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December 2014 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


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].

  • Returning to life as a well person and regaining identity
  • Reducing isolation and connecting to others
  • Comfort from pain and suffering
  • Surviving illness: future focus and hope
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.

Special Note to the Network from Article Co-Author Florence Gelo:

This research allowed me to seek answers to questions that I had about innovative ways to provide pastoral care to hospitalized patients. I wondered if works of art that could be held in one's hand could act as a trigger to facilitate a conversation. The inspiration came not from my pastoral care practice, but from my volunteer activity as a docent at the Philadelphia Museum of Art and the Woodmere Art Museum, giving tours for all age groups, including students and people with disabilities, where I learned very quickly the power of images. Dramatic narrative paintings often invited emotional responses from viewers. In one instance, the painting Massacre of the Innocents (c. 1640) by Pacecco de Rosa (Francesco de Rosa) brought a student to tears: "Look at that mother ... look at her face ... how could they do this ...."

As a result of my experiences as a docent I became interested in testing whether images could be used as a vehicle to facilitate conversations about emotions in a manner that was both nonthreatening and healing for patients.

I am not a trained researcher, only a direct care practitioner with direct care experiences. For this reason, I sought out research colleagues and added the flesh of emotion to their theoretical expertise.

There were new skills to learn while doing research and vigilance needed to insure the quality of my study. When interviewing patients using a protocol with a list of questions, I followed the patient's dialogue and at times thought it was more important to honor the rhythm of their disclosure rather than my list of questions. At that moment, I became the patient's chaplain and left behind the rigors of research protocol.

Since research never answers all of our questions, I now intend to build upon the findings of this pilot study to explore whether this methodology is beneficial to those with emotional needs at the end-of-life.


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.

  1. Ugolino and His Sons, sculpture, 1860-1861, by Jean-Baptiste Carpeaux
  2. Forest Landscape No. 2, painting, c. 1935, by Emily Carr
  3. Storm in the Mountains, painting, 1847, by Frederic Edwin Church
  4. The Titan’s Goblet, painting, 1833, by Thomas Cole
  5. "Untitled," 1991, by Felix Gonzalez-Torres [The image is of an empty but recently occupied bed, shown on a street-level billboard in New York City as part of Projects 34: Felix Gonzalez-Torresby the Museum of Modern Art, 1992. The same Untitled image appeared on billboards in New York City in 2012, as part of the Museum of Modern Art's installation, Print/Out.]
  6. Still Life with Bowl of Citrons, painting, late 1640s, by Giovanna Garzoni
  7. Artist’s Bedroom, Nyack, photograph, 1903-1906, by Edward Hopper
  8. Railroad Sunset, painting, 1929, by Edward Hopper
  9. Room in Brooklyn, painting, 1932, by Edward Hopper
  10. Stairway, painting, 1919, by Edward Hopper
  11. The Autumn Gate, painting, by Thomas Kinkade
  12. The Scream of Nature (popularly known as “The Scream”), painting, 1893, by Edvard Munch
  13. Reservoir, oil, wood, graphite, fabric, metal and rubber on canvas, 1961, by Robert Rauschenberg
  14. Third Time Painting, mixed media “combine” piece (painting incorporating working clock, shirt, chain and broken neck of a bottle), 1961, by Robert Rauschenberg
  15. “Mali: Hospital of Gourma-Rharous,” photograph, 1985, by Sebastiao Salgado [The image is of a woman with her prominent hands holding her head.]
  16. A Sunday on La Grande Jatte - 1884, painting, 1884-1886, by Georges Seurat
  17. Annunciation, painting, 1898, by Henry Ossawa Tanner
  18. The Starry Night, painting, 1889, by Vincent van Gogh


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, 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:

Gottheil, E. A. and Groth-Marnat, G. "A grounded theory study of spirituality: using personal narratives suggested by spiritual images." Journal of Religion & Health 50, no. 2 (June 2011): 452-463. [(Abstract:) This study expanded on traditional concepts of spirituality through an analysis of narratives derived from images with spiritual content. Twenty-five participants were selected based on their being actively involved in spiritual practices. They were requested to tell TAT-type stories to a series of twelve images that revolved around spiritual themes. The resulting 300 stories were coded according to Grounded Theory procedures. A theory of spirituality emerged that centered upon the expression of suffering and the expectation of it being relieved. Results suggest that the personal spiritual process is one that expects and seeks transformation of the suffering through a connection with another, a connection with the transcendent, acquiring wisdom, or transforming the internal state.]

Symonds, L. L., Yang, L., Mande, M. M., Mande, L. A., Blow, A. J., Osuch, J. R., Boivin, M. B., Giordani, B., Haan, P. S. and Smith, S. S. "Using pictures to evoke spiritual feelings in breast cancer patients: development of a new paradigm for neuroimaging studies." Journal of Religion & Health 50, no. 2 (June 2011): 437-446. [(Abstract:) This study was designed to develop and validate a method for enhancing spiritual feelings, particularly in women who have received a diagnosis of breast cancer. The protocol specifically was developed to be used in functional magnetic resonance imaging (fMRI) studies. Eighteen breast cancer survivors rated pictures for their ability to enhance feelings of spirituality, happiness, and sadness. Results indicate that presenting carefully selected pictures with spiritual content (e.g., nature scenes, people engaged in contemplative behaviors) can effectively enhance spiritual feelings among breast cancer survivors. Future fMRI studies will explore the use of the protocol developed in this study for investigating neural activity during spiritual feelings and states.]


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):

Johnson, K. D., Rao, H., Wintering, N., Dhillon, N., Hu, S., Zhu, S., Korczykowski, M., Johnson, K. and Newberg, A. "Pilot study of the effect of religious symbols on brain function: association with measures of religiosity." Spirituality in Clinical Practice 1, no. 2 (June 2014): 82-98. [(Abstract:) Religious symbols are used throughout the world to evoke specific meaning in adherents. However, it is unclear if the impact of symbols is based upon their meaning or the inherent effect of the visual symbols on the brain. There has never been a study that has assessed the impact of religious symbols, of both positive and negative emotional content, on the brain. In addition, it would also be important to correlate the neurophysiological effect of various religious symbols to specific measures of a person's perspective on religion. Using functional magnetic resonance imaging to study 20 healthy subjects from different religious backgrounds, we found that neural activation in the primary visual cortex was significantly suppressed in response to religious negative symbols compared with neutral and nonreligious negative symbols. No such deactivation was observed for religious positive symbols. Subjects' scores on the Quest scale, an index of religious and spiritual orientation and belief, correlated significantly with activity in the primary visual cortex for negative symbols, but not for positive symbols. In addition, scores on the Beliefs About God Assessment Form (BAGAF), that measures the adaptability of a person's religious beliefs, correlated significantly with activity in the amygdala and insula when observing religious symbols. These findings suggest an early stage visual mechanism underlying the interaction between processing of visual religious symbols and both spiritual quest and adaptive religious beliefs. In addition, the emotional nature of a person's beliefs appears to interact with the emotional perceptions of different symbols.]



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