Introduction

During my four months of training to become an art therapist, I spent a brief but resonant period in a hospice in Singapore. Palliative care services support patients at their end-of-life stage (typically with a prognosis of three months or less), and reduce the caregiving burden their loved ones experience. Services normally encompass pain and symptom control, emotional support, grief assistance, and caregiver training (Timm, 2023). As an art therapy trainee, my role was to provide group art-as-therapy sessions and individual, bedside art-in-therapy sessions. I witnessed how the title of art therapist offered me a privileged position to invite clients into the therapeutic process. Art therapists, like other professionals in the hospice, were viewed by the patients as authority figures. The unbalanced power dynamic reflects the collectivist values that are still present in modern-day Singapore (Tan & Lim, 2010). This asymmetrical therapeutic relationship became a double-edged sword, as it both created opportunities and built invisible barriers between the clients and me. For instance, some clients might have felt obliged to participate in an art therapy session and might have tried to present the ‘correct’ answers in therapy. While I expected the clinical work to be challenging, I was unprepared for the psycho-emotional depth that emerged in response to the uncertainty, ambiguity, and presence of those nearing the end of life.

During this period, I found myself turning to work with soft, tactile materials – such as fabric and lightweight foam clay – as a way to process my internal responses and remain grounded. Creating response art after each session helped me to express unconscious thoughts and emotions, and offered a reflective distance for me to make sense of my experiences (Nash, 2019). These materials activated multiple levels of the Expressive Therapies Continuum (Hinz, 2019), enabling me to uncover, express, and regulate emotions that were previously difficult to articulate in words. My personal art-making became a quiet dialogue with uncertainty. It also became a mirror for therapeutic concepts such as transference, externalisation of the unconscious, and the delicate task of ‘holding space’ for another person as they confront issues of existence.

This essay reflects on my inaugural experience as an art therapist, exploring how embodied, reflective art-making deepened my attunement and informed my understanding of therapeutic presence in end-of-life care. Through this lens, I examined how material softness offered an entry point into deeper therapeutic awareness and connection with my clients.

Understanding suffering through total pain theory

Losing a loved one to cancer a few years ago exposed me to the spectrum of end-of-life care. Hospital visits were often dominated by medical jargon, and, as a family, we struggled to navigate the weight of anticipatory grief. While it was available, there was little discussion about the emotional and psychological support both patients and caregivers needed.

The dynamics of Singapore’s collectivist culture, which prioritises the needs of the community, creates a complex tension for end-of-life care. While many middle-aged and older Singaporeans avoid being a burden to their families, they also value the ability to maintain control over their care decisions (Malhotra et al., 2012). This interdependence on family is further underscored by research indicating that ageing parents in Singapore express a high level of trust in family members for joint decision-making, even when their specific wishes haven’t been discussed (Lee & Ng, 2020).

This cultural avoidance makes conversations surrounding death and dying remain uncomfortable or taboo in the public sphere (Yeo et al., 2023). Until recently, my grandmother hesitated to use a wheelchair despite her growing frailty. She believes that sitting in a wheelchair is a prelude to physical disability. Other traditional beliefs, such as the gift of a clock implying that time on earth is running out, pervade the ideology of the older generation in Singapore. Moreover, some view therapy as a form of ‘airing dirty laundry’ in public, which can be associated with the cultural reluctance to ‘lose face’, thus making it difficult to openly explore psycho-emotional issues. Indeed, local researchers confirm that public health authorities must recognise “deep-seated beliefs and superstitions surrounding the concept of mortality” (Yeo et al., 2023).

The theory of total pain, first introduced by Dame Cicely Saunders, offers a holistic understanding of suffering in patients with terminal illnesses. It recognises the complex interplay between the mind and body, and how physical pain is often intertwined with spiritual, psychological, and social distress (Saunders & Baines, 1984). Rather than viewing pain in isolation, this theory acknowledges that a patient’s suffering is multifaceted – shaped by their relationships, identity, beliefs, and emotional state (Mondanaro et al., 2025). This idea also resonates with concepts of embodiment in both psychology and art therapy. As the body begins to deteriorate, the experience of self can shift dramatically – individuals faced with mortality confront deep questions of identity, meaning, and loss of control. During my internship at a hospice in Singapore, I found myself resonating deeply with the concept of total pain. As I attuned and empathised with my clients, their shared feelings of helplessness, isolation, or fear heightened my awareness of their distress at being admitted into a hospice setting.

Bridging unfamiliarity through the use of materials

Most of the clients I worked with belonged to Singapore’s Pioneer Generation – seniors born before the 1950s who played a vital role in the nation’s early development (Ministry of Health, 2014). For many in this generation, art – let alone art therapy – is seen as a luxury, unfamiliar and distant from their lived realities. Consequently, an art therapist is often perceived with a sense of reverence or detachment, as someone possessing skills and resources far removed from their own. This dynamic initially posed challenges in engaging the seniors meaningfully in art-based therapeutic work.

To bridge this gap, I intentionally selected materials and set directives that evoked a sense of familiarity, comfort, and cultural resonance. Rather than relying on conventional art materials such as paints or coloured pencils, I turned to clay and fabric – mediums that reflected aspects of their everyday experiences. These materials not only aligned more closely with tactile activities they might have done in the past, such as hand-building or sewing, but also served as a bridge back to their embodied memories, making the art-making process more accessible and meaningful.

As I interacted with my clients and the art materials, clay and fabric started to contain my experience as a trainee art therapist. This process of embodiment (Koch & Fuchs, 2011) bridged what was experienced in the body and mind. By focusing on the materials’ textures, I was engaging in a form of embodied aesthetics (Koch, 2017), where the tactile experience mediated my emotional state. For instance, there were moments when I struggled to make sense of my clients and the sessions. My own uncertainty led to moments of feeling like an outsider – observing from a distance and not quite belonging. Using the available foam clay to reflect on my experience, an image emerged: two swollen, red eyes stared back at me, with alien green skin and bright blue hair. Molly (Figure 1) is half-concealed as she peers from the corner of a piece of paper.