population (Janowiak, Mei-Tal & Drapkin, 1995; Souter & Moore, 1989; Marquis, 1996). Empirical studies of bereavement group therapy are found in the investigative work of Yalom and Vinogradov (1988); Lieberman and Videka-Sherman (1986); Vachov, et al. (1980) and Levy and Darby (1992). Yalom and Vinogradov (1988) cited diverse types of bereavement groups, including structured groups led by doctoral candidates in clinical psychology, groups using a less structured approach led by psychiatric nurses, and others operating without leadership by mental health professionals as part of a national self-help organization. They found that when the beneficial results of treatment in a brief psychotherapy bereavement group and a mutual-help group were compared, the treatments were found to be equally effective and helpful for the bereaved.

Many hospices have found support groups to be a cost-effective method of service delivery for large numbers of grieving individuals (Hopmeyer & Werk, 1994; Hughes, 1995; Kirschling, 1993; Zimmerman & Applegate, 1992; Zambelli, Clark & Heegard, 1989). Support groups are useful at all stages of grief and can focus on coping with adjustment to loss and bereavement (Rognile, 1989; Rosenblatt, 1988). Support groups offer many benefits to people facing grief including: the ability to meet others in similar circumstances, to share methods of coping and develop new relationships at a time of isolation (Zimpfer, 1991). Groups have also been shown to improve adjustment, mood, coping and quality of life for people dealing with grief (Couldrick, 1992; Mosley, Logan & Bently, 1988). Other advantages of the group modality include an exchange of information; problem-solving skills; mutual support and encouragement; and a sense of belonging and socialization (Schimmel & Kornreich, 1993; Yalom & Vinogradov, 1988).

Effectiveness of Grief Counseling

Powers and Wampold (1994) identified five factors that increase the likelihood of positive outcomes as a result of bereavement counseling: 1) social support - research findings reveal that the availability of and satisfaction with social support is associated with improved bereavement outcome; 2) health protective behaviors - there appears to be an association between the practice of heath protective behaviors such as relaxation, nutrition or exercise and the maintenance of well being ; 3) identify themes - an individual's ability to identify themes of grief are more likely to understand the distressing feelings they experience which minimizes the sense of helplessness and disorganization; 4) meaning - the attribution of personal meaning to loss can be critical for successful adjustment; 3) connection to deceased - the individual is able to let go of the intense pain of grief without perceiving that s/he is de-emphasizing the importance of the deceased; 4) modulate pain and normalcy - the ability to experience the emotions of grief and also begin to re-invest into life by enjoying normal life activities.

Parkes (1986) reviewed a number of research studies in an attempt to evaluate the effectiveness of grief counseling. He looked at both professional and volunteer group support and concluded that professional services and professionally-supported voluntary and self-help services are capable of reducing the risk of psychiatric and psychosomatic disorders resulting from bereavement.

Art Therapy with Grieving Individuals

The idea that art making can be helpful in processing a loss is certainly not new. In one sense, humankind may have developed art to alleviate or contain feelings of anxiety, fear, crisis, and threat (Johnson, 1987) as well as to mark the importance of events such as death through the creation of visual imagery (Dissanayake, 1988). The desire to self-express through an artform during times of mourning has been explored by many (Peckman, 1965; Hatcher, 1985; Dissanayake, 1988). Hatcher (1985) describes this phenomenon from an anthropological standpoint:
Whatever the theoretical explanation, it is clear that art somehow helps human
beings cope with the trauma of death. Beauty and art forms have been part of
funeral ceremonies since Neanderthal times. This universal human problem is met
everywhere with symbolic solutions to satisfy the mind and esthetic solutions to
release the emotions (pp.106-107).

Many art therapists have described and investigated the specific use of art expression with those who have experienced loss (Junge, 1985; Raymer and McIntyre, 1987; Simon, 1981; Speert, 1992). Art therapists consistently observe the power and potential of art to help identify, cope with, and heal the pain experienced during the grief process (Forrest & Thomas, 1991; Grant, 1995; Graves, 1994; Orton, 1994).

Given that there are few words to describe the variety of thoughts and emotions associated with grief, individuals often need to utilize various means of non-verbal communication and coping techniques to work their experience into some coherent form (Simon, 1981). Art expression seems to be a natural modality for the expression of grief when words are not enough (Raymer & McIntyre, 1987). By participating in creative expression and communication with a trained art therapist, grieving individuals can find support and guidance to acquire new coping skills (Schimmel & Kornreich, 1993).

According to Simon (1981), bereavement art seems to represents an attempt to work through the conflict and usually occurs in three overlapping stages. The first stage consists of expression of the conflict, bringing closer to consciousness the feelings that lie behind the sense of stress. In the second stage the art provides an image that enables the suffering of the expressive stage to find containment as it is slowly converted into mourning. The third stage brings resolution and the client comes to view death tranquilly as the natural end of life and is able to use initiative to better effect in his/her life.

As stated earlier, many art therapists and grief counselors have acknowledged the benefits of using art therapy with the bereaved. After reviewing several successful bereavement art therapy programs, this author has identified several factors that contribute to the usefulness of group art therapy as a tool for ameliorating grief. The benefits of group art therapy with grieving individuals include the following:

" Hastens Grief Process & Promotes Coping Skills
Raymer and McIntyre (1987) state that the "grief process seems to be hastened by drawing on the individual's creative skills" (p. 29). Zambelli, Clark, Barile & de Jong (1988) also agree that creative expression, including art making, hasten the grief process and promote increased problem solving and coping skills. Simon (1981) posits that "the stress of bereavement lies in the lack of proper mourning rather than its excess" (p. 135) and suggests an individual must experience the grief, fear, and anger associated with loss in order to reach resolution. In a supportive environment, resolution through expression and containment in art frees creative energy necessary to deal with daily living.

" Remember and Commemorate the Deceased
Art has often been made in the memory of someone who has died, and art can be a means to remember or commemorate what has been lost (Graves, 1994). In her studies of loss, Fleming (1983) supports the use of art therapy as an intervention in the grief process and suggests "creativity can become a way of maintaining that special relationship" (p. 57). Creativity in art therapy can also "lead to remembering, to experiencing the rage and the loss, and to regaining the past in all its warmth and its imperfection...to mourning of losses and to getting to know oneself and others" (Fleming, 1983, p.57). Junge (1985) describes the use of art therapy with grieving families, in which creating a book in memory of the deceased assisted in reconnecting the family members and providing them with realistic picture of the deceased.

" Creation of Healing Rituals
Through the images of time, art making has been a part of the funeral and death ritual in many cultures. Johnson (1987) noted that "art originally developed as a means of expression of and relief from traumatic experiences. Art, song, drama and dance in primitive times were motivated by a need for catharsis and gaining control over threats to the community" (p.7). Describing the use of art over time Hatcher (1985) noted that "art somehow helps human beings cope with the trauma of death. Beauty and art forms have been a part of funeral ceremonies since Neanderthal times" (p.106).

" Helps to Organize & Regain Sense of Containment
When grief causes people to feel that their life is out of their control, art tasks can help them to organize and regain a sense of containment (Aldridge, 1993; Irwin, 1991). Simon (1982) found that since art therapy stimulates the expression of both the conscious and unconscious thoughts and feelings, it was a good method for allowing unmet bereavement needs to come to the surface. Overwhelming thoughts and feelings evoked by death can be contained in symbolism, which creates a sense of control, organization, and containment which permits individuals to be productive in their daily lives and gain resolution of the grief process (Junge, 1985).

" Promotes Exploration and Expression of Feelings
Art can transform suffering by facilitating the expression of the many emotions associated with grief (Aldridge, 1993). Art is often recognized as being less threatening than words and can therefore provide a safe outlet for the expression of feelings associated with grief, including isolation, loss, and fear, thereby reducing their level of stress and avoiding future negative repercussions (Borden, 1992; Irwin, 1991; Kubler-Ross, 1982; Simon, 1981; Zambelli, Clark & de Jong 1994).

Art therapy invites participation in a safe and supportive environment, where individuals' efforts at self-expression are reinforced in an effort to confirm that their feelings are valid, fears are understood, and their needs are legitimate and important (Irwin, 1991; Zambelli & de Rosa, 1992). Art therapy can be particularly helpful in identifying misconceptions or issues of conflict and bringing negative or disparate feelings about the deceased to the surface, thus facilitating the healing of grief (Junge, 1985; Simon, 1981).

Images that appear in the individual's art can serve as a starting point for discussions that otherwise may not have surfaced (Irwin, 1991; Simon, 1985). Because visual images are capable of working on many level, and of expressing seemingly contradictory ideas and feelings simultaneously, art making allows an individual the comfort, support and energy to go on with life (Graves, 1994). Art seems to allow people to explore feelings on a deeper level than they were able to previously (Rogers, 1997; Schimmel, Kornreich, 1993). "Art provides a balance for feelings, thoughts, and experiences. It is this balance which provides hope and nurturing" (Raymer & McIntyre, 1987, p. 15)

" Facilitates Cathartic Effect and Kinesthetic Release
Art can allow for the cathartic expression of the emotions of grief, and that catharsis allows the healing process to begin (Furth, 1988; Rubin, 1987; Irwin, 1991; Junge, 1985). Davis (1989) posits that "art uses active methods to experience or cathect feelings...and allows destructive energy to be expressed and sublimated into a constructive channel" (p. 273). Irwin (1991) states: "when words fail in the grief process, art therapy can permit the cathartic venting of emotions of loss" (p. 486).

Art therapy can also provide clients with a kinesthetic release. In processing the loss of her infant from SIDS, one client found the relief of scribbling so cathartic that she continued to use the scribble technique independently as an outlet for the expression of her grief (Orton, 1994). Speert (1993) found that art making allows the grieving individual to focus inward and to express and release emotions that family, friends, and others have been unable to accept. In Speert's (1993) work with women who had experienced perinatal loss, she found that the art expressions often revealed rage; and that clay, as a resistive medium, was helpful in releasing this rage. Clay was also effective in relieving some of the pain in the chest and arms that some women experience after the loss of a child due to the force necessary to form clay, clients reduce the somatic component of their pain directly through body movement with the art materials.

" Encourages Communication and Discussion
Art therapy in a group setting has been found to be a powerful means for individuals to express their feelings and receive support from others (Aldridge, 1993; Grant, 1995). Therapists Schimmel and Kornreich (1993) responded to widows' drawings in a group art therapy by reflecting the individuals' emotions and ideas. Additionally, the therapists encouraged discussion among group members by using the art as a basis for discussion. By actively identifying the feelings expressed in the art and demonstrating acceptance of them, it was found that the individual would become increasingly able to communicate and discuss their feelings with others.

" Encourages Self-awareness, Growth & Healing
The process of making art allows for self-awareness and the artworks are safe outlets for individuals to express their grief at their own rate, with the emphasis on discovering and investigating relevant personal concerns (Schimmel and Kornreich, 1993). Art therapy offers individuals the opportunity to explore their views about death and develop new coping skills, in a safe and trusting manner (Black & Simpson, 1993). ). Artistic expression can lead to increased self-awareness and release innate healing potential (Lane-Graham, 1994). Baker (1991) says: "often the experience of drawing itself becomes part of the healing process that occurs" (p. 173). Therefore, art can be used to focus on well-being, wholeness and healing (Rogers, 1997).

" Pleasurable & Relaxing Activity
Art making, as a healing process, has been shown to be effective in that it promotes a sense of joy, peace and relaxation (Rogers, 1997). Schimmel and Kornreich (1993) found that art materials were usually reminiscent of pleasurable childhood activities, and that members of the group often enjoyed making art to express themselves. Many grieving individuals have remarked about how appreciative they were of the art therapy experientials, and how much better they felt after making the art (Graves, 1994; Schimmel & Kornreich, 1993; Speert, 1993).

" Art as Symbolic
With its emphasis on the non-verbal, art therapy can allow the unspeakable to emerge in images which evoke the symbolic expression of grief (Mayo, 1996). Through the use of symbols, clients can engage in the personal meaning of loss (Tate, 1989). The artwork created during grief are infused with symbols and images of profound meaning that may be unable to be translated into words. The use of metaphor through art allows the grieving individual to focus on a graphic image that symbolizes their experience (Borden, 1992). Focusing on the symbol enables the grieving person to express their overwhelming feelings without having to refer directly to specific details related to the death (Irwin, 1991; Mango, 1992).

" Final Product & Permanence
Even though the emphasis is on the process, with art therapy, clients are also rewarded for their efforts with a final product which provides them with insight and a record of their work (Schimmel & Kornreich, 1993). At a time when clients are attempting to assimilate loss, this small permanence may provide them comfort (Irwin, 1991). Baker (1991) also states that art provide a concrete memorial and gives grief a place in the world. In addition, clients may view a finished product over time and allow the images and symbols to continue to resonate with their own voice (Rogers, 1997). They can engage with them, discern meaning and increase their self understanding as they become ready.

Bereavement Art Therapy Groups

Many hospice programs are now implementing art therapy programs (Gulshen, 1998; McIntyre, Nutter & Adams, 1989; Raymer and McIntyre, 1987). For example, "HEALS: The Art of Healing Childhood Grief" (Black and Adams, 1993) and "The Healing Journey" (Grant, 1995) both use the expressive arts and ritual to create paths for healing and caring in the group setting. According to McIntyre (1990), the goal of a group art therapy program is twofold: (1) to provide social sanction for the expression of grief and (2) to promote adaptive mourning responses.

Art therapy provides grieving individuals with a creative outlet and the group setting provides individuals with the opportunity to connect with others in a relatively informal atmosphere, thereby reducing social isolation and withdrawal (Schimmel and Kornreich, 1993). The sharing of artwork augments and deepens the connections made during normal verbal communications in groups (Schimmel and Kornreich, 1993). These important interactions between participants, art therapist and the art process help the participant move from isolation and loneliness to connection and empowerment; from denial to acceptance; from loss of control and anxiety to relief; and from despair to hope.

Schimmel and Kornreich (1993) describe the use of art and discussion with bereaved individuals who had been widowed less than a year. The bereavement group therapy consisted of one year of weekly meetings loosely formatted around Kubler-Ross's (1969) theories of five stages of grief and acceptance of death, Yalom and Vinogradov's (1988) work with bereavement groups, and group art therapy concepts. The goals of the group were to identify the emotional experiences that group members could share, how members could help one another, and how they might gain relief from sadness, continue with their lives, and grow emotionally. The meetings were structured by the leaders to encourage discussion of the members' experiences of grief. Art therapy directives were provided to the participants in order to facilitate expression of their experiences related to loss and growth. The leaders asked for explanations by members about their artwork and facilitated group discussion concerning the illustrated issues. Even when the meaning of the art was not dealt with directly, the process of recognizing thoughts and feelings seemed to aid in the alleviation of the griever's sorrow.

Speert (1993) developed a four-part, one-day workshop to specifically address perinatal death through art therapy. Each part of the workshop was designed to address the various phases of the grief cycled. Simple art materials were used to provide a spontaneous art expression as a graphic, metaphoric representation of the self; symbolically explore personal loss; work with the theme of personal growth; and express connection and wholeness through creating group art expressions. Speert (1993) states, "Art expressions created at the time of loss, and for months afterwards, often graphically express a lost sense of self. In a group, the individual could express her loss and, in seeing similar symbols created by others, reduce her sense of isolation. Although alone in the art making, the woman has allies in reviewing the art expression and can try out new ideas with the encouragement of others in the group" (p. 123).

In the first part of the workshop conducted by Speert (1992), simple art materials are introduced first in order for the participants to become comfortable with the art media. During the second part of the workshop, a process is used which Speert developed is utilized. First, each women is asked to tear a shape to represent herself form a color that feels right for her. Second, she chooses a color to represent her loss and tears it into an appropriate shape. Third, she uses rubber cement or glue stick to attach these shapes onto piece of white cardboard. Lastly, she draws with oil pastels what is needed to bring comfort, wholeness, or peace to the torn-paper images. During this process, the room is silent. Women often comment later that they had forgotten they were in a group and that they felt totally alone as they worked. The group then spends as much time as needed to talk about the process and the product.

The third phase of the workshop is designed to focus on the individual. Each participant creates a collage to represent her self, using a variety of materials such as feathers, cloth, glitter, nature objects, tissue, paint, etc. The wide selection of art materials is offered to encourage exploration and evoke early feelings of creativity and freedom. After talking about these individual collages, the final part of the workshop is introduced. In the fourth part of the workshop, a group mural is assigned and each woman is asked to incorporate e her own sense of self into the mural. This process puts the women in connection with others in the group. By this stage in the workshop, the women have established connection and intimacy with others in the group. In summary, the entire four part workshop process provides the opportunity for both individual insight and group support through art making and discussion.

Conclusion

Art making, by nature of its two-step process of expression and reflection, allows both the isolation of internal focus and the connection with others. As the visual symbols of loss are shared with others in the group, they also promote deeper self understanding as well as connection. Participants have the opportunity to demonstrate these elements of cooperation, creativity and re-creating of their personal vision by experimenting with art media.

Many art therapists and grief counselors are increasingly utilizing the group workshop format in place of individual therapy because they find the group therapy format provides more reflective surfaces to both contain and mirror each individual's experience of loss and validate his/her sense of self (Birnbaum, 1991; Lane & Graham-Poole, 1994; Sontag & Henry, 1994; Speert, 1993; Zamierowski & Gorden, 1992). As Surrey (1991) observes, "the joining of visions and voices creates something new, an enlarged vision …thus the sense of connection and participation in something larger than oneself does not diminish, but rather heighten the sense of personal power and understanding" (p. 172).

In summary, the creative experience of making art during the time of traumatic loss provides a tremendous opportunity for self exploration, healing and growth. Art therapy can support the individual's need to express and creatively transform the issues of grief and can help prevent some of the psychological, social and behavioral problems resulting from unresolved grief. Additionally, the values of empathy and connection are enhanced by the process of creating art together in a group format.

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