Introduction

Psychological flexibility is the capability to cope with changes and to seek alternative solutions. Such capacity impacts the emotional well-being of individuals. Broadly, psychological flexibility refers to a scope of capabilities, including the recognition of and adaptation to demands in certain situations; the adjustment in mindsets and change in personal and social functioning; the ability to foster a balanced approach to different life issues; and the awareness, openness and commitment to upholding values (Kashdan & Rottenberg, 2010). Caregivers of frail older adults need psychological flexibility to sustain their own emotional well-being in a role that requires a lot of decision making.

The effectiveness of expressive arts therapy in enhancing the psychological flexibility for the above population has been worthwhile to investigate. The objective of this study, completed as part of a dissertation for the Master of Expressive Arts Therapy at The University of Hong Kong, was to explore the impact of expressive arts group therapy for female caregivers of older adults. The inclusion criteria for this study were female caregivers aged 55 to 80 who were taking care of frail older adults.

Literature review

Caregivers of frail older adults

A caregiver is “a person who provides care and support to someone else” (World Health Organization, 2015, p.226). As reported, older adults depend on their primary female caregivers for their care  (World Health Organization, 2017). As more women have joined the workforce over time, there has been a decrease in their capacity to care for older members of their families (World Health Organization, 2015).

In Hong Kong, the Census and Statistics Department (2021) reported that the population of older adults increased by 54.2% between 2011 to 2021, reaching a total of 1,451,514 people aged 65 or above. It also stated that over 70% of this population live in their own household, either with their spouse, with their spouse and children, or with their children only. Moreover, the share of older adults living with their spouse and/or their children rose from 53.3% in 2011 to 58.9% in 2021, indicating a higher frequency of family members “being the primary caregiver of older family members” (Census and Statistics Department, 2021). There has also been a high prevalence of the “elderly taking care of the elderly”, especially among female caregivers, with a recent study finding that 69.9% of caregivers in Hong Kong were female family members, 26.8% of whom were 60 years old or above (Leung et al., 2022).

Primary caregivers, known as ‘family caregivers’, have as their care recipients their loved ones, as opposed to formal caregivers, who offer additional services to the family (Powlen, 2021). Caregivers experience caregiving burdens from various sources. The caregiving burden has been conceptualised as a three-factor model of ‘caregiver strain’ including ‘perception of caregiving’, ‘empathetic strain’ and ‘adjustment demand’ (Chow et al., 2023). Caregiver burdens can arise from factors such as the age of the care recipients (Chow & Ho, 2015; Kurtz et al., 1995), the education level of caregivers (Rosdinom et al., 2013), caregiving time per week (Ding et al., 2022), the physical and psychological health condition of caregivers (Isac et al., 2021), the level of demand of all-around care of the care recipients (Huang et al., 2021), the type of relationship with the care recipients (e.g., spousal or parent–child relationship [Isac et al., 2021]), external environmental and cultural factors such as filial piety in traditional Chinese culture (Chan & Chui, 2011; Ding et al., 2022), cultural differences upon migration (Gallart et al., 2013; Kung, 2003; Neufeld et al., 2002), and perception of caregiving (Chow & Ho, 2015).

A systematic review concluded that family caregivers of palliative care patients need immense psychosocial support, but that there is a lack of intervention studies (Hudson et al., 2010). Moreover, other scholars have called for future research into creative arts interventions for caregivers of older people (Donorfio et al., 2010). Respite care is seen as one of the goals for managing the caregiver burden through providing rest from the caregiver role (Gilmour, 2002). Given this research context, this study included an evaluation of an expressive arts therapy experimental group for caregivers.

In another systematic review, the authors found that caregivers could reduce their stress and burden, and be more adaptive to the role, through a resilient coping style (Palacio et al., 2019). Multiple studies have likewise suggested that adopting resilient coping strategies can lead to positive changes for caregivers’ well-being by enhancing their active coping skills (Pakenham, 2007; Palacio et al., 2019).

Not only can the caregiving burden lead to reduced quality of life (Contreras et al., 2021), but it can also affect the relationship between the caregiver and their care recipient (Isac et al., 2021). The caregiving burden has been found to be more positively associated with a caregiver who is the daughter or daughter-in-law of the care recipient (Lee et al., 2017). In addition, a study in Singapore showed that both the factor of filial piety and the role of primary caregiver were positively associated with caregiver burden for those caring for frail old adults (Ding et al., 2022). There has recently been a paradigm shift, advocated by a systematic review that suggests focusing on ‘caregiver resilience’ instead of ‘caregiver burden’ (Isac et al., 2021).

A correlational study from Lebanon found that emotion-focused coping strategies were positively associated with resilience among female caregivers (Séoud & Ducharme, 2015). A study of gender difference in well-being, meanwhile, showed more diverse prominence and manifestation of well-being among female caregivers than male caregivers (Bhan et al., 2020). Both these studies suggest investigating how coping and emotional adjustment can help to lower the caregiver burden.

Psychological flexibility and emotional well-being

Psychological flexibility

Psychological flexibility is well regarded as a mediator for well-being (Browne et al., 2022) and has been defined in various research settings. It can refer to the ability to adjust to a change in environment or shift in perspective, as well as the ability to strike a balance in achieving one’s desires and goals in life even when there is distress (Kashdan & Rottenberg, 2010). It has also been referred to as the ability to “disengage from an initial pattern if the initial pattern of response is no longer effective for the specific situation” (Morris & Mansell, 2018, p.4).

The significance of psychological flexibility in emotional well-being

Psychological flexibility serves as a malleable factor to improve emotional well-being (Steenhaut et al., 2019). It buffers stressors in life events (Fonseca et al., 2020) and is suggested to lessen the negative views of emotion, specific emotion schemas and risk-averse decision making (Leahy et al., 2012). Furthermore, higher levels of psychological flexibility may reduce stress and promote well-being (Wersebe et al., 2018), as well as impact coping repertoires (Dawson & Golijani-Moghaddam, 2020), adaptivity (Waldeck et al., 2021), and quality of life (Contreras et al., 2021). In terms of evaluating depression risk, being psychologically flexible can promote flexible responses as well (Madison, 2021).

The impact of psychological flexibility on different populations during Covid-19

Psychological flexibility helps facilitate psychological health and adjustment (Kashdan & Rottenberg, 2010). Given the role of psychological flexibility as a mediator of distress, and its relationship with coping, a wide range of research, including studies on stress reduction and emotional distress, was conducted during the Covid-19 pandemic among multiple populations, including children and teenagers (Waldeck et al., 2021), Turkish undergraduate students (Arslan & Allen, 2022), adults with adverse childhood experiences (Browne et al., 2022), adults with obesity (Guerrini Usubini et al., 2021), and community-dwelling adults in Switzerland (Gloster et al., 2017).

When psychological flexibility functions as mediator

Apart from studying the direct association with emotional well-being, recent research has examined indirect factors that may be associated with emotional well-being, including the relationship between well-being and family functioning (Crasta et al., 2020), the association between distress and sleep quality (Peltz et al., 2020), the impact of well-being on depression and anxiety (Landi et al., 2020; Pakenham et al., 2020), and the effect of distress on suicidal ideation (Crasta et al., 2020). Psychological flexibility is thus regarded as a mediator between adversity and the outcome of well-being (Arslan & Allen, 2022).

How psychological flexibility is being enhanced in the Unified Flexibility and Mindfulness (UFM) scale

The Unified Flexibility and Mindfulness (UFM) scale (Rogge & Rasmussen, 2024) organises “aspects of psychological flexibility into distinct stepwise stages of responding to difficult thoughts, feelings, and experiences” (Parker et al., 2024, p.1). It provides “a foundation for the dimensions of the psychological flexibility model to be incorporated into mechanistic models of interpersonal functioning” (Parker et al., 2024, p.2).

Parker et al. (2024) also agree that the dimensions of the UFM scale, including dimension (v) values and dimension (vi) committed action, which will be further evaluated in this article, are associated with psychological flexibility. The UFM scale explains how psychological flexibility is enhanced through the adoption of the mindful awareness lens, which can be linked with other aspects of psychological health (Crasta et al., 2020; Rogge & Daks, 2021). The UFM scale illustrates the mechanisms that enhance psychological flexibility through acceptance and commitment therapy (ACT) and that improve emotional well-being as a result.

The function of psychological flexibility in the UFM scale, as proposed by Parker et al. (2024), is aligned with the mediation of health, as proposed by Kashdan and Rottenberg (2010). The essence of psychological flexibility is well illustrated in the UFM scale, in which the individual’s increased awareness of the here-and-now gradually leads to a higher level of psychological flexibility, followed by their experience of flexible acceptance towards difficult feelings and maintenance of a broader perspective. The latter effect is similar to how the ‘decentring’ stage of the intermodal expressive arts therapeutic approach works. Then the more flexible and value-driven behaviours overtake the aimless and haphazard behaviours, directing a person towards functional wellness (Parker et al., 2024).

As flexibility is one of many factors that mediate well-being, studies have also compared the mediation effect of other factors with that of psychological flexibility. These include self-compassion, adaptivity and time factors. For example, there have been studies showing that psychological flexibility is more associated with emotional well-being than self-compassion is (Marshall & Brockman, 2016; Woodruff et al., 2014). Research investigating the pathway of associations between psychological distress, adaptivity, psychological flexibility and well-being has yielded preliminary evidence that psychological flexibility has impact on the association between adaptivity and psychological distress. Hence, this research indicates that flexibility impacts adaptivity and may lead to a reduction in distress, though the causal relationship is yet to be validated (Waldeck et al., 2021). In a study on the associations of time factors, especially the present dimension, with well-being, researchers highlighted a higher association between psychological flexibility and avoidant coping. Such impacts were more significant in the Covid-19 pandemic among adults living in the United Kingdom (Pyszkowska & Rönnlund, 2021). This was supported by Dawson and Golijani-Moghaddam (2020).

Counter arguments on how psychological flexibility mediates

The association between psychological flexibility and coping has often been challenged. Various studies on the mediation pathway have found that there are other more significant pathways that impact coping. Therefore, psychological flexibility is not regarded as having the only direct association with coping (Dawson & Golijani-Moghaddam, 2020). Another counter argument regarding the definition of psychological flexibility involves questioning the association between brain plasticity and well-being (Giommi et al., 2023). Neither of these counter arguments has been thoroughly investigated, but future studies on these aspects may further indicate the mediating role of psychological flexibility with regard to emotional well-being.

It should be noted that there may be various arguments about the borrowing of the concept of psychological flexibility to evaluate the effectiveness of expressive arts therapy. The use of the AAQ-II, which has been frequently used to assess psychological inflexibility (Waldeck et al., 2021) rather than psychological flexibility, is also a controversial issue under debate in the field of acceptance commitment therapy. Hence, the findings in this study only serve as a starting point for the use of expressive arts therapy for enhancing caregivers’ psychological flexibility.

Expressive arts therapy and emotional well-being

The use of expressive arts interventions has been shown to yield positive impacts on emotional well-being, such as reducing stress, anxiety and depression, and improving quality of life (Liddle et al., 2012, 2013; Phillips et al., 2023; Weziak-Bialowolska et al., 2021). In one study, both patients with a chronic condition and health care professionals were able to gain support and see a positive impact on their mental health through the use of arts (Vaartio-Rajalin et al., 2021). A study in Taiwan showed that expressive arts therapy helped older people with dementia to improve emotional well-being through enabling them to express their emotions and thoughts (Lin, 2021). Another study in Taiwan examined the effectiveness of an art intervention on long-term depression among older people living in a senior-home-care setting (Wen et al., 2015). The use of expressive writing was found to help a group of nurses, as formal caregivers, to express and regulate their emotions, which then enhanced their ability to cope with their daily work of caring for their patients (Sexton et al., 2009).

Creative arts interventions in groups have been shown to establish meaningful connection and support among informal caregivers of older individuals in two systematic reviews (Phillips et al., 2023; Watt et al., 2022). In addition, a wide range of studies has shown the effectiveness of arts-based therapy in lessening caregiver burden (Harvey et al., 2018), reducing caregiver burnout and stress (Levenberg et al., 2021; Loewy, 2015; Wharton et al., 2019), reducing caregiver depression (Wharton et al., 2019), and improving caregivers’ quality of life (Richards et al., 2019).

The therapeutic mechanism of improving emotional well-being through expressive arts therapy has been studied extensively. In a scoping review, De Witte et al. (2021) determined that the therapeutic factors of creativity were critical for individuals’ openness and adaptivity towards new possibilities as spaces were offered for clients to explore and try out alternative coping strategies. Meanwhile the changes in modalities of the intermodal expressive arts intervention enhanced participants’ openness and flexibility in accepting new perspectives and alternative creative pathways, and ultimately in reaching their therapeutic goals (Orkibi, 2012; Ram-Vlasov & Orkibi, 2021).

De Witte et al. (2021) suggest that the therapeutic factors of modulating time and space affect the creative space offered to the clients. As the here-and-now is more emphasised than the there-and-then, clients undergo the greatest potential to change and grow through the imagination (De Witte et al., 2021). The extension of the imaginative space also coincides with the concept of the decentring stage, as proposed in the intermodal approach in expressive arts therapy, which further leads to the client’s openness and flexibility to accept themselves by widening their play range.

Methodology

Research method

This study is a quasi-experimental study in which the staff in the community elderly centre coordinated the recruitment procedure. The inclusion criteria for this study were female caregivers aged 55 to 80 who were taking care of frail older adults. Research participants were required to give their written consent on the service agreement, and had to be willing to attend pre- and post-group individual interviews. Participants refusing to offer written consent were withdrawn from the study. The exclusion criteria were those with psychotic symptoms within two years or those with bereavement experience within one year.

A privacy statement was included on the written consent form that explained how data collected via the survey would be stored and used. All the data and materials collected would be preserved on an encrypted drive and kept until the end of the dissertation research period to preserve the data anonymity.

The participants were recruited from Pak U Neighbourhood Elderly Centre through open recruitment and referral by the social workers, then the social workers balloted the recruited participants into the experimental group and the control group before the student researcher first met the participants in the pre-group individual interviews. The agency disclosed the participant list for the experimental group and the control group to the researcher. A total of eleven female participants, aged 55 to 80 and caregivers of frail older adults, were recruited. Six of them were assigned to the experimental group with five sessions of expressive arts therapy, and five of them were assigned to the control group.

All the participants were invited to attend one pre-group individual interview session and one post-group individual interview session for the questionnaire and post-group semi-structured individual interviews, arranged by the agency staff and held in the agency meeting room by the researcher. Clinical observations of the experimental group were made for qualitative analysis.

At the beginning of the study, Participant E decided to withdraw from the experimental group after attending Sessions 1 and 3, because she was personally not ready to engage in the expressive arts as an intervention process. For the remaining five participants, there was an attendance rate of 90%. Almost all participants had full attendance, with the exception of participant C who requested leave for medical reasons in Sessions 4 and 5, and participant D who requested leave for family matters in Session 4.

Clinical observations and the participants’ ideas about the artwork they created were consolidated through notetaking after every session by the student researcher (who was also the student therapist), and the student co-therapist took photos of artworks at the end of each session. Meanwhile, participants’ responses in the semi-structured interviews were recorded in notes by the student researcher, also in the agency meeting room.

The qualitative data below were first presented with respect to the clinical observations, referring to the process of the architecture during the intermodal expressive arts therapy approach, including the building of a safe environment, decentring, the extension of play range, the engagement of felt senses, self-discovery through aesthetic analysis, and the impact of group dynamics during the harvesting stage. Later, the sharing content during the harvesting stage was coded, then analysed according to the UFM’s six dimensions, including (i) acceptance, (ii) cognitive defusion, (iii) being present, (iv) self as context, (v) values and (vi) committed action (Hayes et al., 2006). The imagination is enriched through engagement of felt sense, the analysis of dimension (v) values and dimension (vi) committed action are captured in this paper as follows.

The study received ethical approval from the Human Research Ethics Committee of the University of Hong Kong. The study and the student investigator were under the supervision of Professor Rainbow Ho Tin-hung in the Department of Social Work and Social Administration at The University of Hong Kong.

Quantitative measurements

The Acceptance and Action Questionnaire II (AAQ-II) (Bond et al., 2011), which is the most widely used scale of psychological flexibility (Bond et al., 2011; Rochefort et al., 2018; Tyndall et al., 2019; Wolgast, 2014), was included in the pre- and postquestionnaires. The Chinese version of the scale, which has been validated for the measurement of experiential avoidance in Hui and Kazak adolescents (Wang, 2015), was adopted in this study.

The 7-item AAQ-II, which computed 7 subscales scored on a 7-point Likert scale (1 = never, 7 = very often) as the sum of items, included:

1. My painful experiences and memories make it difficult for me to live a life that I would value.

2. I’m afraid of my feelings.

3. I worry about not being able to control my worries and feelings.

4. My painful memories prevent me from having a fulfilling life.

5. Emotions cause problems in my life.

6. It seems like most people are handling their lives better than I am.

7. Worries get in the way of my success.

The responses to the pre-group and post-group questionnaires, which were collected during individual interviews one week before the first experimental group session and one week after the last experimental group session.

Qualitative measurements

Clinical observations included an assessment of the participant’s decentring and self-disclosure in the harvesting process during the experimental group sessions, and the semi-structured interviews held one week after the last session of the experimental group. Participants were required to respond to the following seven questions:

1. As a caregiver, what kind of decision is the most difficult for you to make?

2. What are/were the top priorities in your role as a caregiver?

3. What are the changes for you after joining the expressive arts therapy group?

4. What kind of arts modality do you usually get in touch with in daily life?

5. What kind of arts modality do you usually get in touch with after the study?

6. What do you think are the potential benefits for caregivers to receive expressive arts therapy interventions?

7. What do you think are the potential challenges for caregivers to receive expressive arts therapy interventions?

Intervention

Participants in the experimental group were invited to join a total of six sessions of the intervention program with the therapeutic goal of enhancing self-acceptance. Participants in the control group did not receive any intervention during the same period. The session plan is shown in Table 1. The first session began with rapport and safe-space building, followed by the goal of self-understanding in Session 2. Sessions 3 and 4 aimed to help the participants to explore new possibilities, while Session 5 aimed to help them to accept their alternative selves. The final session marked the end of the experimental group through celebration and closure. In each session, an intermodal expressive arts therapy approach was adopted (Knill et al., 2005) and the therapist-researcher led the harvesting with aesthetic analysis to assist the participants to identify the message from the artworks to themselves.