December 2014 Article of the Month
Gelo, F., Klassen, A. C. and Gracely, E. "Patient use of images of artworks to promote conversation and enhance coping with hospitalization." Arts and Health: An International Journal for Research, Policy and Practice 7, no. 1 (2015): 42–53. [This article was originally featured ahead-of-print.]
SUMMARY and COMMENT: "The aim of this study was to explore the use of representational (not abstract), nonreligious images to enhance a pastoral encounter with hospitalized patients" --exploring the use of such images "to promote conversation and to examine how artworks might serve as an additional resource for chaplains, health care professionals and lay spiritual caregivers who provide care to a religiously diverse hospitalized patient population" [p. 43]. The lead author, Florence Gelo, DMin, NCPsyA, is an experienced hospital and hospice chaplain and pastoral psychotherapist, in addition to being Associate Professor in the Department of Family, Community and Preventive Medicine at Drexel University College of Medicine. [See her special note to the Network (below).] Her co-authors from Drexel are Ann Klassen, PhD, Professor in the School of Community Health and Prevention and Associate Dean for Research, and Edward Gracely, PhD, Associate Professor in the program for Epidemiology and Biostatistics.
The authors observe that while "[c]haplains and other spiritual caregivers routinely engage in intimate conversations with persons who are sick and dying," they "rely most often on verbal communication" [p. 43].
Images of paintings may be used to facilitate conversation, rather than using direct questions about the patient’s experience of illness and hospitalization. In this way, an image allows a patient to focus on something other than himself or herself and may stimulate thought. Frequently it is easier and less threatening for a patient to talk about an image, painting, photograph or sculpture that captures his or her attention than to speak directly about fears, concerns, loneliness and pain. Using images of artworks draws from narrative therapy and the process of externalization to express emotions…. [p. 43]This pilot study took place over a 10-month period in 2012 at a large city hospital, using CPE residents to identify a sample that led to 20 patients being interviewed (audiotaped, 5-20 minutes with a 15 minute average) by Dr. Gelo. Participants were given 18 laminated images [--see Related Items of Interest, §I (below)] that had been selected by the researchers for their "narrative potential" [p. 44] and asked to create two piles of those they liked and disliked, then to pick one image from the "liked" pile for discussion. "The interviewer then asked the participant[s] a series of questions based on a method called visual thinking strategies [--see Related Items of Interest, §II (below)]…, to promote observation, communication and thinking skills. The questions are of a "progressive nature" [p. 45] and are listed on p. 44. Examples are: "What do you think about when you see this image?" "Where are you in this photograph/painting/sculpture?" "What does this photograph/painting/sculpture say about where you are in this stage of your illness?"
Of the 20 participants, 18 "found the experience of viewing images to be a positive one," while "[i]t was not possible to engage the sustained attention of one patient and [one] patient was simply not interested in the images; to her, they were merely attractive paintings without personal significance" [p. 45]. Analysis of transcripts followed a modified grounded theory approach and identified themes in the interpretation of the images. Each theme is elucidated with quotes from the patients [--see pp. 46-48], and the authors note that "[t]heir words capture a vividness describing the lived experience of illness and hospitalization, which is not always articulated by patients during conversations with caregivers" [p. 45].
Although a wide range of themes emerged, all 18 participants who had a positive experience suggested that looking at the images and talking about them offered them comfort. Participants noted the emergence of hope, peace, comfort, serenity and the ability to see a "bigger picture" than that resulting from confinement with illness. [p. 45]
Overall, the results "showed that patients report the positive value of participating in such activity" and suggest that "participants easily engage with the images and that using narrative images in conversations with patients may be beneficial" [p. 50].
Narrative images can provide a way for patients to express feelings that they might not have expressed otherwise, to escape momentarily to a "better place" emotionally, to envision freedom from hospital confinement and to glimpse a self beyond illness. To this end, narrative images can evoke in the patient feelings that might not ordinarily surface in conversations. Narrative images provide one way to reduce stress and to assist patients to cope more effectively with illness and hospitalization. [p. 50]
However, the authors do recount how for two of the participants the experience was not positive, and they explain that the images could in some cases evoke "disturbing feelings and concrete reactions" [pp. 48-49]. They also consider a question raised by one of the involved CPE residents about how introducing artistic images "might be unnecessary to inspire conversation" [pp. 49-50], and how photos of family members in patients' rooms could be an alternative resource, albeit one with its own possible complications. Moreover, they observe a number of practical challenges with conducting the activity in an acute care hospital, including the control of disruptive noise and managing the interruptions of patient care necessities [--see esp. p. 49], leading them to suggest that a long-term care/rehabilitation facility might provide a more workable setting.
Overall, though, the researchers conclude that "works of art could serve as useful jumping-off points for chaplains and other providers of spiritual care and provide a means for patients to express feelings that might otherwise be difficult to elicit" [p. 51]. They encourage further research "with the goal of ascertaining how effective it is as an aid to supporting patients, how to maximize that effectiveness and whether subgroups of patients can be identified for whom art is an optimal source of spiritual care" [p. 51]. Regarding future research, in addition to the authors' suggestions, this reader was left thinking about two areas: the dynamics of the range of patients' visual capacities/difficulties and the use of representational images with patients from spiritual traditions that have rules around representational images in a religious context.
The bibliography is quite thorough, and the authors give a good sense in the text of the nature of particular references. A notation of which images were discussed by patients, in the listing of all 18 images in the Appendix [p. 53], is helpful for understanding how varied were patients' choices.
Suggestions for the Use of the Article for Student Discussion:
Prior to meeting for discussion, students could be asked to select one of the images used in the study [--see Related Items of Interest, §I (below)] and explain why that has drawn their attention and what it evokes. They might additionally be invited to bring an image of their own and talk about why it might be useful with particular patients. Note that the authors of this month's article advise: "To be successful, paintings, sculpture or photographs must have content that is dramatic (i.e., color, mood or action) and that could evoke a narrative, storytelling response from participants" [p. 49]. What do students think of the interview questions [--see p. 44] and of the idea that a "process of externalization" [p. 43] may help some patients express emotion? The group could look particularly at the table of Spiritual Benefits to Patients When Viewing and Discussing Art [p. 48] and consider some of the many examples given of patients' responses in the interviews [pp. 45-49]. How does this topic in general raise for students questions about the engagement of patients verbally and visually as well as cognitively and emotionally? Do any students have experience of incorporating elements of other "expressive art therapies" [p. 43] in their pastoral practice?
Related Items of Interest:
I. The 18 works of art used in this month's study are identified in the article's Appendix [p. 50]. Chaplains may easily perform Internet image searches to see these. In a couple of cases in the list below, additional information has been bracketed in light of this reader's own attempt to locate the particular images employed.
II. The article refers to a method called "visual thinking strategies" (VTS), used to guide the creation of the interview questions. For more on VTS, see http://vtshome.org, from which the 2001 publication, Housen, A., and Yenawine, P., "Visual thinking strategies: understanding the basics," cited in the bibliography, may be downloaded [--from the website's Articles & Other Readings section].
III. The bibliography of our featured article offers a good selection for further reading (see especially the introductory section), but two cited studies may be particularly interesting to chaplains:
IV. This month's article focused on secular images, but Network members may recall a recent study by Chaplain Kyle Johnson, et al. on religious images -- research that took a cognitive processing approach -- noted in our Fall 2014 Newsletter (--see item #5):
If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at firstname.lastname@example.org