Hospice techniques ________________

The use of creative art forms to enhancecounselling skills of hospice professionalsin dealing with the bereaved

Margaret J. Zamierowski, MPSAbby Gordon, RN

Poet~

is indispensable—ifIonlyknewwhatfor.1 Manyyears ago, JeanCocteaumadethis note of the in-

trinsic valueof the creativeprocessin man’sattemptto discovermean-ing in humanexperience:univer-sallyknownyetnot soeasilyunder-stood.In this paper,weexaminetheuse of two creative forms, poetryand collage, conductedin a groupsettinginexplorationof thebereave-mentprocessamonghealthcarepro-fessionalswho care for the dyingandtheir families.

In Facing Death: Images, In-

Margaret J. Zamierowski, MPS, is BereavementCoordinator, The Brooklyn Hospice, Brooklyn,New YorkAbby Gordon, RN, isAdministrator, The BrooklynHospice, Brooklyn, New York.

sights and Interventions,authorSandraBertmandiscussesthe ca-pacityof theartsto portraysimulta-neously the dualities of life (anddeath)and,therefore,theusefulnessof including the study of art andliterature in deatheducation.2Theinherentpropertiesof art havebeenpreviouslyexaminedby ErnstFis-cher in The Necessityof Art. Hestatesthat man’s experienceof~hisown life is not enough,that he al-wayslongsfor somethingoutsideofhimself, that he longs to be whole.Hedescribesartasbeing“the indis-pensablemeansfor this mergingoftheindividual with thewhole.” Theduality of being involved yet dis-tanced,absorbedin realtiy yet ableto control it, is the processof crea-tivity.3 But Rob May bringsto this

dialogueperhapsthemost intimateconnectionin the relationshipbe-tween deathandcreativity in hisbook, The Courage to Create:

.the essenceof being humanis

Poetryisindispensable—

if lonlyknewwhat

for.

that,in thebriefmomentweexistonthis spinning planet,we can lovesomepersonsandsomethings, inspiteof the fact that timeanddeathwill ultimately claimusall...By thecreativeact,however,weareableto

TheAmericanJournalof Hospice& PalliativeCamJanuary/February1995

reachbeyond our own death.”4

“Creativity is ayearningfor immor-tality. . .we know that each of usmust developthe courageto con-front death.Yet, wemustalsorebeland struggle against it. Creativitycomesfrom thisstruggle—outof therebellionthecreativeactis born.”5

“Grief is anancient, universalpowerthat linkall human beings

together...”

Fischerstates:“In orderto be anartistit isnecessarytoseizeholdandtransformexperienceinto memory,memory into expression,materialinto form.”6 Theartworkthatresultsfrom anactof creativitycanbe seenasthe form whichembodiesourex-pressionof innerfeeling.

The reasonfor our choiceof theuseof poetry was aptly putby JeanCocteau,asstatedearlier.EdithWal-lace, in Healing throughthe arts:AJungianapproach, articulatesrea-sons for using collage. “Workingwith tissue paper, glue and brushbrought forth freer shapes,whichseemedto emergefrom a greaterdepthof the psyche:it actedas anopenerandchannelbuilder.Eventu-ally shapeswould emergethat hadgreatimpactandmeaning.”7

Theuseof creativemodalitiesaf-fords us the opportunity to meet aparticularchallengeto manypracti-tionersin thehumanserviceprofes-sions:howtoaccomplishthecontactwith andexpressionof the individ-ual’s innerworld within thecontextof a group setting. Edith Wallacealsostates:“All art is meditation...

With all the excitement,onceonetakesbrushinhandacalmdescends,a concentrationensues,whichmakesthe‘listening’ possible.”8AndMolly Fumia, in Safepassage:Wordsto help the grievingholdfastandlet go, providesuswith reasonsto cometogetherin a group. “Griefis an ancient,universalpower thatlinks all humanbeingstogether.Itempowers,opensusup to the con-nectednessof humansuffering...(and) the healing possibilities insharedgrieving for a world sosteepedin sorrow.’9

Fourbereavementgroupswereconducted.Poetrywasusedwith agroupof graduatenursingstudentsat The State University of NewYork (SUNY) HealthScienceCen-teratBrooklynandwitha groupofThe Brooklyn Hospice socialworkers, nurses andother healthcare professionals.Collage wasemployed in two groups of TheBrooklyn Hospice staff, onecon-sistedof professionalworkersandthe otherconsistedof undergradu-atestudentinterns.All groupscon-sistedof individuals from diversecultural and ethnic backgrounds.Both sexesanda wide age spanwererepresented.

As illustratedin thecollagesandpoems,five processeswere identi-fied that depict various aspectsofgriefwork for theprofessional.Theyare:

• Discoveryof culturaldiver-

sitiesandsimilarities;

• Therole of symbolism;

• The effects of witnessingsufferingin patients;

• “Opening the door” to theexpressionof grief for thenew worker;

• Making ongoing internalprocessesexternal for theseasonedstaffmember.

Cultural aspectsThe first poemincludedin Ap-

pendix 1,Deathwishes,was writtenduringatrainingsessionof graduatenursing students.Caribbean,Fili-pino, European-American,andAfro-Americancultureswererepre-sented.Spontaneousdiscussionofculturalaspectsled tothecreationofa group poem. Eachof the imageswere articulatedby individuals intheclass,manyof whomweretryingto describewaysin whichpeopleoftheir culturesmourn. Of particularnoteis the line, “Theappearanceofabat orbutterflysignalsdeath.”Thegroupwasamazedto discoverthatafew cultures,Caribbeanand Fili-pino, held this belief. “The phoneringing atmidnight...” was acknow-ledgedto be a universalnotion.Thegroupwas able to educateeachothertotheirowncultureaswell asto iden-tify with sharedpersonalexperiences.

A striking feature of collagesdoneby peoplefrom the Caribbeanis theuseof brilliant colorandform.Someusedimagesof the sea,withits bright blues andgreens,as wellas strongreligiousimages.Thesein-dividualswere ableto speakto therestof the group aboutfamily and

TheAmericanJournalof Hospice& PalliativeCamJanuary/February1995

Theuseofcreativemodalities

affords us theopportunityto

meeta particularchallenge...

church activities that makeup anintegralpartof thesocialfabricand,therefore,thegrief process.

...theseindividualsbecamemindfulof the

needto “take care” ... inpainful areaswhich theyhadgrownaccustomedto viewingaspreviously

resolvedissues.

SymbolismTheuseof the visual imagewas

apowerful tool for thedepictionofsymbolismandits role in uncover-ing meaningfor individuals whoparticipatedin collage activities.Discussionin thesegroupsessionscenteredaroundexplorationofthesesymbols. Time and mortalityseemedto bedepictedby the useofclocks andwatches. One hospiceworkerusedher imagesof time toillustrate someof the cyclical ele-mentsof life anddeath.Seaandskyseemedto suggesteternalanduni-versalforces.Candlesand flowersdepictedspiritual themes.Gunsre-presentedmurderand someof thestarkerelementsof death.Nakedbodieswere usedto representsex,deathandvulnerability.Many box-likestructureswereviewedasrepre-sentationof feeling trapped.Oneworkeridentifiedheruseof acar asdepictingconfinementof her ownemotionas well as ameansof pro-tectionof her innerselfagainsttheonslaughtof the pain of others.Food,analmostuniversalsymbolofnurturance,was usedin the specificcontextof shareddeathrituals,such

as wakes, funerals, and “sittingshiva.”

Juxtapositionof wordsand im-ageselicited a lot of materialfromgroupmembers.One student,con-trasting imagesof sex andmurderand death,spoke at length of theforces in his urban world: HighcrimeratesandAIDS, to nameafew.He seemedto be illustrating howworkingwithdying patientselicitedsomeof theeverydayfearshecarriesaroundwith him. The collagepro-jectcontributedto theintegrationofthesevarouselementsof his life.

SufferingA few hospice workers used

wordsconnotingsufferingandpainin theircollages.Thiswasa disturb-ingdiscoveryfor thematfirst.Mem-bersofthegroupdiscussedthewaysthey usually avoidedawarenessoftheseaspectsof deathand dying:Attendingto concretetasks,busyingthemselveswith comfortingothers.However, in groupdiscussion,andafterwards,in workdayinteractions,theywereableto acknowledgeandmoreclosely identify the powerfuleffect that witnessing suffering inothershadon them.Becomingcon-sciousof this phenomenonaffordedthem the opportunity to lendeachothersupportandtoidentify individ-ual meansof coping.

“Opening the door”

Oneworker,new to hospice,be-ganto usethe discoveriesshehadmadein thebereavementsessionstoprocessher griefreactionswith pa-tients. A PanamanianwomanfromanHispanicculture,shehadidenti-fied religiousthemesthat wereim-portant to her in hercollage.Later,she experiencedthe impendingdeath of a patient as particularly

traumatic.It seemsthatthepatient’sfamily sharethe samereligiousbe-liefs thatshedoesandareHispanic.Thepatientchosetoaccepttherelig-ion,whichhehadlongdenied,in herpresenceduring one of her visitswith him. Shewasableto identifypersonalbereavementfactors,in thiscase,bydiscussingherreactionwithfellow staff members.Shehad infact been the one to articulatetheimagethat inspiredthegrouppoemin the poetry bereavementsessionwith hospicestaff. After discussinghowhardit isto endhomevisitswithpatientswhenrealizingthatthismaybethelasttime shewould seethemalive, shestated, “I can’t stand toleavewhenthey’re beggingme notto go.” (SeeAppendix2, “Beggingmenot to go.”)

Thispaperclearlydemonstratesthat

hospicepersonnelhavea strongneedfor

exploration oftheirown bereavement

processin order towork moreeffectivelywith their clientsand

families.

Making the internalprocess external

A few seasonedworkers weresomewhatamazedat elementsintheir collages.Expressionsof reac-tionsto others’sufferingandwaysofprotectingoneselfwerethemesthat,althoughnot new to theseworkers,hadaprofoundeffecton theseindi-viduals. Similarly, elementsin the

7TheAmericanJournalof Hospice& PalliativeCamJanuary/February1995

their clientsandfamilies.

References1. Fischer E: The necessity of art. PelicanBooks, 1963:7.2. BertmanS: Facingdeath:Images,insightsand interventions. HemispherePublishingCorp.,Worcester,Mass.,1991.3. Ibid:8-9.4. May R: The courage to create. BantamBooks,NewYork, NY, 1976:19.5. Ibid:27.6. Fischer:9.7.WallaceE: Healingthroughthevisualarts:A Jungianapproach.In Aron Rubin J (ed):Approachesto arttherapy:Theoryandtech-nique. Bruner/Mazel, New York, NY,1987:114-133:120.8.Ibid:123.9. FumiaM: Safepassage:Wordsto helpthegriefmghold fastandlet go. Conan Pmss,Emeryville,Calif.:3.

poemproducedby hospicestaffde-scribedwaysin whichthe workerswere avoiding their own painfulmemoriesby focusing on theircaregiverroles with patientsandfamilies. (“I see my mother, Mymind goesblank; I throwit off.”) Itseemedthatthe periodic re-discov-ery of familiar themeswas just asimportantas discoveringnew onesin theprocessof grief workamongprofessionals.Each of theseindi-vidualsbecamemindful of theneedto “take care” of herselfonceagainin painful areaswhich they hadgrown accustomedto viewing aspreviouslyresolvedissues.

In summary,variouselementsofgriefwork wereillustratedin theuseof poetry and collage amongstaffwho carefor the dying andthebe-reaved.Reasonsfor the useof crea-tive modalitiesin staffbereavementgroupswere established.Culturalaspectswereexploredas well as as-pectsof grief that are specific tohosiceworkersandotherhealthcare

professionals.This paperclearlydemonstratesthathospicepersonnelhaveastrongneedforexplorationoftheir own bereavementprocessinorderto workmoreeffectivelywith

TheAmericanJournalof Hospice& PalliativeCamJanuary/February1995

Appendix 1.Death images

Seeingmy motherstandingthere,watching.

Feelingsomeonepulling atmewhenmygrandfatherdied.

Seeingthe windowsopenandcloseatthe patient’slastbreath.Hearingmy mother’svoice,callingmy name,soclear.

The sensationof fizzing “bubbles”arisingfrom my father’sbody.

Thesweetscentof flowers,as if shejustpassedby.

Your hair standsup, yougetachill, whenaspirit isnear.Thedoghowls whenit sensesdeath.

The appearanceof abator abutterfly signalsdeath.

Dreamsof weddingsandfuneralsinterchangemeaning.Dreamsof someonedying...don’ttell anyone!

The phoneringing atmidnight...no onethere.

Appendix 2.Begging me not to go

Beggingmenot to go.

We’re friendsso closesosoon.Thecourageof theverbaloneswho don’t wantto suffer—butdo.

I seemy mother.My mindgoesblank; I throwit off.

Peoplesaytheyunderstandbut howcantheyuntil theyhaveexperiencedloss?

I seemyselfhugging,comforting,strokingonethatjust hada loss.Why did it haveto happento me?

Whenwill it end—mylife is on hold.

I hopeyou’ll betherewhenI go.

Why am I working here?I know...to bring as muchcomfortaspossiblein the end.

I’ve learnedto live for nowbecauseno oneis assuredof tomorrow.