Introduction
This program is an outline for art therapists working with individuals who have experienced some type of reproductive loss. It is informed by current bereavement models, art therapy techniques and ‘The Healing Process Model’ By Gray and Lassance, a program designed to educate and train professionals at the Centre for Reproductive Loss in Montreal. The proposed program is not a fixed set of directives, but a guide for therapists to adapt and draw from. The exercises are not limited to specific sessions or sequences, and are designed to work with the emotional pace of the client. This program may also be adapted to fit a group therapy setting should the facilitator have the resources to offer group services. The program was designed to ensure respect for the unique circumstances of the grieving individual and can be adapted to each of their situations. The following outline provides program goals, facilitation considerations, program limitations, ethical considerations, and suggested exercises and art therapy materials.
Goals
1. To facilitate healing from the complicated or disenfranchised grief of reproductive loss.
2. To offer an alternative to traditional counselling and therapy for women grieving reproductive loss.
3. To acknowledge and work through the difficult emotions surrounding abortion on a sociocultural level.
4. To provide art therapists with suggested resources and exercises for working with individuals in this population.
5. To acknowledge and support the need for emotional care in women’s reproductive health and advocate for women’s reproductive rights.
6. To encourage and create a supportive space for dialogue about reproductive loss.
Facilitator Considerations
Facilitators for this program will be certified art therapists who have a desire to contribute to the emotional care in women’s reproductive health. Having an interest and some background knowledge in women’s health and reproductive rights is recommended. Facilitators should be aware of their attitudes and beliefs regarding abortion. These opinions should not be imposed upon or come into conflict with the client’s experience or beliefs at any time. Facilitators should also be familiar with the aforementioned theories on bereavement, mourning and grief and loss. Through clinical art therapy training, fundamental counselling skills are expected of the facilitator. Unconditional support, compassion, acceptance and positive regard for the client’s circumstance are required to build a safe space for them to express and explore their feelings around their loss. In a time of deep emotional distress, empathetic listening and understanding on behalf of the facilitator is of utmost importance. Cultural intelligence regarding the attitudes, values, beliefs and practices in women’s health should be put in check and assessed on behalf of the facilitator.
Ethical Considerations
Grief, loss and mourning are experienced within a cultural framework. Culture defines how individuals make sense of their world and will therefore determine how individuals express and represent their grief (Neimeyer, Harris, Winokuer, & Thornton, 2011). Behavioural norms across cultures will govern the emotional expression of grief and determine what is acceptable and for how long (Neimeyer, Harris, Winokuer, & Thornton, 2011). Additionally, gender roles across cultures will moderate the expression and acceptability of emotions around the loss. Therapists and facilitators need to be sensitive to the unique backgrounds and histories of each client. Maintaining cultural and emotional intelligence is imperative for understanding the bereavement needs of each client.
Program Format
The program is designed for a minimum of eight one-on-one art therapy sessions and is loosely based on grief and loss therapy models. These directives may be re-visited multiple times and can be used at varying times. Should the facilitator encounter an opportunity for group therapy, the directives may be modified and adapted to fit a group model. Information on grief and loss and the complicated nature of reproductive loss will be addressed and made available to the participants. It is important for the therapist to check in with the participant regarding other reproductive losses, as well as losses in general. The participant’s history of other losses may influence the way they manage their current loss. The therapist will present the suggested directives and encourage reflection and exploration of the art work. The directives follow a suggested sequence but do not need to follow any particular order, with the exception of the introductory and closing activities. Based on the needs of the participant, the directives may also be revisited or repeated. This program can take place at any time in a woman’s life, immediately following or long after she has experienced her loss. Descriptions and explanations of each directive will be provided to support the activity and aim to give the participant a holistic understanding of the program and process.
Participant Criteria
This program is intended for women who have experienced reproductive loss and are seeking support in their process of mourning. Participants may be of any age and their loss does not need to meet any time limitations. No previous experience in art making or artistic skill is necessary. Should this program be offered to a group, no more than five participants should be cared for at one time. Should the partner of the woman wish to participate in the program, the directives may be adapted for that individual or for joint participation.
Theoretical Underpinnings
Art making and working within the creative process allows individuals to think and act in a way they could not from an ordinary standpoint (Morgan, 2000). The arts give individuals a vehicle for communication in another language that can perhaps better suit their needs for expression. This program is based on a client-centered approach and promotes reflection and exploration of the artwork from the perspective of the participant. This program works with the notion that art making and its processes facilitate healing, growth, compassion and understanding. The meaning-making and reconstruction theory supports the story-telling components of the art therapy program and is reinforced by the research identifying the dynamic and effective ways this model can impact bereaved parents (Keesee, Currier, & Neimeyer, 2008). McNiff’s theories regarding images as messengers and angels from our inner world can be applied to these directives should the client wish to explore and dialogue with their work. The therapist’s role in this process is to provide a safe and nurturing environment for the participant, and to observe, notice, reflect and empathize with the participant throughout the process.
Art Materials
A variety of art materials allow participants to fully explore and express their emotions and mourning process. Paint (watercolour or acrylic), pencil crayons, charcoal, oil pastels, clay, images for collage, embroidery floss and hoops, fabrics, and a variety of paper should be sufficient for the program directives.
Introducing Art Therapy
A brief introduction to art therapy and the program design should be addressed at the beginning of the sessions to provide some understanding of the methods and goals of the process. Key concepts that may be discussed include:
• the importance of the process and not just the product
• no artistic skills are required for participation
• the artwork will not be interpreted by the therapist
• there is no correct or incorrect way to do the directives, each activity is open to the participants own interpretation
• each session will begin with a ‘check-in’, whether it be verbal, written or visual. A journal may be provided for this purpose.
Suggested Exercises
1. Exercise title: Warm-up and Explore
Directive: Give participants watercolour paper and ask them to drop or gently spread water on the paper in any way they feel comfortable. Participants will do the same with watercolour paints, creating different shapes and patterns with the paint. Participants may have an opportunity to look for images, feelings or actions within the paint.
Rationale: A gentle warm-up activity allows participants to get acquainted with some of the materials and begin their art therapy journey with a low-pressure activity. For individuals who have not had much experience in art, this activity facilitates building a relationship with materials, colour, shapes and feelings. Watercolour paints can be softer and lighter than acrylic or tempra and may promote a sense of relaxation. By looking at random colours, patterns and shapes the participant may find a way to express their feelings and reflect on their situation. This activity will allow time and space for the participant and the therapist to develop a relationship before they move on into other directives.
2. Exercise title: Telling Your Story
Directive: Ask participants to write, draw, or paint their story around their loss. Encourage the participant to recall as many details they can remember around the event, the weather, their clothing, the food they ate, etc. This activity may be written or expressed artistically on paper or in a journal or book.
Rationale: Telling the story or re-telling the story around a loss to a non-judgmental and compassionate listener is integral to healing. Story telling can aid in processing the loss and provide a framework for mourning. Additionally, story-telling, or writing the self-narrative, is an ideal way to develop and facilitate meaning-making.
3. Exercise title: Body Scan−Practicing Mindfulness
Directive: Guide clients through a body scan while encouraging deep breathing. Clients will focus on relaxing their bodies from head to toe, noticing where they feel discomfort or changes in temperature and what feelings arise. Possible questions during the body scan may include: Does your discomfort have a colour, shape or pattern? How big or small is it? Does it move? Following the body scan, clients may draw or use a template of an outline of a body to express what they experienced and where.
Rationale: A variety of emotions may come and go for someone going through grief and loss. Feelings of anger, shame, guilt, blame, relief or regret may resonate with the participant throughout their grieving process. Identifying these emotions, allowing them to come forward, noticing them the in the body and expressing them outside of the body will contribute to healthy processing and growth.
4. Exercise title: Making Connections
Directive: Participants may be asked if they have named or wish to name their deceased foetus. Once this has been established (or not), participants will create a memorial piece for their baby. This piece may take any shape or form and may be worked on over a couple of sessions. Suggested activities or materials include using clay to create a statue or small monument; embroidery floss and fabric to create a patch or quilted piece; collage using any documents or materials related to the pregnancy.
Rationale: Establishing a name and acknowledging the baby as a unique individual can affirm the reality of the loss. Naming the baby will establish its own identity and distinguish it from the mother’s; it will give the baby a place on the family tree. The lost baby will have never been known or seen on her own, naming will establish her identity. Creating a memorial piece will allow the bereaved to maintain a connection to their loss by honouring, and making a place for the piece in their home.
5. Exercise title: Identity Landscape
Directive: Using a piece of card stock or heavy watercolour paper, fold each side inwards to meet in the middle. This will be a template for exploring the outer and inner landscape of the self. Ask clients to design their inner landscape on the inside of the card, where are they situated? Where is their deceased situated? What season is it? What time is it? Encourage clients to address all facets of their landscape. The client may continue by designing the outside of the card, or re-visit this piece at a later session. The outside is intended for exploring the self which they present to the world, the primary pieces that have always been a part of who they are.
Rationale: Reproductive loss often implies a loss or confusion of identity. Not only are women dealing with the loss of their baby, they are dealing with the loss of motherhood, and their unique hopes and wishes that may accompany that. Exploring the woman’s identity and making a space for the loss can aid in integrating this life event into her self-narrative. Reflecting on the woman’s story, her coping abilities and her strengths, participants are encouraged to make a place for their loss within their identity.
6. Exercise Title: Creating a Vision
Directive: Direct clients to create a vision of how they would like the future to look through a collage of images, words, fabrics, natural found objects or any other appropriate materials. This vision may include how they will remember their loss, and how they wish to live their life from this point forward.
Rationale: By providing a future-oriented directive the client will have an opportunity to realize their goals and organize their thoughts and feelings about where they are and where they would like to go in regards to living after the loss and integrating the loss into their altered world.
7. Exercise title: Self−care Mandala
Directive: Instruct participants to place a piece of fabric in a round embroidery hoop and make sure it is secure. By using paint, collage or thread, participants will identify what they need to make sure they are giving themselves the compassion and care they need.
Rationale: Coping with grief and loss is a stressful life event and being gentle with the self is important. Physical, emotional and psychic energy have been depleted. Therefore participants should be encouraged to take care of their mind and body, seek further assistance should they need it, and maintain a spiritual connection or practice. This may involve a ritual, poem, prayer, meditation, piece of music etc. The term ‘spiritual’ in this activity can be interpreted or used however the participant wishes to use it.
8. Exercise title: Planting a Message- Creating a Ritual
Directive: Ask participants to write a letter, poem or message on to their deceased baby. The message should be written on recycled paper or newsprint. Once the letter is complete participants may plant the letter in a garden with a flower, tree or other type of plant. If the participant does not have access to a garden or space where they feel comfortable planting, the facilitator may provide a small planting pot and soil. Encourage the participant to choose the plant they wish to use.
Rationale: Sending a message or poem to the deceased allows the participant to maintain a connection and show love and care for the lost baby. By planting the letter, the message will be represented by the plant; this plant can serve as a memorial piece for the deceased. Some participants may find comfort in the notion that the living plant may carry their message out into their world and to their deceased baby. Visiting the plant or tree on a regular basis is an opportunity to create a ritual which honours the loss.
Summary
Given the unique nature of reproductive loss and the possibility for disenfranchised grief, traditional models for coping with grief and loss are inadequate. By taking into consideration the unique nature of reproductive loss, these directives will facilitate healing and growth, while promoting self-care and well-being. Acknowledging and discussing the nature of disenfranchised grief will further support the healing process. Through the nurturing and flexible art materials clients will be able to tell their story, honour their loss, practice mindfulness, create a ritual, explore their identity, set goals and practice self-care. It is recommended that therapists take notes following each session to maintain a record of the clients pace and progress. Reviewing these documents will aid in choosing, following or revisiting the suggested directives.
In addition to supporting women who have experienced reproductive loss, this program brings awareness to and makes room for dialogue regarding women’s reproductive and mental health.
