Running head: MEDICAL ART THERAPY SIBLINGS

Addressing Sibling Needs Through Medical Art Therapy Interventions

Selena Sandruck

ART 790: Research in Art Therapy

Dr. Penelope Orr

Edinboro University of Pennsylvania

December 1, 2021

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Table of Contents

Abstract ................................................................................................................................ 4
Chapter I: Introduction .......................................................................................................... 5
Purpose of Sibling Support Group Curriculum .................................................................................6
History of Art Therapy in Medical Settings with Children .................................................................7
Effectiveness in Art Therapy in Medical Setting ...............................................................................7
Childhood Illnesses ........................................................................................................................9
Acute vs Chronic .......................................................................................................................... 10
Treatments and Surgeries ............................................................................................................ 10
Conclusion ................................................................................................................................... 11
Definition of Terms ...................................................................................................................... 12

Chapter II: Literature Review ............................................................................................... 14
Medical Art Therapy: The Patient ................................................................................................. 14
Medical Art Therapy: The Siblings................................................................................................. 15
Needs of Child Siblings of Medically Compromised Patients .............................................................................17

Available Support for Siblings and Families in Medical Settings ..................................................... 17
Well-being interventions....................................................................................................................................17

Effects of childhood Illness on Siblings and Family ........................................................................ 18
Importance of Mental Health ............................................................................................................................18
Effects of sibling on family involvement with hospitalized child .......................................................................20
Sibling Preparedness ..........................................................................................................................................22

Family Art Therapy in Medical Settings ......................................................................................... 22
Art Therapy for Grief and Loss ...........................................................................................................................22
Art Therapy for Anxiety ......................................................................................................................................24

Conclusion ................................................................................................................................... 26

Chapter III: Methodology ..................................................................................................... 27
Purpose of Medical Art Therapy Curriculum for Siblings ................................................................ 27
Focus of the Medical Art Therapy Curriculum for Siblings .............................................................. 28
Organization and structure of the Medical Art Therapy Curriculum for Siblings.............................. 28

Chapter VI: Curriculum......................................................................................................... 30
Introduction ................................................................................................................................ 30

Chapter V: Discussion .......................................................................................................... 54
Limitations................................................................................................................................... 54
Future Application ....................................................................................................................... 54

References........................................................................................................................... 56

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Appendix ............................................................................................................................. 62

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Abstract

Hospitals are stressful and fast-paced environments for children who are confined to inpatient
stays and have continued medical care. Siblings of medically compromised patients are
overlooked and suffer mental health problems due to vicarious trauma, changes in family
dynamics and challenges with identity formation. Throughout this paper, the mental health
challenges of this population are explored alongside the history of medical art therapy and the
uses of applying this strategy with this population. This resource aims in helping siblings of
medically compromised patients within an 11-session flexible group to focus on challenges faced
by this population. This resource also provides the reader with directives and goals of each
intervention to allow understanding and knowledge of how to guide a session facilitated by
individuals who are art therapy students or art therapists.

Keywords: Art Therapy, Identity Formation, Medically Compromised Patients, Resource,
Vicarious Trauma

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Chapter I: Introduction

Imagine having a brother or sister who is unable to have a regular childhood due to a
chronic illness while you have to sit on the sidelines. It is estimated that “13-32% of children
and younger people (ages 0-19) suffer from a chronic or life-limiting condition” (McKenzie
Smith et al, 2018, pg.246, as cited in Fraser et al. 2012). A life-limiting condition is unresponsive
to treatment, ultimately leading to death (Fraser & Parslow 2017). In a hospital setting, children
can develop mental health issues associated with the psychological and physical trauma due to
chronic illness. McKenzie Smith et al. (2018) stated that “it is estimated that around 54.6% of
families have two or more children (Organization for Economic Co-operation and Development ,
2016), which means that approximately 7-17% of children have a sibling with a chronic illness”
(p.246-247).
This project focuses on the siblings of unhealthy children who are in the hospital
undergoing medical treatment, as well as those with sudden or acute illnesses. Unhealthy siblings
left alone in the hospital, and unsure of their prognosis, can influence the mental health of
siblings. There is an urgent need to understand these issues because very few research articles
focus specifically to art therapy tailored to what siblings go through during this challenging time.
This project provides suggested assessments and art therapy interventions for this population to
provide care for siblings of children with chronic or sudden traumatic illnesses, for example
chron’s disease, sickle cell disease, cancer, car accident incidents, etc.
Research articles cited showed adequate evidence of the benefits to art therapy for the
medical population. Art therapy “is particularly effective during times of crisis, especially in
coping with isolation, changes in circumstance, trauma, and grief” (AATA, 2020). As addressed
by the American Art Therapy Association (AATA), art therapy helps foster self-esteem, promote

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insight, enhance social skills and communication, helps resolve or reduce distress as well as
improve cognitive functions (AATA, 2017). Because art therapy is known to help improve these
conditions for individuals, this paper introduces a curriculum for art therapists to use as a
resource for sibling support groups within the hospital.
Because of the lack of investigation and research, identifying methods to provide sibling
support through art therapy may be a lifechanging experience for siblings. The information
provided in this project may assist art therapists in a hospital setting to help siblings cultivate and
maintain emotional regulation, improve self-awareness as well as providing extra support
outside of their family with other siblings in similar situations.
Purpose of Sibling Support Group Curriculum
Sibling art therapy support groups will allow healthy siblings to work on several areas of
emotional distress relating to their unhealthy sibling’s situation. A curriculum for this support
group will help art therapists assess the group’s needs and identify what materials are needed for
the support group intervention. The curriculum covers areas that are relating to anxiety,
depression, self-expression, self-awareness, etc. to allow individuals to express through
therapeutic art and feel supported within a safe environment.
Research by Prager (1995), Ramdaniati & Hermaningsih (2019), Ciucci & HeffnerSolmeo (2018), Clapp et al. (2019), Stuckey et al. (2010) and Wallace et al. (2014) demonstrated
that art therapy had clinical utility in a hospital setting involving caregivers, patients, and healthy
siblings. Creating a curriculum based on recent research and effectiveness of art therapy will
help to organize the support needed for siblings for art therapists in the hospitals.

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History of Art Therapy in Medical Settings with Children
Hospital care has evolved since the early 1750’s (Wallace, 2014). Starting in the 1940’s
to 1950’s, art therapy has been used in psychiatric unit patients. Since then, the use(s) of art
therapy have extended to those who have chronic and acute illnesses and are unable to cope with
their illnesses as well as to families of patients. Adrian Hill, a pioneer Art Therapist known for
his work within hospitals in the 1940s, was one of the first to conduct art therapy with medical
illnesses in the hospital. Hill (1947) stated that he had conducted several art therapy sessions
with hospital patients and those sessions “have been enhanced in their therapeutic value”. Hill
(1947) addressed the benefits of art therapy with patients and discussed the art therapist’s role in
implementing this form of therapy for individuals in this setting. He stated, “the success of the
patient to draw and paint depends entirely on the enthusiasm and resource of the art therapist”
(Hill 1947, p.6). He also stressed that art therapists must be flexible and give proper instruction
for interventions (Hill 1947).
In addition to Adrian Hill, other art therapists have tailored art therapy techniques toward
quality of life, anxiety, improved mood, positive behavior, and stress within a medical setting
with pediatric populations, according to a systematic review done by Clapp et al. (2019). This
systematic review compares several studies and research with art therapy methods for children in
hospital settings who have leukemia, post-traumatic stress disorder, sickle cell disease, pain, and
asthma. Art Therapy is now more common in hospital settings to help pediatric populations cope
with hospitalization and address treatment associated anxiety and stress.
Effectiveness in Art Therapy in Medical Setting
Historically, art therapy has demonstrated clinical utility in patients with chronic or
sudden illnesses. Ramdaniati & Hermaningsih (2019) compared play and art therapy for

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reducing anxiety and stated that “almost at every stage of development of the child’s age, anxiety
and fear due to hospitalization is still a major problem” (p. 48). Their study found that
hospitalized children saw a significant reduction in the anxiety levels, as measured by the
modified Facial Affective Scale (FAS), after intervention with art therapy. The modified FAS
utilizes before and after (3 day) comparisons of 4 images of the participant’s face to assess
whether art interventions for 15 to 30 minutes were affecting anxiety levels in a positive or
negative way (Ramdaniati & Hermaningsih (2019).
Ciucci & Heffner-Solimeo (2018) also demonstrated the effectiveness of art therapy.
Their study was focused on caregivers who have children with cancer and have gone through
bone-marrow transplants. They conducted a structured art therapy intervention of altered
bookmaking in a group setting. In conclusion, their “importance of togetherness… and the
impact of creativity within a structured process”, (Ciucci & Heffner-Solimeo 2018, p.97) helped
with support in a group and self-care for this population during their child’s sickness.
Another study done by Elkis-Abuhoff and Gaydos (2018) demonstrates the effectiveness
of clay manipulation therapy in those with Parkinson’s Disease (PD). While PD is not curable,
addressing secondary effects of diagnosis, such as emotional distress or somatic dysfunction,
with clay may have clinical utility (Elkis-Abuhoff & Gaydos, 2018). Although their research was
conducted with individuals over the age of 50 with PD and not with children, the benefits of clay
manipulation therapy, increased brain activity and decreased emotional distress, may be
translatable to pediatric populations.
Art therapy interventions have also been done in the siblings of stem cell transplant
patients. Wallace et al. (2014) examined the utility of feeling mandalas, family drawings and
clay manipulation and building animal metaphors, in helping siblings understand their anxiety,

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self-concept as well as improving family functioning. These interventions were shown to
decrease stress related to their sibling’s conditions and become more capable of reducing
maladaptive reactions as well as increase coping strategies.
With these studies presented through art therapy research, it has shown much
effectiveness in utilizing this creative expression in medical settings for various individuals, even
those who are not medically ill.
Childhood Illnesses
In 2012, children accounted for 5.9 million hospital stays (Witt et al., 2014). Witt et al.
(2014) presented an overview of hospital stays for children in the United States. According to
Pelletier et al. (2021), roughly 5.4 million patients within 49 children’s hospitals were admitted
into the hospital system and found a 45.4% reduction in admissions from January 2020 to June
2020.
Children come into the hospital with a variety of illnesses including respiratory,
digestive, nervous system, musculoskeletal, connective, ear nose and throat illness, metabolic
and nutritional disorders as well as mental health issues (Witt et al., 2014). Of these, respiratory,
digestive system, and nervous system disorders (in order of decreasing frequency) account for
most hospital stays (Witt et al., 2014). Several specific conditions associated with hospital stays
in individuals between the ages of 0–17 years of age include burns, blood disorders, trauma,
poisonings, kidney or urinary tract infections, asthma or respiratory system conditions, HIV
infections, epilepsy, pneumonia, chemotherapy or radiotherapy for cancer, skin tissue infections,
mood disorders, acute bronchitis and fluid disorders (Witt et al., 2014).

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Acute vs Chronic
Illnesses can be categorized as being acute or chronic. Acute illnesses develop suddenly
and are short-lived, lasting a few days or weeks (NCOA, 2016). Acute illnesses include broken
bones, flu, acute bronchitis, pneumonia, burns, an asthma attack, or cold symptoms (NCOA,
2016). Acute illnesses can also be severe enough to lead to chronic conditions if they are not
treated or are prolonged (Vorvick 2020). Such acute illnesses include broken bones or other
conditions related to car accidents or traumatic experiences. A chronic illness is classified as
having a long-lasting syndrome and can develop or worsen over long periods of time (Vorvick,
2020). These conditions need medical attention and/or limit one’s activities in their daily life
(CDC, 2021). Examples of chronic illnesses include heart disease, blood disorders, diabetes, and
cancer (CDC, 2021).
Treatments and Surgeries
Siblings with an illness may go through a series of procedures to help their conditions.
These include being hooked up to a nasogastric tube (NG) for removing stomach content,
intravenous tubes (IV) for fluids, and blood draws taken for diagnostic tests. These methods all
involve the use of needles, and with patients who are young, it can become traumatic because of
needle phobia being common among children. The incidence of needle phobia in children and
adults is around 2-4% (Willemsen 2002). Being exposed “to needles cause an immediate anxiety
response which often leads to avoidance type behaviors” (Willemsen 2002, p.611). Consistent
exposure to treatment involving needles could cause higher anxiety levels to patients in hospital
care.
Surgeries are another form of treatment for children. These surgeries can be classified as
minor or major and can be elective or required surgeries. Minor surgeries listed by the Stanford

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Children’s Hospital (2021) include placing ear tubes, removal of skin lesions, biopsy of growths,
hernia repairs and correction of bone fractures. Major surgeries are repair of congenital heart
disease, transplant of organs, repairing intestinal malformations, correcting problems in lungs
and other organs in fetal development, corrections of bone malformations of the face and of the
skull and removal of tumors (Stanford 2021).
Children going through some treatments and surgeries for their conditions are confronted
with being restrained and can become angry or experience discomfort due to their inability to
understand medical procedures (Karlsson et al. 2019.) Karlsson et al. (2019) states that “if
children experience painful medical procedures while not really understanding the purpose, the
feeling of fear increases” (p.1). This fear can also extend to the family system. Understanding
procedures in hospital settings for children, siblings and parents can give more insight on what
things are being done for the ill child and can ultimately decrease that stress associated with the
procedures being done.
Conclusion
Through treatments, surgeries and conditions with patients, support is needed for healthy
siblings through times of their ill sibling’s hospital stay(s). Art Therapy has shown promise to
siblings and caretakers of hospitalized individuals. This curriculum provides potential art therapy
interventions for siblings who may have distress associated with their medically compromised
sibling’s condition or situation. Art Therapists can use this as a resource to help guide art therapy
group sessions to help improve self-esteem, self-awareness, and reduce anxiety associated with
the impact of their sibling’s illness.

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Definition of Terms
Art Therapy is a form of expressive arts therapy that involves the use of artistic materials to
express oneself. This is particularly of interest for this curriculum because art therapy involves
several different art materials like pencils, paper, glue, paints, etc. to allow people to improve
self-awareness and self-expression.
Art Therapy Experiential is a term used through art therapy practice that is an activity or
intervention within a therapy session. This includes the procedure and materials of the
Experiential and the purpose of the task.
Complicated Grief is an ongoing state of mourning that can often be heightened and can prevent
one from healing after a loved one is lost due to illness.
Emotional Regulation is the ability to control one’s emotions without assistance from a
counselor or therapists help.
Expressive Therapies Curriculum (ETC) is a model that allows one to flow through the levels of
creative functioning. This model includes 4 areas of creative functioning. These are
Kinesthetic/Sensory (K/S) level, Perceptual/Affective (P/A) level, Cognitive/Symbolic (C/S/)
level and the Creative level. The creative functioning model flows from the K/S level up to the
C/S level while the creative level is seen within all levels of creative functioning.
Identity Formation is when an individual develops a clear understanding or view of themselves
in identifying self-concept, self-awareness, personality development and values and norms.

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Vicarious Trauma, also known as secondary trauma, is an empathetic engagement of survivors
of traumatic events or incidents but do not experience physical trauma first-hand. This trauma
can cause secondary traumatic stress as it is a repeated exposure to other’s traumatic experiences.

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Chapter II: Literature Review
Medical Art Therapy: The Patient
Art Therapy has grown into a versatile mental health intervention that allows people to
utilize several forms of art to express themselves through body language, words, and creativity.
Within the context of sibling support groups in hospital settings, art therapy can be a source to
help those who struggle with their siblings’ condition and family situation. Wallace et al. (2014)
discussed how hospitalized children with stem cell transplants and their healthy siblings are both
at a higher risk for developing anxiety, low self-esteem, PTSD as well as some maladaptive
behaviors. After using an art therapy intervention, Wallace et al. (2014) stated that “siblings
gained mastery and processed their emotional responses effectively through the art therapy
intervention” given in their research (p.10). In this study, they used interventions such as clay
making, family drawings and well as mandala art. Using these techniques, they report that
implementing art therapy interventions for healthy siblings, allowed them to express their
emotions using art rather than words.
An art media which has proven to benefit in a hospital setting with patients is clay. Using
molding clay can be “a powerful way to help people express these feelings through tactile
involvement at a somatic level” (Stuckey, 2010, p.257). These conclusions are based on a study
of women with cancer who used art to help them understand their unconscious feelings and their
current emotional understanding of their disease. This study showed that through sensory
involvement, using clay and other fluid art materials, women were able to identify their positive
life experiences and express their feelings while using symbolic art. While this study focused on
women with cancer, it can give some insight on the similarities of arts interventions that can be
used with children. Since art is a universal media and can be beneficial to all populations going

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through complicated mental health challenges, this knowledge can be used to create a curriculum
specifically designed for siblings of ill children. Fluid art materials, like clay, are used more for
their sensory and “visual manifestations of energy” (Lusebrink 2013, p.76 ). When consulting the
Expressive Therapies Continuum (ETC) in regard to what material to use, fluid art material’s
sensory and kinesthetic properties help to decrease sensation experience and increase the focus
of sensory exploration (Lusebrink 2013).
Prager et al. (1995) discussed strategies and practices regarding pediatric art therapy for
children in hospital settings. This research discussed the challenges associated with art in the
hospital with children who have illnesses. These challenges included Intravenous injection (IV),
accessibility for plugs, inability to grasp materials due to condition, turnover rates of patients in
and out of hospital, as well as self-consciousness about how patients look. Prager et al. (1995)
identified some additional challenges regarding children in hospital settings including the lack of
support from art therapy colleagues. Acknowledging these challenges faced by patients and art
therapists are important for successful art therapy interventions within a group therapy
environment.
Medical Art Therapy: The Siblings
Because siblings, who are not in treatment, may be unlikely to receive mental health
interventions like their siblings receive in the hospital. Wallace et al. (2014) stated that siblings
of patients in hospital developed trauma as well as maladaptive behaviors associated with life
inside the hospital setting. These maladaptive behaviors include posttraumatic stress, low selfesteem, and anxiety. Early intervention with this population has shown to have reduced
maladaptive behaviors as well as increasing their coping strategies (Wallace et al, 2014).
Children with illnesses and their siblings are exposed to trauma-like situations, such as needles

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and prolonged treatments. Siblings should have an “early mental health intervention” including
art therapy that “should be considered for increasing siblings’ coping strategies and reducing
maladaptive behaviors” (Wallace et al. 2014, p.10). Symbolic interpretation through sensory
materials can help them create abstract art in reflection of their feelings.
Jo et al. (2018) provided several examples of the negative impact of having an ill sibling
on self-esteem, anxiety, and other behaviors. Potential interventions identified in Jo et al.’s
(2018) study include the use of squiggle drawings, finger paintings, animal family drawings, the
‘emotional package’, ‘my family clay gift’, ‘wish tree’, introduction of self, ‘my sweet home’ as
well as ‘knowing my strength’. These interventions addressed getting to know themselves,
releasing and expressing feelings about their family as well as enhancing their self-esteem
through art making. Introducing myself, squiggle drawing game and collage, and finger-painting
interventions helped establish rapport and exploring of the inner self to help form friendliness,
relieve feelings, reduce resistance against art making and showing one’s inner self (Jo et al.
(2018). Interventions such as the animal family drawing, family mind garden, emotional play,
emotional package, my sweet home, and “my family clay gift” expressed one’s feelings about
their family and helped express feelings in a safe way and assisted in providing family
acceptance within the group. Jo et al. (2018) found that there was a significant increase in selfesteem scores and a slight decrease in some problem behaviors but did not show a significant
effect in anxiety scores due to a low number of individuals participating in the study. Because
this study addressed the siblings of cancer patients only, it was challenging to find a large group
of participants for the study. Nevertheless, showing that there have been previous benefits of art
therapy in siblings of ill children may help guide other studies to help siblings, in other clinical
settings, with issues regarding self-esteem, problem behaviors, anxiety, and depression.

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Needs of Child Siblings of Medically Compromised Patients
Healthy siblings of ill children may exhibit mental health problems when their sibling is
hospitalized. This includes internalized and externalized behaviors. Siblings may face the lack of
attention from their parents, possible limitations to seeing their medically compromised sibling,
as well as their attendance in school. With these situations, some possible mental health
problems of the healthy sibling include, “negative feelings, such as loneliness, depression,
helplessness, jealousy, guilt, and anxiety” (Jo et al., 2018, p. 178).
Many siblings also experience post-traumatic stress and interpersonal relationships being
affected, especially those with friends (Jo et al., 2018). Velleman et al. (2016) state that siblings’
also experience lack of attention from parents, negative public perceptions, and negative impacts
of peer relationships. A study within Velleman et al.’s (2016) research found that siblings had
worries of “apparent parental dilution of care or concern’, a change in the sibling relationship”
and restrictions on family activities (Jackson, 1999). These impacts from family and ill sibling’s
diagnosis can create mental health complications for healthy siblings which include depression,
anxiety, as well as behavior, aggression, and social problems for siblings (Velleman et al. (2016).
Understanding the negative behaviors of healthy siblings provide adequate support of the need
for support groups for this population.
Available Support for Siblings and Families in Medical Settings
Well-being interventions
A person’s overall well-being involves one’s hedonism and eudemonia (Keeman et al.,
2017). Hedonism is the sense of feeling good while the eudemonia is one’s functioning (Keeman
et al., 2017). Keeman et al. (2017) discusses the use of well-being interventions within a work
setting for employees’ gratification toward work. This information can be applied to a group

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setting for individuals suffering from anxiety or depression related to their sibling’s illness.
Keeman et al. (2017) discusses 5 ways of well-being as connecting, being active, taking notice,
keep learning and give. Connectivity helps develop social connections for support and help
protect against mental ill health (Keeman et al. 2017). Having connection or closeness within a
support system helps with “functioning well in the world; connecting with people is a key way to
well-being” (Aked et al., 2009, within Keeman et al., 2017, p. 3).
There have been several studies that involve art therapy interventions and other
expressive interventions to help siblings cope with their ill siblings’ conditions. McKenzie Smith
et al. (2018) conducted research on the impact of well-being interventions on healthy siblings.
Well-being interventions used for this study involved were “group interventions, sibling training,
camps and family-based support” (McKenzie Smith et al. 2018, p.248). They determined that
with the use of these well-being interventions, those with mental health conditions were
benefited by them to help will illness knowledge and improving their internalized and
externalized behaviors (McKenzie Smith et al. 2018). Implementing well-being interventions
within art therapy support groups can help enhance that group cohesion and provide additional
information to healthy siblings.
Effects of childhood Illness on Siblings and Family
Importance of Mental Health
Mental health is important through any challenges in life especially through the time of
change with sudden or chronic illnesses. With that change, illness/diagnosis, and confusion, it
can become a challenge to overcome by oneself. Some children are faced with illnesses such as
cancer, Respiratory Syncytial Virus (RSV), car accident injuries, diabetes, seizures, etc., and
may pose risks for mental health complications for siblings and family members. Besier et al.

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(2010) stress that within several studies, siblings of those with chronic illnesses are more likely
to have risks of mental health complications and psychosocial adjustment. While some children,
in a patient standpoint, fight and adjust well through these challenges, healthy young children
and adolescents in the situation along with their sibling, still poses a risk with underlying mental
health conditions. Illnesses with children “challenges the balance within the family system and
probably disrupts all family members” (Besier et al. 2010 pg. 686, as cited in Houtzager et al,
1999). These disruptions include stress on the family, anxiety, and relationship strain.
With cancer or other illnesses that hospitalize children, cancer can result in psychological
distress within siblings (Barrera et al. 2018). This trial conducted a controlled group for siblings
of children with cancer and reported that stress within siblings happens within the initial stages
of cancer treatment or even years after their sibling’s diagnosis. With diagnosis of a chronic
illness, it was even reported that there was alcohol abuse with siblings later into adulthood, as
well as having family difficulties and impaired health (Barrera et al.). Within the effects of
mental health, depression and anxiety as well as post-traumatic stress can be a result of diagnosis
early on in a child’s treatment. Within Barrera et al.’s (2018) article, results showed that average
sibling scores were in normal range for having symptoms related to anxiety. This information
was obtained by the Multidimensional Anxiety Scale for Children (MASC) and found that 28%
of males and 17% of females had higher total MASC scores (Barrera et al, 2018). Ultimately,
Barrera et al.’s (2018) research concluded that attending to the needs of siblings as well as care
givers, creates a positive ripple through the family even that being the sick child through active
treatment. When treatment is provided for siblings and caregivers during a time where their child
is in the hospital for a chronic illness, treatment is important for not just the ill child, but for the
sibling or and whole family.

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Another study conducted through a mixed methods approach by Velleman et al. (2016)
discussed the negative experiences of families who have children with chronic illness. They
reported that there are feelings of exclusion, lack of attention, impacts of peer relationships and
negative public perceptions of this population (Velleman et al., 2016). The feeling of exclusion
from parents and the effects of their social life can have a great impact on siblings of children in
the hospital. Velleman et al. (2016) also state that with these negative perceptions there are also
benefits of having siblings with a chronic illness. These benefits include the change in sibling’s
relationship, family cohesion being increased as well as maturity within the family and
independence. A study by Jackson et al. (1999), found that siblings had worries with a change of
sibling relationships, family activities being restricted as well as the obvious “parental dilution of
care or concern” (Jackson et al. 1999 as cited in Velleman et al. 2016, p.619). Effects of sibling
illnesses influence the whole family and have a great strain on sibling relationships. Mental
health and social support have a direct effect on the well-being of siblings and “serves as a buffer
between the negative health consequences of a stressor and distress, also among children with
cancer and their families” (Eilertsen et al. 2016, p.301). During this time, it is imperative that
siblings be educated and helped through this challenging time, so they have minimal effects of
their sibling’s chronic illnesses.
Effects of sibling on family involvement with hospitalized child
When a child is put in a position where they feel isolated because their sibling is
receiving more attention for their medical condition, it can have a negative effect on that child.
Wallace et al. (2014) reported that siblings start to feel more isolated from their families due to
the length of hospitalization stays for the sick child. This interferes with their typical daily
routine of healthy siblings going to school. They must deal with the loss of parental attention for

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themselves. Because there can be positive and negative views from siblings on family cohesion,
the majority of reported healthy siblings stated that there is a shift in the attention from their
parents (Deavin et al. 2018). Deavin et al. (2018) reflected on several articles pertaining to
family involvement with ill children and their healthy siblings and helped give a voice to those
individuals who found it challenging to disclose emotions and find their own positive identity.
Healthy children have stated that there have been large family involvements as it gives the
family something in common for each other, but that there is a greater shift in that attention
toward their siblings (Deavin et al. 2018). Because children have said this in their findings on
their own family cohesion, they “acknowledged the increased attention was necessary” for their
ill sibling (Deavin et al. 2018, p.6).
Sibling’s school is negatively impacted from their parent’s unavailability to tend to their
healthy child as they see lack of participation in school and extracurricular activities (Alderfer et
al., 2010). The effects of sibling’s education include academic functioning, psychological effects,
their attendance as well as relationships among peers (Bortes 2019). Bortes (2019) examines
previous research conducted in the effects of healthy sibling’s health and educational outcomes.
This research found that “academic achievement was not examined as an outcome” with any of
the previous research conducted (Bortes 2019, p.408). Because siblings share the same parents
and their resources, there are limited resources shared with all siblings evenly. Bortes (2019)
describes these resources as being parent-child companionships, access to material goods, and
the attention received by parents. Because parents shift focus to the care of their ill sibling, these
resources may diminish over time depending on the ill sibling’s condition.
Other studies report that there may not be effects of siblings with family involvement and
educational interventions. Gursky (2007) reported that siblings go through feelings of anxiety,

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confusion, isolation, and separation anxiety. In addition, he reported no emotional or behavioral
problems associated with healthy siblings. Gurksy (2007) stated that this may be the case
because parents are unable to accurately assess the healthy child’s condition. This research was
not significant since the recent studies used qualitative interview procedures to gather
information, as well as no known control groups within recent studies.
When a family’s cohesion is diminished or strengthened with an ill child, it is important
to involve the whole family with treatment and be free to “speak together about the illness with
siblings to allow them a forum to express their concerns to help them understand and feel heard
and included” (Deavin et al 2018, p.9). Having a support system outside of their family can help
strengthen that ability to be heard with other siblings with similar experiences.
Sibling Preparedness
When children are in hospitals, healthy siblings may not know exactly what is happening
with their sibling. Sibling preparedness and early education have shown to help in decreasing
stress and the response to anxiety with siblings (Gursky, 2007). Gursky (2007) conducted
education interventions for siblings to understand their unhealthy sibling’s conditions in the
hospital. Implementing educational information about their sibling’s illness helped with the
decrease of anxiety scores. This meaning, addressing a sibling’s confusion of a diagnosis early
on in an unhealthy sibling’s hospital stay, through a child life specialist, will decrease stress
levels (Gursky, 2007). Within a support group with healthy siblings, it is important to have
discussions and understandings of different diagnosis to provide educational importance for
answers.
Family Art Therapy in Medical Settings
Art Therapy for Grief and Loss

MEDICAL ART THERAPY SIBLINGS

23

Loss and grief can bring symptoms of sadness and depression if there is no support given
during this time complicated grief is likely to occur. Grief is a way of responding to an event of
loss or trauma. Grief is different for everyone as people deal with their loss in their own unique
way. Symptoms of grief can be crying, changes in appetite or digestive problems, lack of energy
(fatigue), detachment, inability to experience joy, and increased irritability (2021). Complicated
grief is when an individual doesn’t experience grief normally through a short period and prevents
them from going forward in their normal lives. This grief can deal with several other
characteristics that can involve finding no meaning or purpose, lack of trust with others,
detachment, problems accepting the death, and the inability to enjoy life long after a loved one
had past (Mayo Foundation for Medical Education and Research, 2021).
Family therapy, during a challenging time of losing a sibling or child, is hard for
members of a family to cope with after their loved one is gone. During this time, loss may be
traumatizing, especially if it's from a sudden illness or situation and “people get stuck in their
grief and can’t seem to find a way forward” during this time (Phillips, 2021). Grief affects
everyone differently and some siblings, and caregivers/parents may take grief personally as
mourning is a personal journey. Involvements in families and support groups have shown
promise in helping families cope with sudden change according to Junge (1985). Junge (1985)
discussed a case study of a family that had lost their loved one by creating an art book/narrative
about how their father died. Utilizing this approach of narration, “families are given permission
to express, communicate and work” together to help with their grieving and having a trusted
group to help them move beyond their grief (Junge, 1985, p.8). When groups or families are
brought together for the loss of a child, sibling, parent, relative, etc., it is a time to reflect on that
loss in a positive way with others to help aid the healing process of grief. Community support is

MEDICAL ART THERAPY SIBLINGS

24

important during challenging times, as discussed by (Li et al, 2016). In Li et al’s (2016) research,
it was confirmed that the social support systems were able to improve their social support and
subjective feeling within a population which struggled with having HIV/AIDS.
Art Therapy for Anxiety
A child who has a severe chronic illness “changes the balance within the family system
and probably disrupts all family members” (Besier et al., 2010, p.686). In Besier’s (2010) study,
they used measures that involved the Strengths and Difficulties Questionnaire (SDQ) a
behavioral screening questionnaire to help identify emotional symptoms, peer relationships,
hyperactivity-inattention, conduct problems and prosocial behavior (Besier, 2010, p.689).
Prosocial behavior is when one helps or shares to benefit others, for example to feel empathy for
others. Emotional symptoms may include jealousy, anger, fear or anxiety, and feelings of
loneliness. In Besier’s (2010) study, the SDQ found a significant risk with healthy siblings
having possible emotional symptoms associated with their sibling being ill compared to those
who did not have siblings in the hospital or ill. It was discussed that hyperactive and inattentive
symptoms increased as well as emotional and behavior problems compared to the control group
being examined as well (Besier, 2010). Besier’s (2010) study concluded that with the family
oriented inpatient rehabilitation programs that were studied, they found that a reduced risk of
emotional and behavioral problems was shown by those who participated in the study. It was
determined that with even a small population that had been observed and studied, there was a
significant effect on the mental health of those sibling and family members with an ill child
(Besier, 2010).
A study done by Nielsen et al. (2021) discussed family therapy from an inpatient mental
health facility standpoint. This study looked at several cases to help identify needs for using art

MEDICAL ART THERAPY SIBLINGS

25

therapy with family members and adolescents. Interventions such as ‘weather conditions’, ‘raw
rage’, ‘heartfelt difficulties’, ‘horizontal stripes’, ‘vertical stripes’, ‘tree trunk rings’, ‘wilted
flower’, ‘angry caterpillar’, and ‘gloomy pit’ were created between family and adolescent to
provide a clearer understanding of the effects of adolescents in inpatient settings compared to the
parents’ thoughts or feelings. Positive reinforcement was also utilized with these cases to allow
for them to artistically create and explore issues seen. These cases showed that family art therapy
has helped in identifying undiagnosed mental illness in the parent which can contribute to the
patient’s ability to recovery from their mental illness (Nielsen et al., 2021).
A study done by Barrera et al. (2018) looked at the anxiety levels of both siblings and
family members using the Multidimensional Anxiety Questionnaire (MAQ). The MAQ was for
adults and focused on social phobia, worry and fears, negative affectivity, and physiological
panic (Barrera et al. 2018). This study also used the Multidimensional Anxiety Scale for
Children (MASC) which measured social anxiety, harm avoidance, separation, and panic anxiety
as well as physical symptoms. The MAQ and the MASC concluded that there were elevated
levels of symptoms within family members. The results showed “28% of males and 17% of
females in siblings had elevated MASC scores” (Barrera et al., 2018).
Anxiety is a result of common forms of behavioral problems for children as well as
negative feelings described previously by Jo et al. (2018). Jo et al. (2018) discussed in other
research by Alderfer et al. (2003) and Prachal et al. (2012) that a third of siblings with cancer
have experience with post-traumatic stress as well as half of siblings have the inability to
experience happiness and relaxation along with several other positive feelings. Jo et al. (2018)
conducted several measures for self-esteem, anxiety, depression, and problem behavior. Problem
behaviors include absence of emotion and aggressive tendencies that affect relationships

MEDICAL ART THERAPY SIBLINGS

26

(Healthline, 2019), while behavior problems are “a pattern of disruptive behavior that generally
falls within social norms and does not seriously impair a person’s functioning” (American
Psychological Association 2020). Problem behaviors identified in Jo et al.’s (2018) research
were withdrawal, somatic complaints, anxious/depression, social problems, thought problems,
attention problems, aggressive behavior, delinquent behavior, internalizing and externalizing
problems, sex problems and emotional instability.
Conclusion
Through several research articles, studies and interventions identified above, art therapy
has shown adequate evidence how it can improve a healthy sibling’s impact from their sibling’s
medical condition. Factors affecting their need for group art therapy include family strain, effect
on school, relationships, sibling’s condition, as well as lack of knowledge of their sibling’s
diagnosis. With recent studies, art therapy and other interventions are shown to be effective in
helping improve family cohesion, reducing stress and anxiety, becoming prepared for grief and
loss, increasing knowledge of diagnosis, and using well-being interventions for a positive
mindset. Utilizing these methods in a group art therapy setting for healthy siblings contribute
several benefits in their coping through creative expression.

MEDICAL ART THERAPY SIBLINGS

27
Chapter III: Methodology

Purpose of Medical Art Therapy Curriculum for Siblings
With gathered research about healthy siblings of hospitalized patients and current
literature based on this population, there were a significant number of articles that identified the
use of art therapy with healthy siblings. Many of these articles were promising, yet while many
showed several limitations to previous research regarding art therapy and healthy siblings, the
benefits of these articles outweighed the challenges. The purpose of this project was to create a
group art therapy curriculum to be used in a hospital setting with siblings of ill pediatric patients.
Goals of this curriculum are to help individuals with self-esteem, knowledge of hospitalized
sibling’s condition, processing secondary trauma and identity formation. Based off the literature
review, I was able to find previous mental health or art therapy support for healthy siblings of
those with a sick sibling suffering with a chronic or acute illness. Much of the literature
supported an individual session standpoint rather than group support with healthy siblings in a
hospital. Because of these findings, implementing ways in which to direct healthy siblings
toward support groups is what was intended for this curriculum.
There are several mental health challenges, such as anxiety and depression, associated
with siblings who have ill brothers or sisters. Based off the evaluation of research on this
population as well as the knowledge of mental health complications involving this population, I
thought it would be best to create a curriculum based in a group setting for this population rather
than individual session interventions. Research indicated that individual art therapy interventions
were unable to confirm the effectiveness in improving depression, anxiety, and self-esteem for
this population. Conducting a curriculum that also involves social skills with art therapy
interventions may shine a light on what previous literature had already addressed.

MEDICAL ART THERAPY SIBLINGS

28

Focus of the Medical Art Therapy Curriculum for Siblings
This curriculum will be utilized by art therapists who work in a medical setting and are
knowledgeable about children and family populations. Within this curriculum, sibling
participants can create images to help with self-awareness, self-esteem, anxiety, and symptoms
of depression. As this will become a resource for art therapists within the hospital setting, finding
siblings in need of mental health or art therapy services should be developed before utilizing the
curriculum. It is recommended to create a network throughout the hospital of services for this
curriculum as it will differ from hospital to hospital. Checking in with families about sibling’s
adjustments with their ill sibling’s conditions can help address mental health early for this
population.
The sibling support group curriculum will be implemented with children and adolescents
to help with building community support for individuals going through similar challenging
experiences. The topics and interventions will be categorized by purpose or goals so that the art
therapist is able to apply art therapy experientials appropriately within their support group.
Topics will also include the importance of educating healthy siblings about illnesses for sibling
preparedness if an ill sibling’s is more than likely to pass of their physical illness.
Organization and structure of the Medical Art Therapy Curriculum for Siblings
Within the curriculum, interventions will be categorized with issues presented within the
group and will include a list of materials to use. Interventions will utilize a wide variety of art
media, ranging from more fluid materials (i.e., watercolors or clay) to a more rigid material (i.e.,
colored pencils or pens) based on the group’s needs. Art materials may be substituted based on
appropriateness and comfortability. The interventions will include step-by-step procedures as
well as pre-activities such as icebreakers or introductions to a specific topic. The group

MEDICAL ART THERAPY SIBLINGS

29

curriculum will be flexible, as siblings will come and go in the setting depending on their
unhealthy sibling’s hospital condition or stay.
Alongside goals, procedures, and materials, process questions will be provided to help
wrap up the intervention. These questions will pertain to the directives and creation of the
group’s artwork to help unveil information that the group may feel comfortable with sharing in a
trusting environment. Multiple questions will be listed after the intervention procedures to
provide the therapist multiple options depending on the direction of the group.
This curriculum may be a useful tool for individuals who are in the field of art therapy
working with children and families within a hospital setting. Topics and goals of each
intervention will address vicarious trauma, self-esteem issues, identity formation, and knowledge
of procedures or hospitalized siblings with this population.

MEDICAL ART THERAPY SIBLINGS

30
Chapter VI: Curriculum

Support group curriculum for affected children and adolescents during sibling illness
Introduction
This curriculum is intended to support siblings who may face challenges with their ill
siblings’ medical conditions between the ages of five to eighteen. The population for this
curriculum involves children and adolescents who have a sibling who has a chronic or severe
illness within the hospital who are in and out of procedures or are in recovery of a traumatic
incident. The support group curriculum created addresses common problems faced by this
population such as: helping identify who they are as an individual, coping with traumas faced
with their sibling's condition or family life, as well as building their self-esteem in a group
environment. This curriculum should only be facilitated by those who are licensed art therapists
or art therapist in training under supervision to help children who are affected by their ill
sibling's hospital stays, process emotions, and use another outlet to express their feelings. Since
this curriculum also focuses on the education of ill sibling's conditions, it is encouraged to
become knowledgeable of common diagnoses of children/adolescents in the medical field. Please
see Appendix D for common illnesses and descriptions. This knowledge should be implemented
within session for members to reflect upon diagnoses in a safe space with support from other
group members.
Alongside this curriculum, it is recommended to educate siblings about the benefit of
using art outside of group therapy. During the first few sessions, it is important to note that using
a journal outside of the group can benefit a client through self-expression. Within the first lesson,
allowing clients to become more aware of how to utilize a journal will help them to learn to use
materials outside of the group. It is good to note the group rules during the beginning of each

MEDICAL ART THERAPY SIBLINGS

31

members start to discuss confidentiality and why it is important to maintain for group members.
Reasoning for confidentiality is to create a safe environment for members to feel welcome and
relaxed and feel support from others without breaking trust. The start of each group should lead
with a game or ice breaker to allow clients an easier transition into discussion and creation of
sensitive material. Allowing members to participate in a safe and friendly opening will build
trust between group members.
This curriculum is designed to help siblings who are challenged by changes in family
dynamics and have loss of self-identity due to their sibling being admitted to a hospital or who
have chronic ongoing illnesses. This curriculum provides the population with the support needed
to challenge emotions and feel heard within their community on a similar experience to allow
siblings that sense of not feeling alone. Utilizing this resource for a flexible group session is
important for this population regarding what the therapist seems fit to implement for each
session. Because of this flexibility, discussion can be guided through the therapist's best
judgment as well as materials becoming more flexible for the group's comfort. While this
curriculum is for a flexible group, the length of group sessions may differ, as well as the length
of group therapy for this population. For example, the group may be at a length of 90 minutes
some days and the number of sessions may vary depending on the client's sibling recovery.
When a client's sibling is discharged, it is encouraged to continue group sessions to help improve
areas of self-expression, self-identity and having group support on how to transition into
changing family dynamics.

MEDICAL ART THERAPY SIBLINGS

32

Introduction to utilizing a
creative journal outside sessions

Time: 40 minutes
Goals:
Materials:
•
•
•
•
•
•
•
•
•

Book (sketchbook, old
book, journal (with or
without lines), pieces of
paper.
Materials accessible to
client's outside group
sessions
Colored pencils
Markers
Glue
Paint(s)
Pens
Collage Materials
o Newspapers
o Magazines
o Tissue paper
o Scrapbook paper
o Colored paper

• Members will utilize art materials outside of the
group to express thoughts, emotions, and
experiences in a comfortable space

Purpose:
• To build comfort using art materials in a safe
space
• To explore feelings and experiences
• To provide documentation of experiences or
activities

Directive/Procedure:
•

P

1. Allow for athe clients to explore which book is appropriate to use
outside ofpsessions and to discuss accessible art materials.
e importance of using a journal for externalizing thoughts
2. Discuss the
into a safer physical space. (See Appendix A)
3. Provide examples of art or creative journals to give understanding to
utilizing a journal in their own time. (See Appendix A)
4. Once determined of canvas material, allow clients to decorate their
journal and create an image on a plain sheet of paper, using
comfortable materials to externalize thoughts onto paper.
5. Discussion

MEDICAL ART THERAPY SIBLINGS
33
Continued…Introduction
to utilizing a creative journal
outside sessions

Reflection:
1. Were you able to find art materials that you felt comfortable
using?
2. Is there any experiences or story behind what you created?
3. When do you feel you would be able to utilize your creative
journal?
4. What were your thoughts on creating paper or within your
book?
5. What uses can this book provide you?
6. Were there any negative emotions/feelings creating your
book?

Modifications:
1. Because this introductory session is very flexible, questions may
vary to adjust to client’s products and comfort level.
2. Clients may not feel comfortable yet sharing artwork within
their journal, therefore question 2 may not be appropriate for
all groups.

MEDICAL ART THERAPY SIBLINGS

34

Mindfulness Breathing Melody

Time: 30 minutes
Goals:
Materials:

• Blank sheet of paper
8x10 Blank
Paper
•• Colored
Pencils
•
Colored
pencils
• Markers
• Markers
• Erasers

• Members will focus on breathing to develop stress
tolerant skills using mindfulness techniques.
•

P
a
p
e
r

Purpose:
• To practice controlled breathing in a safe
space.
• To learn about the use of mindfulness.
• To become mindful and aware of the present.
• To feel the release of tension.

Directive/Procedure:
1 Start off with a tension release exercise. Example: pretending to
grab a lemon from a tree, squeeze the juice out with your hand,
then throw it to the ground, repeat three times to allow group to
feel their tension release.
2 Allow the group to now get into a comfortable position and
discuss controlled breathing. (See Appendix B)
3 Turn on relaxing music and allow the group to take 5 minutes to
listen and control their breathing.
4 Once clients have finished their breathing, have the group create
an image reflecting off the experience. Discuss the importance of
taking their time during this reflection. (25 minutes)
5 Discussion

MEDICAL ART THERAPY SIBLINGS

35

Continued…Mindfulness Breathing Melody

Reflection:
1. What were your initial thoughts you had before practicing your
breathing?
2. When was the last time that you felt you needed to take a breath?
3. When could mindfulness be helpful or useful to you?
4. What type of environment do we feel most therapeutic in?
5. What image have we created from our breathing exercise and how
are they important to you?
6. Describe your grip on your art materials throughout the experience
of creating. Did you feel more or less tension?

Modifications:
1. If wanting to use a 3D material, have group members construct a sculpture out of clay
of their breathing.
a. Have them discuss the mindfulness of sculpting the clay and how it helped them
remain in the present.
2. Suggested Music for Session:
a. 1 Hour Zen Music for Inner Balance, Stress Relief and Relaxation by Vyanah
i. https://www.youtube.com/watch?v=iD0bZR6mxyM
b. Beautiful Relaxing Music for Stress Relief ~ Calming Music ~ Meditation,
Relaxation, Sleep, Spa
i. https://www.youtube.com/watch?v=lFcSrYw-ARY&t=5119s
3. An addition to this intervention: have members doodle draw to music with their eyes
closed then allow clients to open their eyes and create a zentangle out of their doodle.

MEDICAL ART THERAPY SIBLINGS

Safe Thought/Worry Box

36

Time: 50 minutes
Goals:
Materials:
•
•
•
•
•
•
•
•
•
•
•
•

Small cardboard box
Precut Affirmations
Markers
Pens
Crayons
Scrapbook Paper
Glue/Glue sticks
Beads
Magazine cut outs
Ribbons
Fabric
Lavender

• Members will utilize box to store thought or
challenging emotions.

Purpose:
• To learn about the use of created box.
• To practice placing worries or thoughts into safe
box.
• To discuss appropriate thoughts to place within
the box that could be helpful with anxiety.

Directive/Procedure:
1. Ask members to think of a place where they have felt safe.
This could be a house, school, the park, etc.
2. Discuss what the use of a worry box is, when to use it, when
not to use it and what to place inside of their worry box.
Important to note having this accessible near a bedside
before going to sleep to help with anxiety before bed.
3. Have members spend 20-40 minutes to decorate their safe
box with provided materials.
4. Toward the end of creation, assist members with creating
an opening for their thoughts to allow easy access to placing
their worries in their box.
5. Discussion

MEDICAL ART THERAPY SIBLINGS

Continued…Safe Thought/Worry Box

37

Reflection:
1. When could you use this box for yourself?
2. Where should you keep your boxes for safe keeping?
3. At what times should you not use your worry boxes?
4. What items on your box are important to you to reflect on
when you use your box? Have you placed any sensory objects
(soft, smooth, smelly) that can help you with your anxious
thoughts?
5. What are you keeping locked up?

Modifications:
1. Instructor can assist members in the beginning of their
creating, to cut a hole or make worry notes accessible to
them after they are finished.
2. If members do not wish to use a box, they can use other
containers, a folder, or plastic jars to create their safe box.
3. Encourage the use of adding sensory materials to help in
times of comfort for them to touch or smell their box when
they are anxious.

MEDICAL ART THERAPY SIBLINGS

38

Calm and Happy Distractions

Time: 40 minutes
Goals:
Materials:
•
•
•
•
•
•
•

Container
3x5 Index cards cut in half
Markers
Crayons
Colored Pencils
Pens
Pencil

• Members will decorate a container provide ideas
of people/places/things/activities they enjoy for
anxious thoughts.

Purpose:
• To provide an outlet for anxious thoughts when
times are challenging.
• To allow creativeness in activities or things of
reflection in times of need.

Directive/Procedure:
1. Start out with a group ice breaker relating to our favorite
activities, things, or people.
2. Discuss what will be created in session and allow members
to choose a container and start decorating it.
3. After the container is decorated, have members thinks of
people, places, activities, or things that make them calm.
4. Have members right each thing on a separate card and
place within their container.
5. Discuss with members the use of creating this to help with
anxious times when we are stuck to give ideas to do or
think of our favorite things.
6. Give time for discussion.

MEDICAL ART THERAPY SIBLINGS

Continued…Calm and Happy Distractions

39

Reflection:
1. How did you feel creating an activity/distraction box during
times of feeling stuck?
2. When do you see yourself using this container?
3. If you could think of other activities/places/things to put in
your box, what would they be? (Members can share ideas
with each other)

Modifications:
1. This can be continued at home to allow more activities to be
placed within their container.
2. Members can also create an image on their index card if they
feel that they would like to draw what they like to do or
someone/thing they wish to think about.

MEDICAL ART THERAPY SIBLINGS

Frustration Invasion

40

This intervention was modified by Buchalter (2017) 250 Brief Creative &
Practical Art Therapy Techniques: A guide for Clinicians and Clients. Pesi
Publishing: Eau Claire, WI.

Time: 30 minutes
Goals:
Materials:
•
•
•
•
•

Blank paper
Markers
Colored Pencils
Erasers
Pencils

• Members will explore the meaning behind their
frustration and anger and what it is symbolized as.

Purpose:
• To provide symbolism to their frustration.
• To explore factors to their frustration/anger.
• To identify ways in which we can help with our
frustration.

Directive/Procedure:
1. Start off the session with an Ice breaker. (See
Appendix C)
2. Have the group reflect off a time or situation where
they had felt anger or frustration. (1 minute)
3. Allow the group to practice deep breathing and muscle
relaxation techniques for 5 minutes.
4. Have the group draw what frustration looks or feels
like to them.
5. Discussion.

MEDICAL ART THERAPY SIBLINGS

Continued…Frustration Invasion

41

Reflection:
1. What things trigger your frustration?
2. How have you been able to handle your frustration in the
past?
3. How does the image that you created reflect off your feelings
of frustration?
4. When do you see your frustration is at its highest?
5. What techniques can you use to help calm yourself?

Modifications:
1. Start off by giving each member 2 clumps of clay. This
intervention can be used with air dry clay. Have members
create angry or a frustrating object or animal with one clump
and create what that object/animal is trying to protect in the
other. Using this resistive material as well as clay modeling
utensils, it allows members to become more intuitive in their
creation and express themselves in a safe and controlled
environment. After creating two sculptures, have members
reflect off their experiences of working with clay and what
things they created, along with previous reflective questions
to further discussion.

MEDICAL ART THERAPY SIBLINGS

Positivity by the Handful

42

This intervention was modified by Buchalter (2017) 250 Brief Creative &
Practical Art Therapy Techniques: A guide for Clinicians and Clients. Pesi
Publishing: Eau Claire, WI.

Time: 40 minutes
Goals:
Materials:
•
•
•
•
•
•
•
•
•

Scissors
Blank thick paper
Crayons
Markers
Colored Pencils
Glue/ Glue sticks
Sequins
Large Poster Board
Tape

• Allow members to become self-aware of one’s
positivity and develop group trust.

Purpose:
• To reflect off loving thoughts and images.
• To connect with others and share thoughts of
positivity to recognize other ways to think positive.
• To help build self-esteem and self-awareness of
oneself.

Directive/Procedure:
1. Start group with an Ice Breaker.
2. Have members trace their hand on a thick piece of paper.
3. Have members create their positive thoughts/loving
thoughts within their hand using markers, pencils, crayons,
glue, and other 3D materials provided.
4. Cut out hands carefully.
5. Allow group members one at a time go and glue/tape their
hand onto the poster board of positivity.
6. Have group members reflect off hands and do discussion
questions with group members.

MEDICAL ART THERAPY SIBLINGS

Continued… Positivity by the Handful

43

Reflection:
1. What thoughts or images did you place within your hands?
2. How does your thinking positive affect out mood and
attitude?
3. Do you believe you deserve to be cheerful, loved and
admired?
4. Is there another hand in the collage that stood out to you?
Why?

Modifications:
1. This intervention can be done individually or with a group
collage depending on the group’s comfort.
2. 3D materials can be provided to glue or tape onto hands such
as:
- Pipe Cleaners
- Googly eyes
- Feathers
- Newspapers/magazines for images

MEDICAL ART THERAPY SIBLINGS

Open Communication

44

Time: 40 minutes
Goals:
Materials:
•
•
•
•
•
•
•

Crayons
Markers
Blank paper
Colored Pencils
Magazines
Scissors
Glue

• Members will create an image of what it means to
have safe discussion about sibling’s condition to
build social skills and understanding of diagnosis
and emotions.

Purpose:
• To educate members on their sibling’s health
condition.
• To build confidence in talking with family
members about thoughts, emotions, and health.

Directive/Procedure:
1. Start group off with an ice breaker.
2. Have a group discussion about how we have in the
past, talked with our family about our sibling’s health
or any challenging thoughts we have had.
3. Refer to Appendix D for education information on
common chronic illnesses.
4. Have members create an image of themselves having
an open communication with trusted individuals on
challenging thoughts or emotions.
5. Allow time for discussion.

Continued…Open Communication

MEDICAL ART THERAPY SIBLINGS

45

Reflection:
1. What does your image tell you?
2. Who else is in your image?
3. How is this person important to you?
4. What challenges do you still face with open communication?
5. How can your reflective journal help you in times where you
do not have someone to talk with?

Modifications:
1. Alongside this intervention, bring up the use of a reflective
journal again.
2. You can also utilize this activity with 3D sculpting clay to have
a sensory component.
- Directive: form your clay into your thoughts on open
communication.

MEDICAL ART THERAPY SIBLINGS

Family Drawing

46

This intervention was modified by Buchalter (2017) 250 Brief Creative &
Practical Art Therapy Techniques: A guide for Clinicians and Clients. Pesi
Publishing: Eau Claire, WI.

Time: 30 minutes
Goals:
Materials:
•
•
•
•
•
•
•
•

Blank paper
Crayons
Colored Pencils
Pencils
Markers
Erasers
Watercolor paint
Paint brushes

• Members will create an image of what your family
looks like and to identify family dynamics.

Purpose:
• To identify problems within your family.
• To identify strengths in your family relationships.
• To identify areas in which things need to be
changed within our family to make it better.

Directive/Procedure:
1. Have members begin with an ice breaker to allow group
members to connect with others relating to family.
2. Allow time to reflect off their family for a couple minutes
before creating.
3. Give clients roughly 30 minutes to create an image of
their family doing something with as much detail as they
can provide with drawing or painting materials.
4. Reflection questions.

Continued…Family Drawing

MEDICAL ART THERAPY SIBLINGS

47

Reflection:
1. Are you included within the picture?
2. What is your family doing?
3. Who seems to be the most dominant in your family?
4. What role do you play within your family?
5. How does your family support you?
6. When thinking of your family, who is the most important and
closest person to you?

Modifications:
1. If members feel they cannot identify what their family looks
like in action, provide magazines with plenty of family photos
to allow clients to reflect off images or use images to help
with creating their family piece.

MEDICAL ART THERAPY SIBLINGS

48

My Powers of Strength

Time: 30 minutes
Goals:
Materials:
-Blank paper
-Colored paper
-Colored pencils
-Markers
-Watercolors
-Paint brushes

• Members identify their strengths and qualities
that make them strong in challenging situations.

Purpose:
• To reflect on personal characteristics of what
things make you strong.
• To practice focusing on strengths during
challenges.

Directive/Procedure:
1. Start session with an ice breaker question: If you could be
any superhero, what would you be? Why?
2. Discuss with group about times that can be challenging to
them and reflect off times where they struggled to find
their strengths or superpowers.
3. Have members reflect off their strength or superpower
using provided materials.
4. Have members create a story about their superhero
character and the strengths they have.
5. Reflection questions.

MEDICAL ART THERAPY SIBLINGS

49

Continued…My Powers

Reflection:
1. How does the superpower you drew help you?
2. What is your superpower?
3. How does your story relate to your life?
4. Are there particular times in which you use your strength?
5. Are there times in which a villain can affect your
superpowers?

Modifications:
1. This intervention can also be used symbolically using only
shapes and colors to indicate their strengths. Have members
discuss what their image symbolizes to them on their
strengths.

MEDICAL ART THERAPY SIBLINGS

50

Creating Our Story

Time: 45 minutes
Goals:
Materials:
•
•
•
•

Watercolor paper
Watercolors
Water
Music

•
•
•
•

Paper
Markers
Colored pencils
Appendix F (if needed)

• Members will self-reflect on comic/film strip to
enhance client’s ability to cope and practice selfawareness.

Purpose:
• To reflect off traumatic experience.
• To improve emotional regulation.
• To identify self-observation skills.

Directive/Procedure:
1. Start the session with a group mindfulness activity to
practice with the whole group. Have clients create an
abstract collage with watercolor to calming music.
2. Prepare members that this session will be in discussion of
our story that we are struggling with.
3. Give members an example of a comic/film strip and have
members create a strip of 5 sections. If members struggle
with creating a strip, see Appendix F.
4. Ask members to think of the beginning of their story and
create an image in that section. Allow members to use their
phones or a computer to help think of images to place
within their strip.
5. Allow time for discussion.

MEDICAL ART THERAPY SIBLINGS

Continued…Creating Our Story

51

Reflection:
1. What were your thoughts about looking at your story?
2. What lessons have you learned from your experience?
3. Has reflecting off your strip helped you gain perspectives on
your experiences in life?
4. What things in your story are you still struggling with?

Modifications:
1. Members can create their story using magazine clippings
on a blank piece of paper if struggling with creating a strip.
a. With this modification, address that there needs to be
a beginning and end to their story on their paper.

MEDICAL ART THERAPY SIBLINGS

Torn Transformation

52

This intervention was modified by Mehlomakulu, C. (2019) Torn paper
transformations. Creativity in Therapy. Retrieved November 4,
2021, from https://creativityintherapy.com/2019/07/torn-papertransformations/.

Time: 40 minutes
Goals:
Materials:
•
•
•
•
•
•
•

Colored paper
Tissue paper
Textured paper
Pens
Glue
Paint
Markers

• Members will reflect on things that they struggle
to move from and transform those negative into
positive thoughts.

Purpose:
• To give a kinesthetic outlet for negative events or
things.
• To activate members cognitive mind in writing.
• To explore how to let go or cope with negative
thoughts.

Directive/Procedure:
1. Start session with a mindfulness activity.
2. Have members choose a couple papers that they like and
one that they can write on.
3. Have members write about unhelpful thoughts, behaviors,
traumas, or things that they are wanting to move on from
on their paper.
4. Instruct members to then rip up their page that they wrote
on and use those pieces to create art with other chosen
paper and materials.
5. Allow time for discussion.
*Allow clients to know all steps of directive first to they are
prepared to tear up their written paper.

Continued…Torn Past Transformation

MEDICAL ART THERAPY SIBLINGS

53

Reflection:
1. What were the things that you were wanting to let go of?
2. What was the process like in creating your image?
3. Does your image hold any meaning to you or have something
meaningful within your image?
4. How did you decide what to create?
5. How did it feel creating your image with your negative
thoughts or struggles?

Modifications:
1. Instead of using paint to make images for members who do
not feel comfortable using paint provide:
a. torn paper, tissue paper, sequins, pipe cleaners, etc.

MEDICAL ART THERAPY SIBLINGS

54
Chapter V: Discussion

This paper explored art therapy interventions and history of medical art therapy that
pertained to children and adolescents who have siblings with an illness. The literature review
discusses the need of providing a curriculum geared toward siblings who are also exposed to
trauma or family complications outside of their sibling’s hospitalization or chronic illness.
Previous literature discussed the effects of sibling mental health and challenges faced by their
sibling’s condition in the hospital. Art therapists or practicing art therapy students using this
curriculum, should be educated about common childhood illnesses and chronic conditions to
become familiar with the member’s sibling condition and help further educate them when
needed. This paper includes an 11-intervention flexible curriculum that covers family dynamics,
self-care, self-awareness, identify formation and vicarious trauma. The curriculum is intended for
the therapist to choose which intervention is appropriate at the time for group members to create
for that session on member comfort. Modifications have been provided to allow more than one
way to guide a session of group art therapy with this population and provides additional
references/resources to refer to for future need.
Limitations
There are a few limitations to this curriculum. The author of this research paper and
curriculum has not extensively explored this population, and based findings off previous
literature to help create a curriculum suitable for members in this community. Previous research
did not directly explore art therapy interventions for use with this population and was created
from literature geared toward those who had chronic conditions within hospital settings.
Future Application

MEDICAL ART THERAPY SIBLINGS

55

The author intends on exploring with this population in the future to ensure that these
goals and intentions of this curriculum provide significant positive effect on sibling’s who have
vicarious trauma or difficulty with identify formation due to their sibling’s medical condition.
Because of the lack of knowing this population, the author intends to explore family dynamics
within hospital systems in the future to become more familiar with this group of individuals.
With the lack of research pertaining specifically to this population and lack of knowledge of
working with affected siblings, this paper and curriculum is just a start to providing art therapy
students and art therapists with evidence-based information on the effect of these interventions
with this population.

MEDICAL ART THERAPY SIBLINGS

56
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Appendix

Appendix A

Visual Journal and Exercises
Materials
• Sketchbook, old reading book (for altered bookmaking), blank paper within a
binder or folder for safekeeping, lined paper subject book, etc.
• Drawing materials (i.g. colored pencils, crayons, markers, pens, graphite pencil,
smelly markers, sharpies)
• Collage materials (i.g. magazines, newspapers, glue, mod podge, scissors)
• Paints (i.g. acrylic, watercolor)

Importance
• A visual journal can be useful in exploring one’s feelings or experiences one
may face in their lifetime.
• A visual journal can act as a diary and can also be a documentation of everyday
experiences.
• A creative journal does not need to have just artwork within your book/folder
but can also contain words to describe your image or feelings that you wish to
further explore.
• Using a creative journal in a safe space helps with self-care, mindfulness, stress
reduction, and freedom of safe expression.

Exercise Examples

MEDICAL ART THERAPY SIBLINGS

63

• Create an image using one color
• Draw an image of your 5 senses (what things you hear, see, smell, touch, taste)
in the present moment.
• Create a Mandala Drawing
• Drawing your current emotions
• Affirmation drawing (find an affirmation and create an image)
Grateful image (what things are we grateful for?)

MEDICAL ART THERAPY SIBLINGS

64

Appendix B

Controlled Deep Breathing
Inhale
•
•
•
•

Place hand on chest and stomach
Your chest should remain stationary and let your stomach do the work
Inhale slowly through your nose for 4 seconds
Focus on your stomach raising when inhaling

Pause
•
•

Hold the air in your body for 4 seconds
Focus on your counting at a slow pace (1-2-3-4)

Exhale
•
•
•

Breathe out slowing with your mouth for 6 seconds
Breathe through mouth like you are blowing through a straw to help
control your slow exhalation
Focus on your stomach contracting when exhaling

https://venngage.net/p/228783/belly-breathing

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65

Appendix C

Ice Breaker Examples
Who am I?
Can use a sheet of paper or
any sized index cards.
Have members draw an
image/doodle/symbol
in each corner related to
statement.
After finishing with breaker
have members share
one corner that they
see is most meaningful to
them.

Time: 10 minutes
1

2

What I want to be when I
grow up.

Something I enjoy or like.

Something I am good at
doing.

Something that I need to
work on or learn.

4

3

Collaborative Symbol Creation

Time: 10 minutes

Have your members choose a different color marker, crayon, or pencil
and an index card. Split into 3 members each or groups of 2.
Each member will create a line, dot, or shape on the index card and
pass to the next member of group. No talking during creation.
Activity should take 5 minutes with 3-5 minute of discussion on
thoughts to come up with what was created and a name.

Collaborative Sculpture Creation
-Gather pipe cleaners, pom poms, tape, fabrics or other simple
3D sculpture items before group.
-Have members divide into a group of 2.
-Give 10 minutes to allow group members to create a
figure/machine/item together in groups.
-Allow 5 minutes of discussion of what was created.

Time: 15 minutes

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66

Appendix D
Description and symptoms modified from Mayolinic.org.

Common Chronic Diagnoses
Crohn’s Disease
An Inflammatory bowel disease of the large intestine
that has fewer than 200,00 cases per year. This disease
can last a lifetime and can range from mild to severe
symptoms. This condition can often run-in families.
There is currently no cure for this condition but is the
primary goal to help with reduction of inflammation and
limiting complications.

Symptoms:
-Diarrhea
-Fever
-Mouth Sores
-Fatigue
-Bloody Stool
-Pain around Anus

-Abdominal Pain
-Cramping
-Kidney Stones
-Anemia
-Delayed growth
-Weight loss

https://www.drug
watch.com/health/
digestivehealth/crohnsdisease/

Asthma
Asthma is a chronic respiratory disease of your lungs.
This is a very common condition and has more than 3
million diagnoses a year. This condition is treatable but
not curable. This condition can interfere with everyday
activities and can even lead to a life-threatening flareup called an asthma attack. This condition can range
from symptoms all the time to infrequent asthma
attacks.

Symptoms:
-Chest pain
-Shortness of breath
-Wheezing
-Coughing
-Fast heart rate
-Throat irritation

https://community
.aafa.org/blog/wha
t-happens-in-youairways-when-youhave-asthma

Type 1 Diabetes: Juvenile Diabetes
Type 1 Diabetes is also known as insulin dependent
diabetes or Juvenile Diabetes. This condition is chronic
and diagnosed early on in a child’s life. The pancreas
produces little to no insulin for this type of diabetes and
makes it a challenge to allow glucose to produce
energy. This chronic condition does not have a cure and
is monitored by regular glucose tests. There are a few
complications with this condition involving nerve
damage, heart disease and kidney damage.

Symptoms:
-Chest pain
-Shortness of breath
-Wheezing
-Coughing
-Fast heart rate
-Throat irritation

Intolife.in/about-diabetes/types-ofdiabetes/type-1-diabetes/

Cystic Fibrosis
Cystic Fibrosis is a chronic condition that it inherited.
This condition causes severe damage to the lungs and
other organs, such as digestive tract with mucus and
sweat. This condition can typically be diagnosed in the
1st month of life and has fewer that 200,000 cases per
year. This condition is uncurable and requires consistent
follow-ups with a doctor. This condition can cause other
complications like damaged airways, chronic infections,
respiratory failure and coughing up blood.

Symptoms:
-Wheezing
-Persistent cough
Tamc.co.il/article/cystic-fibrosis
-Repeated lung infections
-Exercise intolerance
-greasy stools
-Poor weight gain
-Chronic-severe constipation

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67

Appendix D

Common Chronic Diagnoses
Cancer
Cancer is a term used for several diseases involving
malignant tumors within the body. These tumors attach
to areas within the body and get larger overtime
creating more than one area of tumors to get rid of.
Some causes of cancer include mutations to the DNA in
cells. These cells can stop normal functioning and
become cancerous tumors. Cancer can be curable if
found early enough and treated vigorously after
diagnosis. Even after curing cancer, there is still a risk
that cells may stop functioning normal again.

Common Types:
-Leukemia (Blood Cancer)
-Lymphoma (Lymph Nodes, Spleen, Bone Marrow)
-Brain and Central Nervous System Cancer

Symptoms:
-Fatigue
-Lump under the skin
-Difficulty swallowing
-Weight changes
-Unexplained bruising
-Unexplained bleeding
-Changes in bowel/bladder habits
-Pain in joints
Fevers or night sweats

Nytimes.com/2021/02/05/healt
h/lung-cancer-drug.html

-Neuroblastoma (Adrenal Glands)
-Kidney Tumors
-Bone Cancer

Sickle-Cell Anemia
This inherited condition is not curable but can be
treated. Sickle-cell Anemia occurs when someone has
sickle-cell disease and is when there are not enough
healthy blood cells to help carry oxygen through your
body. These unhealthy cells are sickle like, crescent
shaped. The cells get stuck more easily than healthy red
blood cells and can block blood flow to parts of the
body.

Symptoms:
-Anemia
-Pain
-Swelling of the hands and feet
-Frequent infections
-Delayed growth
-Delayed puberty
-Vision problems

Kidshealth.org/en/parents/sickl
e-cell-factsheet.html

Tuberculosis
This condition is treatable and can be partially
preventable to those who get vaccinated. There are
roughly 200,00 cases per year and can be spread by
airborne droplets. Tuberculosis is a serious infection of
the lungs and is most likely spread from relative to
relative as it is harder to get from a random person in
public. Sometimes one does not have symptoms of TB
but can spread it to others by coughing or sneezing.

Symptoms:
-Coughing for 3-4 weeks Livescience.com/tuberculosis.html
-Fatigue
-Fever
-Chills
-Chest pain
-Unintentional weight loss
-Loss of appetite
-Coughing up blood or mucus

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68

Appendix E

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69

Appendix E