Expressive Arts for Grieving Youth: A Pilot Project
Department of Psychology, University of New Brunswick, Saint John, New Brunswick, Canada
Department of Nursing & Health Sciences University of New Brunswick, Saint John, New Brunswick, Canada
NB Copes Child & Family Grief Centre, Saint John, New Brunswick, Canada
Academic Editor: Gerhard Litscher
Received: August 31, 2022 | Accepted: January 10, 2023 | Published: January 28, 2023
OBM Integrative and Complementary Medicine 2023, Volume 8, Issue 1, doi:10.21926/obm.icm.2301009
Recommended citation: Law MA, Pastirik P, Shamputa IC. Expressive Arts for Grieving Youth: A Pilot Project. OBM Integrative and Complementary Medicine 2023;8(1):19; doi:10.21926/obm.icm.2301009.
© 2023 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
The health, social, and economic impacts of the complex grief resulting from the COVID-19 pandemic, coupled with Canada’s fragmented, under-resourced and insufficient grief support services, is predicted to have prolonged, adverse psychological effects on millions of Canadians [1,2,3]. The social isolation in which people grieved the loss of a loved one was unprecedented [4,5]. Deaths throughout the pandemic were not solely due to those contracting the SARS-CoV-2 virus, but also suicides , and lack of access to primary care for chronic and acute conditions . The availability of formalized grief support has been a chronic concern across the country . Although some recognize there are pockets of counselors that provide individual grief support, it is generally not considered a priority in mental health services . Given unresolved grief creates significant downstream costs to health systems and the economy  and the fact that there were significant losses for so many during the current pandemic efforts, our project attempted to address this gap in services for grieving youth by providing expressive arts therapy by a professional artist and certified counsellors, rather than an art therapist .
The value of expressive arts therapy in trauma work with youth is well established . Its value has been documented by those working with inner city youth , immigrant children  and victims of abuse . There is a burgeoning literature citing the effectiveness of expressive arts therapy with children and youth for a variety of outcomes including loneliness, trauma, substance abuse, and bereavement [15,16,17,18,19]. Youth experiencing grief during the COVID-19 pandemic faced significant barriers in accessing social support, exacerbated loneliness, and lacked safe spaces to grieve well [20,21]. The current project stems from this work.
Vulnerable youth are already known to have significant mental health challenges and inequities, and often feel marginalized [22,23]. The combination of induced strain from unprecedented social mitigation during the COVID-19 pandemic  coupled with an adverse event, e.g., death of a family member created increased vulnerabilities for an already disenfranchised population; however, to date, it is unknown what the cumulative impacts will be. Grief, overall, is viewed as a “normative” life event, yet bereaved children and youth are often ill-equipped to cope with a sudden or significant loss (e.g., death). The death of a parent, sibling or other important attachment figure is one of the most disruptive and potentially traumatic experiences for a child or youth, yet it receives little attention in efforts to mitigate future risk . Youth have significant risk factors for mental health issues after the loss of a family member yet are considered disenfranchised or “silent mourners” due to their lack of ability to access support and/or their developmental stage . Further, children and youth from marginalized populations have higher incidence of bereavement compared to the general population. A study of 77,000 bereaved children in Ontario conducted by the Child and Youth Grief Network (https://www.childrenandyouthgriefnetwork.com/), found that marginalized populations are disproportionately represented in bereaved groups. Although it is unknown if similar trends exist in the New Brunswick (NB) youth population, the annual report from the NB Child and Youth Advocate  highlights the significant vulnerabilities of youth living in poverty. Within the findings of this report, there is an expressed concern that many of these youth feel marginalized and lack a feeling of belonging. These are often concerns expressed by grieving youth, in general, so it is posited that grieving vulnerable youth are in particular need for the validation of their grief experiences, particularly in the context of COVID-19 where traditional social and emotional supports for grief have not been accessible . The effects of COVID-19 have caused “grief-like” behaviours for all youth, and it is posited that those grieving the death of a family member during COVID-19 will have more mental health challenges  and lost any support networks that existed . Hence, with limited traditional resources from health care systems and community providers, exploring alternative avenues of support for this vulnerable population appears warranted [3,29,30].
The foundation of our expressive arts therapy approach in this study with grieving youth emerges from a philosophy of person-centred expressive arts therapy . A person-centred multi-modal approach rooted in the belief that an environment of empathy, honesty, and care, supports individuals to find appropriate directions in their lives. While providing a safe psychological environment with the goal of helping grieving persons navigate their grief experience  expressive arts therapy is known to foster creativity, self-confidence, empathy, and a felt sense of inclusion . By connecting grieving youth with one another, the goals of reducing feelings of isolation, normalizing the grief process and offering an opportunity to explore healthy ways of coping are sought . “By creating art together, these students would be able to process and share their past experiences and be able to make connections with each other”  . Therapists and peer mentors give the needed support and encouragement without a prescriptive approach to the creative process and allow thoughts, ideas, and conflicts to emerge through art forms . In past studies, positive outcome statements from participants reflect the power of expressive arts therapy to support grieving youth: “I don’t feel so alone and lost, it has made me feel stronger and I feel we have united like friends when you most need a friend” .
The full impact of COVID-19 on grieving youth is yet to be known. Supporting these youth through evidenced-based approaches has the potential to mitigate further mental health risks that have emerged due to COVID-19 [24,29]. There appears to be an immediate need to connect, educate, and support youth who are grieving for a variety of reasons . The aim of this project was to address the needs of vulnerable youth by decreasing social isolation, providing an outlet for grief expression, and to clarify feelings associated with grief and loss [36,37]. Previous grief work conducted with adolescents have highlighted the necessity of addressing loneliness [38,39,40], depressive symptomology [34,41], and suicidal ideation [42,43,44]; hence this study targeted these evidence-based outcomes for our participants. It is anticipated that this work will contribute to the growing body of research supporting expressive arts therapy as an approach to improving well-being and coping skills after the loss of a close family member [32,45,46]. The primary innovation in this pilot project is the blended service delivery using a professional artist and certified counsellors to deliver grief services when art therapists were not readily available due to the locale and COVID-19 conditions.
2. Materials and Methods
2.1 Research Design
The Healing HeARTS project is an expressive arts therapy program adapted from a program being delivered by a team of certified counselors and a professional artist that volunteer with NB COPES (Connecting Others, Providing Education & Support), a registered charity with the mission to ensure no child, youth, or adult feels alone in their grief. Healing HeARTS was developed based on previous similar programs and theoretical frameworks [31,32,33,34,35] that involve a series of invitations to engage in various activities that represents the artistic expressions of the participants’ grief journey. Individuals are then invited to include their art in a final mural project collectively expressing their grief work as a group . This program has never been formally evaluated.
The program is typically delivered over an eight-week period, two hours every week. Due to restrictions on social gatherings, access to public spaces and concerns of fluctuating public health measures that could potentially terminate the project, the program was truncated to a four-week, four hours every evening delivery in the late spring of 2021.
This is a mixed-methods study in which participants were recruited through local youth centers and community service providers via social media, posters, and word of mouth. Screening interviews were conducted by certified therapists to ensure the suitability of the program for each of the six participants. The inclusion criteria for being considered a vulnerable youth was someone aged 13 to 18 years, experiencing fiscal poverty, food insecurity, and had previously received services for mental health support. Racial/ethnic background was not considered during this screening. Vulnerable youth were then included in this intervention if they had experienced the death of a loved one in the previous year; not all deaths were due to contracting the SARS-CoV-2 virus; some deaths were suicides or due to lack of primary care for an existing condition. This time frame was used for inclusion as it is suggested interventions are most effective within 6-18 months of the loss and it usually takes 1-2 years for people to recover from acute bereavement distress . Exclusion criteria included youth that demonstrated severe or prolonged grief disorder, as assessed by certified therapists at the screening interview, that would limit their ability to actively participate in the project.
One youth peer mentor was recruited to work with two certified therapists and one professional artist for four weeks to help youth design and create a mural that represents both their individual and collective grief/loss experience. A combination of guided peer group support along with instruction on the creation of the art mural [34,47] were conducted during the four-week program . This program was originally developed to be delivered over an eight-week period, two hours per session, however, due to unstable pandemic conditions it was truncated in order to be delivered in a shorter time period.
This study was reviewed and approved by the University of New Brunswick (File no. #010-2021) and the Horizon Health Network (file no. RS 2020-2937) Research Ethics Boards.
The leadership team was composed of two licensed counseling therapists from New Brunswick with a background in youth grief support, and experience in working with vulnerable youth provided all psychological interventions during this project. The therapists trained one peer mentor, who had lived experience with grief/loss, to support the youth on the program objectives and skills for listening to and communicating with grieving youth. The professional artist who delivered the art component, has a background in supporting expressive arts programs and experience working with grieving youth. The therapists and professional artist had completed the two-day Dougy Center Training centered on being grief informed, working with children, complicated grief, traumatic grief, and professional/personal response to grief. Further, all leadership members had lived experience with loss and grief of family members. The youth peer mentor had been recently involved in grief support using arts-based therapy and was coping well. They had expressed a desire to support other youth who were experiencing grief. Their specific role was to engage in the art invitations and encourage others to share their stories. The therapists facilitated the group dialogue and verbal/emotional expressions evolving from the art. Two therapists were present in the event a participant needed more support or dialogue and could remove themselves from the group to receive one-on-one assistance. The professional artist supported the project with art materials and supplies, provided personal guidance on art activities when needed, and helped the youth design the mural.
A total of six youth, ages 15 to 18 years (M = 16.25, SD = 1.25) participated in the expressive arts therapy for grieving youth during a four-session program adapted for COVID-19 safety protocols during the yellow phase in New Brunswick, Canada, May 2021. Participants were recruited through local youth centers and community service providers via social media, posters, and word of mouth. Inclusion criteria were youth between the ages of 13 and 18 who lost a family member (sibling/parent/significant other) in the last 6-18 months and expressed interest in the study and committed to attending all therapy sessions. Types of loss included suicide, sudden cardiac event, and cancer/illness. Pre-program interviews were conducted (n = 6) by certified counsellors involved with the program to determine their suitability resulting in five young women and one young man being accepted into the program.
Intake interviews with the licensed counselling therapists were conducted to ensure the readiness of the youths to participate in the project; including the youth’s interest in the group, their current loss experience including their relationship with the deceased, experience with death/loss, details regarding any other group involvement or therapy, how COVID-19 has impacted their grieving process, any fears or questions about the program. Counsellors reviewed the informed consent form with potential participants, detailing the purpose, procedure, and potential benefits and risks if they decided to participate. Issues involving privacy, confidentiality and freedom to leave the program at any time were emphasized. Youth were asked if they had any questions about the consent form before signing it. Once informed consent was given, the first set of quantitative measures were taken during this initial meeting before the program started. The counsellor was in the room as the youth filled in the Qualtrics survey on their phone as accessed by an external link. They were encouraged to ask any clarifying questions regarding the measures at this time.
Program Activities. Creative peer group activities have been found to assist grieving teenagers to reduce feelings of isolation, access support from others, explore ways of coping, validate, and normalize grief, maintain connections with their loved one, and provide a safe space for expression of grief . In the study by McGuiness and Finucane , positive outcome statements from participants reflect the power of expressive arts to support grieving youth: ‘I have learned to be more expressive and allow myself to feel sorry and sad whenever I want to – tried to shut grief off’ and ‘I don’t feel so alone and lost, it has made me feel stronger and I feel we have united like friends when you most need a friend’. The Healing HeARTS program was developed based on theirs and similar work that highlighted group dynamics that reduce feelings of isolation, offer support, and help elucidate feelings [31,32,33,34,35]. Activities during each session were centred on creating a safe space for the expression of grief emotions and connection with peers. Participants were encouraged to share whatever thoughts or feelings they had through depiction of words and images during these purposeful art invitations examining the grief experience and connecting with others with the lived experienced of the loss of a family member. The process of engaging in the art activities allows for narratives to organically emerge transforming the art into language to express their grief . The first art invitation had youth create clay masks expressing their emotions while participants were encouraged to share their art process and explore the range of grief emotions experienced during their loss. Therapists provided validation for the range of expressions along with prompts to extend their understanding of the grief process. The second art project one week later was creating a postcard focused on writing a letter to their special person and reflecting on memories. The third art session had the youth being prompted to paint their weather pattern exploring emotions. Each element of the program contributed to the final mural that was created by the participants during the last session together. Previous studies including the formation of murals have shown them to be effective expressive tools for the grief experience and perceived on-going social support [34,50]. The choice of a mural was to foster connection of lived experiences within the group. The process of the mural construction allowed for youth to construct individual art and then share their art with the larger group. The group then made decisions around how to cluster and place art that represented their shared experiences.
Validity/Credibility. Participants were screened for suitability by certified clinicians and were included in the study. Measures used to detect and assess depressive symptomology, loneliness, and suicide risk are well validated and reliable instruments [51,52,53,54]. Thematic content analysis as described by Vaismoradi and colleagues  was conducted by two independent coders experienced in qualitative method analyses, the first author and a graduate student in the Psychology Department, resulting in a high concordance rate (>90%) on identified themes with only one difference requiring discussion. Those conducting the evaluation of quantitative and qualitative data collected did not have any direct contact with youth participants, therapists or peer support worker. The professional artist, who also served as the focus group facilitator at the end of the program, was only in contact with the coders and data analysts before the program started to ensure all measures/questions were ready for distribution.
2.1.2 Data Analysis
All data were collected via Qualtrics survey links, compiled, and cleaned in Excel spreadsheets with descriptive statistics and tables generated using IBM SPSS Statistics-26. Participants were given access to the Qualtrics link in the company of adult therapists and program supervisors capable of answering any questions.
Thematic content analysis  was conducted on the small amount of recorded qualitative data culled from the exit discussion in a focus group format asking participants to share their experience over the four-week program. Two coders conducted independent thematic content analysis, conferring on one point of disagreement, and making slight modifications to merge identified themes.
The aim of this project was to decrease the social isolation that naturally accompanies loss and may have been exacerbated during COVID-19 pandemic restrictions . We also wanted to offer opportunities for youth to express their grief and help them clarify feelings associated with their loss [28,29]. Based on earlier research conducted with grieving adolescents, measures targeting loneliness [30,31], depressive symptomology , and suicidal ideation [33,34,35] were selected. All measures chosen are reliable and well validated with youth. They included an assessment of social and emotional loneliness , a short mood and feeling questionnaire to identify depressive symptomology  and a scale measuring satisfaction with life which is often used to assess mental wellbeing and suicidal ideation . Five questions regarding the youths’ satisfaction with the program and their experience in it were generated specifically for this evaluation.
2.2.1 Short Mood and Feeling Questionnaire
The Short Mood and Feeling Questionnaire (SMFQ) consists of a series of descriptive phrases regarding how the subject has been feeling or acting recently and whether these statements reflect the experience of the respondent most of the time, sometimes, or not at all in the past two weeks. It is an effective and well-established tool for screening depressive symptomology [41,43]. Cronbach’s alpha coefficients in the current evaluation are imprecise due to very small sample but were noted to be 0.54 pre-program and 0.92 for post program measures. The mean values of 13.67 were noted both before and after the program, indicating the group as a whole was experiencing pronounced depressive symptomology, validating their need for this program (Table 1).
2.2.2 The Social Emotional and Loneliness Survey for Adults (SELSA_SMY)–Short form Modified for Youth
The SELSA-S is a 15-item questionnaire that employs a 7-point Likert rating scale assessing experienced levels of family, romantic, and social loneliness . Youth were asked to answer each question, depending on their thoughts and feelings from within the past year during the COVID-19 pandemic. The sample size in this study was too small (n = 6) to generate precise reliability estimates, and the following statistics need to be read with extreme caution, however due to it being a pilot project reliability estimates were still generated. Cronbach’s alpha coefficient for the romantic, family, and social subscales was 0.91, 0.90 and 0.92 respectively, with an overall alpha coefficient of 0.93. Post-program alpha coefficients for the romantic subscale 0.92, family subscale 0.94, social subscale 0.93 and an overall SELSA-S scale coefficient of 0.94 were also very strong.
Overall, there was an encouraging trend noted in overall measures of social and emotional loneliness indicating a decrease in lonely feelings over the course of the four-week program as the mean pre-program score 51.50 decreased to 49.17 after the program was over. One participant did not appear to answer the questions in a meaningful way, putting a value of 1 in for every question on this scale; when that case was dropped for an alternative analysis the decrease in loneliness was more pronounced, shifting from an average overall score from 58.80 to 54.60. It also shifted overall levels of loneliness higher which is what would be more expected in this vulnerable group of youths (Table 2).
2.2.3 The Satisfaction with Life Scale (SWL)
The Satisfaction with Life Scale SWL  is a 5-item questionnaire that uses a 7-point Likert rating scale assessing subjective well-being. It has been used extensively throughout social, health and well-being literature showing it correlates with other measures of mental health and has been established to be predictive of suicidal ideation. Scores on this scale range from 5-35, with scores below 9 indicating extreme dissatisfaction with life, scores above 31 indicating extremely high life satisfaction and a score of 20 representing a neutral point of view. Again, due to the small sample size in this evaluation the Cronbach alpha’s must be interpreted with extreme caution; however, they appear to have high reliability with a pre-program measure of 0.99 and post-program estimate of 0.97.
As can be seen in Table 3, the average level of satisfaction with life was low with average scores of 13.17 and 13.80 in the dissatisfied range. Alternate analysis was again conducted with one respondent who again exhibited a strong response set, replying with the same answer for all questions, in this case with a 5 strongly agreeing with statements such as my life is ideal, the conditions of my life are excellent, which is possible but not likely. Therefore, an alternate analysis seemed warranted, and results showed an overall drop in life satisfaction to a score of 11.40 before the program and a slight increase (11.50) after the program (Table 3).
2.3 Post Program Evaluation Questions
Five questions were asked after the program was completed. As can be seen in Table 4 the participants unanimously agreed there was benefit to the program. On average, participants felt the program helped them not only in a general way, but also in improving their functioning in their family, with school and especially in expressing their feelings. Examining the standard deviations and ranges in Table 4, it is clear there was variability in responses, with some participants strongly agreeing with these statements. Coupled with the data gleaned from focus group discussions this program appears to have been a positive experience for the youth with positive impacts on loneliness, wellbeing and increasing a sense of belonging.
3. Results and Discussion
Although statistics are typically not conducted on small sample sizes such as the current study, the authors considered defensible value in examining this data to identify possible triangulation supporting the qualitative data collected and reported on here. Data collected in future programs will be merged with the current dataset to generate more robust findings. The quantitative data also served as descriptive statistics for our sample and contextualized the qualitative data collected on the last night of the program.
3.1 Thematic Content Analysis
On the last night of the program, the artist asked participants to share their experience over the four-week program. The discussion was recorded using digital voice recorders. All participants were aware they were being recorded. Data was transcribed by the first coder and accuracy confirmed by the second coder. The data collected from this focus group discussion was subjected to a thematic content analysis  in order to identify pertinent themes. Printed transcripts were provided to both coders, who worked independently and confirmed content and thematic analyses at the conclusion of their coding. In the initializing phase of the coding, both coders read through the entire transcript several times in order to understand the progression of the conversation, the sentiment being conveyed and gain an overall perspective on the focus group discussion. Neither coder was present during the delivery of the program or the focus group discussion; neither had any contact with any of the youth throughout the entire process. Transcripts were carefully read. Key terms were highlighted in each line of data. These terms were then colour coded based on their conceptual similarity, i.e., enjoyment of art activity. Similar coded items were applied a descriptive label. These descriptive labels – or codes – were then analyzed to establish themes coming through these statements. Coders conferred on themes and minor adjustments were made in labeling of themes.
Five prepared questions were asked during the focus group discussion in a semi-formal approach that allowed for spontaneous prompts from the facilitator and interactions with their peers. The questions were; 1) ”What was your experience with being in the program?”, 2) ”Were there things that helped in the group?”, 3) “Were there things that you think we could have done to improve?” 4) “What was the best part of the program?”, 5) “Would you recommend it, to someone else?”. The discussion lasted approximately 20 minutes. After the focus group discussion, participants were asked to fill in the post-program survey via a second Qualtrics survey link on their personal cell phones. The counsellor, peer support person and artist were all available to answer clarifying questions.
The following content and themes emerged from the focus group discussion. Several of the identified themes, e.g., shared experience, reduced isolation, connecting with facilitators, indicate the objectives of the program to reduce social isolation and reduce emotional distress were being addressed. This was corroborated by the small amount of preliminary quantitative data that was collected that noted reductions in social and emotional loneliness and improvements in life satisfaction measures taken pre and post program. These quantitative findings can only be noted in a descriptive manner as inferential significance cannot be ascertained given the small amount of data that was collected with this pilot project. Future data added to this pilot project will elucidate this preliminary finding.
3.1.1 Safe Space to Speak and Express Emotions
Participants were very relieved to have the opportunity to express their emotions (n = 3) stating “Here, it was easier to talk about my loss just because almost everywhere else was not as comfortable to talk about it” (P4) and another participant stated, “Here it’s kind of easier to say stuff than it is with, like, my friends or my family” (P2). Another participant confirmed this sentiment, responding, “Being able to express how you’re feeling in a safe space, with facilitators” (P1) when asked what the best part of the project for them was. Quantitative measures of social and emotional loneliness that appeared to be decreasing over the duration of the program may have been reflecting the youths’ need of a space safe to speak and share being addressed.
3.1.2 Shared Experience Comforting/Reducing Isolation
Youth expressed an appreciation for connecting with others with the same struggles (n = 5) and breaking down some of the isolation they have been experiencing (n = 3). These sentiments confirmed the elevated social and emotional loneliness noted in the SELSA-S measurements in the survey at the beginning of the program and the decreases noted among the small number of participants. “Being around people that have experienced similar emotions” (P3) helped them during their time in the program. Poignantly, one participant wrapped it all up by saying, “I think grief is a long-lasting isolation, with or without COVID” (P4) with several participants (P3, P2, P1) agreeing with this statement.
3.1.3 Connecting with Facilitators
This program was also valued by participants for connecting them with the therapist, artist and peer mentor who had lived experience with grief/loss. When asked what the best part of the program was one of the youth said “Probably you, [professional artist]; probably you” (P4), again verbally validated by other participants (P2, P6). This growing connection was also reflected in the quantitative measures taken before and after the program delivery using the SELSA  that indicated decreases in emotional and social loneliness. Finally, most youth voiced their agreement (P1, P3, P4, P5) when asked “If they felt the connection with some of the facilitators [therapists] here was helpful?” with one youth adding “really helpful” (P6).
3.1.4 Enjoyed Artistic Activities
All of the participants enjoyed the art activities (n = 6), for some “the painting was the best part” (P2, P1) and for one youth (P1) it was an opportunity to expand on their established artistic practices as the professional artist reflected “I know you are kind of an artist already. So maybe it was sort of expanding on some of your skills you already had in different ways”. One youth stated, “The art helped because it kind of took my mind off it – some of the grief – so that it was easy.” (P2). Another participant agreed, “It was fun to do the art, it took my mind off stuff.” (P5). One of the participants offered “I found that finding a way to express yourself through all sorts of mediums was really helpful” (P1). This type of comment offers general support for the emerging value of expressive arts therapy beyond conventional counselling that can be appealing and helpful for some individuals . One of the participants asked a question to the group “Did anybody else find it helpful to be able to express what they’re feeling, but not have to name it with words?” (P5) with several youth in agreement (P2, P3, P1).
3.2 Program Satisfaction
As the focus group discussion wrapped up the facilitator asked if there was anything the youth would suggest they change the next time they deliver the program. The response was very positive “I can’t really find any flaws in it.” (P4), and others agreeing “It’s pretty A-Okay.” (P1) and “It’s all been pretty good…” (P5).
Due to COVID-19 restrictions and operational safety plans, the program had to be adapted several times to be delivered in a safe and timely manner. One point of particular concern for the program facilitators was the four-hour sessions and if the youth found them too long, adding in a question that was not planned “[How about] the length of the program” to which several of the youth replied, “It was good” (P1, P2, P3, P5).
The facilitator also wondered if the youth felt there was anything that was missed, any topic of discussion, anything that should have been covered or discussed that was not – given time to think and respond, the youth could not think of anything. The last question “Would you recommend this program to your friends” was met with a unanimous positive response “Absolutely!”, “Definitely!”, and “For sure!” and several “Yeah”s from all participants (n = 6).
3.3 Practical Implications
Based on participant feedback and preliminary quantitative assessments, the expressive arts therapy program delivered by an artist and certified counsellors to vulnerable youth experiencing significant loss during COVID-19 was well executed, well received and demonstrated promising effectiveness in attaining the main focus of its program goals of reducing a sense of isolation and promoting a sense of inclusion for vulnerable youth during the COVID-19 pandemic. There was no indication this program decreased feelings of depression either in the Short Mood and Feeling Questionnaire (SMFQ, ) or the focus group discussion. This may be due to the shortened period of time the program was delivered and in future offerings spanning more time changes in these scores and content in focus group discussions may appear. The SMFQ, however, was helpful indicating that all youth were experiencing significant depressive symptomology and were appropriately placed into the Healing HeARTS program. These findings support similar findings that expressive arts programs have made improvements in the lives of trauma-exposed youth , mentally distressed refugee children [13,56] and adolescents with post-traumatic stress disorder .
A noteworthy feature of the Healing HeARTS program was the fact that all members of the leadership team had lived experience with loss and grief. The professional artist’s loss was almost ten years ago, and the peer support worker’s loss was more recent. The two therapists that facilitated group discussions in the Healing HeARTS program had lost a close family member when they were younger. This was shared at the onset of the group. The therapists were aware of the importance of the SEUS (“safe and effective use of self”) throughout the sessions so that the discussions remained client centred. The therapists also debriefed after each session, allowing them time to reflect and process the participants’ stories and plan for next sessions. It is known that peer support is a powerful component of many grief programs. Although the therapists were not in the peer mentor role, it is hypothesized that their lived experience of grief and loss would support a safe and welcoming space within the group. Future studies should focus on leadership teams with lived experience of loss and grief contextualized within expressive arts therapy.
The final mural project represents the artistic expressions, both personal and as a group, of their grief journey during the Healing HeARTS project (Figure 1). Slight increases in life satisfaction, coupled with the limited feedback during the focus group discussion suggest more intensive services over a longer period of time may continue to increase this positive effect for grieving youth. Likewise, the lack of change in depressive symptoms may suggest more intensive programming may afford more change. This program had been originally designed to be offered over a longer time period however due to impending changes of social mitigation during the extended state of emergency the truncated program may have been not as efficacious. Future programs delivered should strive for longer time periods with participants over several more weeks.
Figure 1 Mural representing the artistic expressions of the participants’ grief journey.
Youth have been found to be capable self-reporters of their mental health issues . However, discussion is warranted concerning the alternate analysis that was conducted, with two of the three quantitative measures, due to concerns with one respondent who appeared to be exhibiting a strong response set, replying with the same answer for all questions for the Satisfaction with Life Scale  and the measures of social/emotional loneliness. These responses may be indicating the youth did not feel free to express their true feelings given feedback was being sought by group leaders, who also have a shared history of loss and perhaps had been engaged in a vulnerable interchange during the program proper. The leadership team was aware of this vulnerability, but it may still have stifled the youths’ desire to share their feelings in a more formal assessment. Additionally, it may be noteworthy this response set was not noted on the short mood questionnaire which asked questions such as “I felt miserable or unhappy” perhaps more socially acceptable feelings at a program targeting grief and loss. The singular youth may have resorted to a sarcastic response to questions such as “my life is ideal”, “the conditions of my life are excellent” that may have been interpreted by the grieving youth as insensitive. In the context of interventions centering on grief, loss and trauma with youth, perhaps this measure may warrant replacement with a measure whose wording may not be perceived as insensitive. This apparent response set may also reflect a broader issue of limitations when using self-report measures with youth may be under-reporting behavioral difficulties . Finally, those delivering the therapeutic portion of expressive arts therapy programs, should be aware that youth may not feel free to fully express themselves in an evaluative focus group discussion after engaging in deep, difficult topics during the program.
The Healing HeARTs program appears to share similar theoretical underpinning of all creative art therapies share in bringing the healing power of multisensory communication, reflection, connection, empowerment, multisensory, and self-expression to their programs . This includes expressive arts therapy , complementary medicine , and arts-based research . The Healing HeARTS project was initially conceptualized under a theoretical framework of an adapted expressive arts therapy rooted in Adlerian Psychology , however, future work on understanding its mechanisms for change may be better suited to the arts-based literature given the lack of certified art therapists available in the local community to deliver it.
Finally, this study suggests future research on the utility of the therapist-artist model presented may be warranted. More rigorously designed studies collecting qualitative data and quantitative measures on groups co-led by a professional artist and certified therapist compared to those interventions with trained creative arts therapists could provide insight into differences in participants’ experiences when engaging these different types of services and the relative efficacy of each approach.
The findings of this study support the need for more diverse and creative approaches to supporting grieving youth. In most cities in Canada, art therapists do not exist. This study offers preliminary evidence suggesting that partnerships between therapists and professional artists may be able to offer limited services to begin to address some social, emotional needs in grieving youth that would otherwise be left unaddressed. It also offers support for the proposed theoretical framework of a person-centered multi-modal approach that proposes an environment of empathy, honesty, and care, can generate a safe space for disclosure and growth. The youth confirmed they enjoyed the opportunities to be creative “I think the art helped because it kind of took my mind off it, some of the grief so that it was easy” (P5) and they felt a sense of inclusion, “I found being here it was easier to talk about my loss just because almost everywhere else was not as comfortable to talk about it, with people.” (P4). These comments regarding inclusion were also reflected in the quantitative measures of social/emotional loneliness. As hoped for, by connecting grieving youth with one another, feelings of isolation decreased and normalizing the grief process appears to have occurred. This pilot project provides evidence of the potential expressive arts therapy has with adolescents, its potential to reduce social isolation related to COVID-19, and the impact of expressive arts therapy has on mitigating the impact of grief. Youth in this study felt safe and connected within the group, while learning that art can be a source of expression, inspiration, and healing. The use of expressive arts is a gentle approach to a difficult matter and there is a need to examine the application of expressive arts in alternate settings such as schools, community centres and youth organizations, especially during times of global upheaval.
Limitations in this study were mostly due to a small sample, which was expected, limiting any meaningful inferential statistical comparisons before and after the program on measures of life satisfaction, short mood questionnaire and social/emotional loneliness. An accumulation of evidence on the efficacy of this program will continue to be evaluated with future offerings; notwithstanding, current findings in this study offer preliminary support that expressive arts therapy shows promise with grieving vulnerable youth in the community. Insufficient participant numbers did not allow for in-depth statistical analysis of the current program in determining if the pre- and post- scores on the various measures were statistically significant; however, descriptive statistical analysis, i.e., examining mean scores of the group, of existing empirical evidence provided some quantitative support for the positive feedback voiced by participants in the closing session. Further, there was no control group, i.e., waitlisted future participants, to make meaningful comparisons on these measures with Healing HeARTS participants. The addition of a comparator group should be included in future evaluation activities with the Healing HeARTS program. Future initiatives with expressive arts therapy may want to explore identifying additional appropriate outcome measures that will clearly measure program impacts, e.g., reductions in grief, increases in hope, and social cohesion, as well as gathering parental perspectives that may lend valuable triangulation with the quantitative and qualitive data gathered from the participants. As data accumulates across future program deliveries and the sample size increases, more sophisticated statistical analysis can be conducted to examine specific characteristics of participants, e.g., type of loss, that may optimize the benefits of future programs.
This study garners preliminary support for expressive arts therapy being offered using a blended delivery mode with certified counsellors partnering with professional artists, when art therapists are not available, as a possible approach in reducing social and emotional loneliness in vulnerable youth who have experienced significant recent loss. Conducting guided art activities with other youth and adult therapists/facilitators generated a sense of belonging through creative expressions of grief and loss during the COVID-19 pandemic.
We want to thank the youth participants for having the courage and the creativity to connect with others through the Healing HeARTS project. We also want to thank the certified therapists and peer support mentor for working with the participants. We would like to sincerely thank the Crescent Valley Resource Centre Inc. for providing meeting space. Finally, we would like to thank the thoughtful reviewers of this original manuscript whose input made the final product infinitely better.
Pamela Pastirik contributed to conceptualization, investigation, writing the draft, visualization and project administration. Moira A. Law contributed to methodology, data analysis, writing the draft, visualization, validation, and reviewing and editing the draft. Isdore Chola Shamputa contributed to visualization, validation, and reviewing and editing the draft.
The Healing HeARTS for Youth Project was supported by the Government of Canada’s Emergency Community Support Fund and Community Foundations of Canada.
The authors have declared that no competing interests exist.
- Eisma MC, Boelen PA, Lenferink LI. Prolonged grief disorder following the coronavirus (COVID-19) pandemic. Psychiatry Res. 2020; 288: 113031. [CrossRef]
- Gesi C, Carmassi C, Cerveri G, Carpita B, Cremone IM, Dell'Osso L. Complicated grief: What to expect after the coronavirus pandemic. Front Psychiatry. 2020; 11: 489. [CrossRef]
- Ricci T. National grief strategy needed to help Canadians cope with loss due to COVID-19, group says [Internet]. Toronto: CBC News; 2020. Available from: https://www.cbc.ca/news/canada/toronto/national-grief-strategy-1.5810829.
- Corpuz JC. Beyond death and afterlife: The complicated process of grief in the time of COVID-19. J Public Health. 2021; 43: e281-e282. [CrossRef]
- Evans A, Ter Kuile C, Williams I. This too shall pass: Mourning collective loss in the time of COVID-19 [Internet]. 2021. Available from: https://larger.us/wp-content/uploads/2021/01/This-Too-Shall-Pass.pdf.
- Banerjee D, Kosagisharaf JR, Rao TS. ‘The dual pandemic’of suicide and COVID-19: A biopsychosocial narrative of risks and prevention. Psychiatry Res. 2021; 295: 113577. [CrossRef]
- Poorolajal J. Neglected major causes of death much deadlier than COVID-19. J Res Health Sci. 2020; 20: e00478. [CrossRef]
- Simon NM. Treating complicated grief. JAMA. 2013; 310: 416-423. [CrossRef]
- Prigerson HG, Maciejewski PK, Rosenheck RA. Preliminary explorations of the harmful interactive effects of widowhood and marital harmony on health, health service use, and health care costs. Gerontologist. 2000; 40: 349-357. doi: 10.1093/geront/40.3.349. [CrossRef]
- Goicoechea J, Wagner K, Yahalom J, Medina T. Group counseling for at-risk African American youth: A collaboration between therapists and artists. J Creat Ment Health. 2014; 9: 69-82. [CrossRef]
- Davis KM. Music and the expressive arts with children experiencing trauma. J Creat Ment Health. 2010; 5: 125-133. [CrossRef]
- Camilleri VA. Healing the inner city child: Creative arts therapies with at-risk youth. London and Philadelphia: Jessica Kingsley Publishers; 2007.
- Kowitt SD, Emmerling D, Gavarkavich D, Mershon CH, Linton K, Rubesin H, et al. A pilot evaluation of an art therapy program for refugee youth from Burma. Art Ther. 2016; 33: 13-20. [CrossRef]
- Ugurlu N, Akca L, Acarturk C. An art therapy intervention for symptoms of post-traumatic stress, depression and anxiety among Syrian refugee children. Vulnerable Child Youth Stud. 2016; 11: 89-102. [CrossRef]
- Auld R. Development of a method-all in the “letters”: Exploring the relationship between expressive arts therapy and the grieving process with adolescents. Cambridge, MA: Lesley University; 2022.
- Boyadjis A. Healing the traumatized child through expressive arts therapy. Superior, WI: University of Wisconsin-Superior; 2019.
- Ju CI. Effectiveness of teaching in expressive arts therapy-emotionally traumatized preschool children. Asian Soc Sci. 2014; 10: 195. [CrossRef]
- McDonald Z. Using expressive arts therapy to develop coping mechanisms to manage substance use. Cambridge, MA: Lesley University; 2023.
- Webb-Ferebee KL. Expressive arts therapy with bereaved families. Denton: University of North Texas; 2001.
- Fitzgerald DA, Nunn K, Isaacs D. What we have learnt about trauma, loss and grief for children in response to COVID-19. Paediatr Respir Rev. 2021; 39: 16-21. [CrossRef]
- Pretorius G, Pfeifer N. Group art therapy with sexually abused girls. S Afr J Psychol. 2010; 40: 63-73. [CrossRef]
- Weinstock L, Dunda D, Harrington H, Nelson H. It's complicated—Adolescent grief in the time of COVID-19. Front Psychiatry. 2021; 12: 638940. [CrossRef]
- Foster CE, Horwitz A, Thomas A, Opperman K, Gipson P, Burnside A, et al. Connectedness to family, school, peers, and community in socially vulnerable adolescents. Child Youth Serv Rev. 2017; 81: 321-331. [CrossRef]
- New Brunswick Child and Youth Advocate. The Impact of COVID-19 on Children & Youth’s Human Rights: An Overview of Risks & Recommended Responses. Fredericton, 2020. Available from: https://static1.squarespace.com/static/60340d12be1db058065cdc10/t/606b4dccda96b3431273bcac/1617645005917/COVID_19s_Impacts_on_Childrens_Rights_Final.pdf.
- Best LA, Law MA, Roach S, Wilbiks JM. The psychological impact of COVID-19 in Canada: Effects of social isolation during the initial response. Can Psychol. 2021; 62: 143-154. [CrossRef]
- Griese B, Burns MR, Farro SA, Silvern L, Talmi A. Comprehensive grief care for children and families: Policy and practice implications. Am J Orthopsychiatry. 2017; 87: 540-548. [CrossRef]
- Kristensen P, Weisæth L, Heir T. Bereavement and mental health after sudden and violent losses: A review. Psychiatry. 2012; 75: 76-97. [CrossRef]
- Canadian Psychological Association. Fact sheet: Helping teens cope with the impacts of and restrictions related to COVID-19 [Internet]. Ottawa: Canadian Psychological Association. Available from: https://cpa.ca/psychology-works-fact-sheet-helping-teens-cope-with-the-impacts-of-and-restrictions-related-to-covid-19/.
- Breen LJ, O'Connor M. Family and social networks after bereavement: Experiences of support, change and isolation. J Fam Ther. 2011; 33: 98-120. [CrossRef]
- Courtney D, Watson P, Battaglia M, Mulsant BH, Szatmari P. COVID-19 impacts on child and youth anxiety and depression: Challenges and opportunities. Can J Psychiatry. 2020; 65: 688-691. [CrossRef]
- Malla A, Shah J, Iyer S, Boksa P, Joober R, Andersson N, et al. Youth mental health should be a top priority for health care in Canada. Can J Psychiatry. 2018; 63: 216-222. [CrossRef]
- Rogers C. Person-centred art therapy. In: Art therapy. 2nd Ed. New York: Taylor & Francis; 2001. pp. 163-177.
- Nazeri A, Ghamarani A, Darouei P, Tabatabaei GG. The effect of expressive arts therapy on emotion regulation of primary school students. J Child Ment Health. 2020; 7: 132-143. [CrossRef]
- McGuinness B, Finucane N. Evaluating a creative arts bereavement support intervention: Innovation and rigour. Bereave Care. 2011; 30: 37-42. [CrossRef]
- Summer D. Honoring Timothy’s spirit: Mural making to express, process, and overcome grief and loss. In: Healing the inner city child: Creative art therapies with at-risk youth. London and Philadelphia: Jessica Kingsley Publishers; 2011. pp. 119-130.
- Snyder BA. Expressive art therapy techniques: Healing the soul through creativity. J Humanist Educ Dev. 1997; 36: 74-82. [CrossRef]
- Kielo JB. Art therapists' countertransference and post-session therapy imagery. Art Ther. 1991; 8: 14-19. [CrossRef]
- Moon BL. The tears make me paint: The role of responsive artmaking in adolescent art therapy. Art Ther. 1999; 16: 78-82. [CrossRef]
- Balk DE, Zaengle D, Corr CA. Strengthening grief support for adolescents coping with a peer’s death. Sch Psychol Int. 2011; 32: 144-162. [CrossRef]
- Boron L, Naderi F, Heydarei A, Bakhtiarpour S, Ehteshamzadeh P. Comparison of the effectiveness of drama therapy and music therapy on loneliness, anxiety, and children with grief referred to Ahwaz clinics. J Health Promot Manag. 2021; 10: 28-40.
- Hartwig EK, Marlow M. Finding hope at camp: An investigation of the influence of grief camp on youth depression, anxiety, and self-concept indicators. J Loss Trauma. 2022; 27: 149-158. [CrossRef]
- Hill RM, Kaplow JB, Oosterhoff B, Layne CM. Understanding grief reactions, thwarted belongingness, and suicide ideation in bereaved adolescents: Toward a unifying theory. J Clin Psychol. 2019; 75: 780-793. [CrossRef]
- Devlin E. Expressive therapies and suicidality in youth. Cambridge, MA: Lesley University; 2022.
- Sandler I, Yun‐Tien J, Zhang N, Wolchik S, Thieleman K. Grief as a predictor of long‐term risk for suicidal ideation and attempts of parentally bereaved children and adolescents. J Trauma Stress. 2021; 34: 1159-1170. [CrossRef]
- Nan JK, Hinz LD, Lusebrink VB. Clay art therapy on emotion regulation: Research, theoretical underpinnings, and treatment mechanisms. In: The neuroscience of depression. London: Academic Press; 2021. pp. 431-442. [CrossRef]
- Sitzer DL, Stockwell AB. The art of wellness: A 14-week art therapy program for at-risk youth. Arts Psychother. 2015; 45: 69-81. [CrossRef]
- Wilkie S. An exploration of community mural making in the context of art therapy and social action: A literature review. Cambridge, MA: Lesley University; 2018.
- Law MA, Pastirik P, Shamputa IC. Expressive art therapy with vulnerable youth: Loss, grief and social isolation. J Loss Trauma. 2022; 27: 588-591. [CrossRef]
- Hecker L, Lettenberger C, Nedela M, Soloski KL. The body tells the story: Using art to facilitate children’s narratives. J Creat Ment Health. 2010; 5: 192-203. [CrossRef]
- Testa N, McCarthy JB. The use of murals in preadolescent inpatient groups: An art therapy approach to cumulative trauma. Art Ther. 2004; 21: 38-41. [CrossRef]
- Angold A, Costello EJ, Messer SC. Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. Int J Methods Psychiatr Res. 1995; 5: 237-249.
- DiTommaso E, Spinner B. The development and initial validation of the Social and Emotional Loneliness Scale for Adults (SELSA). Pers Individ Differ. 1993; 14: 127-134. [CrossRef]
- Sharp C, Goodyer IM, Croudace TJ. The Short Mood and Feelings Questionnaire (SMFQ): A unidimensional item response theory and categorical data factor analysis of self-report ratings from a community sample of 7-through 11-year-old children. J Abnorm Child Psychol. 2006; 34: 365-377. [CrossRef]
- Diener ED, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess. 1985; 49: 71-75. [CrossRef]
- Vaismoradi M, Jones J, Turunen H, Snelgrove S. Theme development in qualitative content analysis and thematic analysis. J Nurs Edu Pract. 2016; 6: 100-110. [CrossRef]
- Kowitt SD, Emmerling D, Gavarkavich D, Mershon CH, Linton K, Rubesin H, et al. A pilot evaluation of an art therapy program for refugee youth from Burma. Art Ther. 2016; 33: 13-20. [CrossRef]
- Lyshak-Stelzer F, Singer P, Patricia SJ, Chemtob CM. Art therapy for adolescents with posttraumatic stress disorder symptoms: A pilot study. Art Ther. 2007; 24: 163-169. [CrossRef]
- Cremeens J, Eiser C, Blades M. Characteristics of health related self report measures for children aged three to eight years: A review of the literature. Qual Life Res. 2006; 15: 739-754 [CrossRef]
- Edelbrock C, Costello AJ, Dulcan MK, Kalas R, Conover NC. Age differences in the reliability of the psychiatric interview of the child. Child Dev. 1985; 56: 265-275. [CrossRef]
- Leavy P. Method meets art: Arts-based research practice. New York: Guilford Publications; 2020.
- Degges-White S, LMHC-IN LN, Davis NL. Integrating the expressive arts into counseling practice: Theory-based interventions. New York: Springer Publishing Company; 2017. [CrossRef]
- Cohen M. What is complementary medicine? Aust Fam Physician. 2000; 29: 1125-1128.
- Finley S. Arts-based research. In: Handbook of the arts in qualitative research. Thousand Oaks: SAGE Publications; 2008. pp. 71-81. [CrossRef]