Relieving Symptoms in Cancer Innovative Use of Art Therapy Journal of Pain and Symptom Management

Abstract

Art therapy has been used in a variety of clinical settings and populations, although few studies take explored its use in cancer symptom control. The specific aim of this written report was to determine the issue of a i-60 minutes art therapy session on pain and other symptoms common to adult cancer inpatients. A quasi-experimental design was used (n = 50). The Edmonton Symptom Assessment Calibration (ESAS) and the Spielberger State-Trait Anxiety Index (STAI-S) were used prior to and after the art therapy to quantify symptoms, while open-concluded questions evaluated the subjects' perceptions of the experience. There were statistically significant reductions in eight of nine symptoms measured past the ESAS, including the global distress score, as well as significant differences in most of the domains measured by the STAI-S. Subjects overwhelmingly expressed comfort with the procedure and desire to continue with therapy. This study provides beginning evidence for the efficacy of fine art therapy in reducing a broad spectrum of symptoms in cancer inpatients.

Key Words

• Hurting
• anxiety
• symptoms
• art therapy
• cancer

Introduction

Pain, fatigue, anxiety, and other symptoms are common in those experiencing cancer.

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In seeking relief, patients increasingly are turning to alternative and complementary therapies, reflecting the growing need for more comprehensive management of these cancer-related symptoms. Several studies suggest that more than 80% of cancer patients may utilize some class of complementary therapy in conjunction with other standard medical treatments such equally surgery, chemotherapy, and radiation.

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A number of complementary therapies such as relaxation, massage, hypnosis, and music therapy have been found to exist constructive in reducing symptoms, improving quality of life, and enhancing cancer patients' ability to cope with distress.

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Art therapy is one of the complementary therapies existence used to save cancer symptoms. Art therapy is a clinical intervention based on the belief that the creative procedure involved in the making of fine art is healing and life enhancing. It is used to help patients or their families increase sensation of self, cope with symptoms, and adjust to stressful and traumatic experiences.

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The objectives of fine art therapy are to use the artistic process to allow sensation and expression of an individual'due south deepest emotions.

For people with cancer, these emotions may be well-nigh the affliction, hospitalization, relationships, or other concerns. The meaning and the power of these emotions frequently are non hands articulated using exact communication. It is the art itself that provides a vehicle for expression, aided by the actual physical motion of artistic materials. Fine art therapy may be preferential to some cancer patients who may be uncomfortable with conventional psychotherapy or those who find verbal expression difficult.

There is a growing body of literature demonstrating that art therapy can be effective in ameliorating symptoms associated with cancer both in children and adults.

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Art that Heals was i of the primeval and most comprehensive programs that demonstrated how art therapy could be useful in an oncology setting past helping patients reinforce positive coping beliefs and increasing their self-esteem and their sense of control.

Since and so similar benefits take been demonstrated past other programs.

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Current art interventions with cancer patients have many forms—from 1-on-one interactions to support groups to a community's participation in art exhibits where art works were created past cancer survivors.

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While this flexibility explains art therapy's appeal to a wider patient base, the nonuniform blueprint of previous studies makes it difficult to draw specific conclusions almost art therapy'southward effectiveness in a detail population, such equally oncology inpatients. While initial reports suggest promising results, virtually art therapy studies are based on patient case analysis, have very minor sample sizes, or are non designed to empirically exam a hypothesis. In addition, most of the current studies evaluated the use of fine art therapy in improving quality of life and emotional well being, with few addressing its furnishings on concrete symptoms. To address these electric current limitations, we undertook an investigation of art therapy in an inpatient oncology population using quasi-experimental, pre-posttest methodology. The specific aim of this innovative research projection was to empirically determine the effect of art therapy in relation to hurting, anxiety, and a variety of other symptoms common to the cancer inpatient population.

Methods

Subjects

Participants were recruited from the inpatient oncology units at a large urban bookish medical center over a four month flow. Patients were included in the study if their diagnosis was cancer, were 18 or older, were cognitively intact, were able to communicate in English, and were capable of participating in a 1-hour session of art therapy. L patients completed the report.

Instruments

The instruments used to measure physical and emotional symptoms associated with cancer were the Edmonton Symptom Assessment Scale (ESAS) and the land portion of the Spielberger State-Trait Anxiety Index (STAI-Southward). The modified ESAS is a 10-item patient-related symptom numeric scale adult for use in symptom assessment of palliative care.

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It has been validated in other populations, including cancer inpatients.

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In the ESAS patients rate the severity of each of the following nine symptoms on a 0–10 calibration: pain, tiredness, nausea, depression, anxiety, drowsiness, lack of appetite, their well being, and shortness of breath. The sum of the patients' responses to these nine symptoms is the global ESAS distress score.

The STAI is the definitive instrument for measuring anxiety in adults.

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The STAI differentiates betwixt the temporary condition of state anxiety and the more general and long-standing quality of trait anxiety. In the present study just the state component of the STAI was used to mensurate how a patient described his or her psychological state at the fourth dimension of the intervention. The essential qualities evaluated by the STAI are feelings of apprehension, tension, nervousness, and worry. Scores of the STAI increase in response to physical danger and psychological stress and decrease as a result of relaxation. The STAI has shown stability, test, retest reliability, internal consistency, and has been validated by thousands of studies, including those that involved cancer patients.

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The participants were likewise asked 3 boosted open up-ended questions at the completion of the art therapy session to capture their full impression of the session: (i) If given an opportunity, would they like to experience fine art therapy again? (2) How did the art therapy session change their overall well existence? (iii) Did they feel comfortable making the fine art?

Procedure

Afterward a patient expressed interest in participating in a study of fine art therapy, the inquiry assistant approached the patient to hash out participation in the study. Informed consent was obtained at that fourth dimension and the baseline cess was completed using the ESAS and the STAI-South. Standard demographic data, along with information about diagnosis, and questions about previous art and art therapy experiences were asked at that fourth dimension. Upon the completion of the survey items, the inquiry assistant exited the room.

A registered fine art therapist, who is licensed as a professional clinical counselor, and then approached the field of study's room with a cart that held a variety of arts and crafts materials (the cart was not brought into the patient's room due to infection control concerns). The subject was given a list of all the materials and projects that were available on the cart (see Table 1). To minimize potential interruptions, each subject's nurse was consulted prior to the session to make sure there were no alien procedures or activities scheduled. The subject was instructed that the session would concluding approximately 1 hour and was asked what goals he or she had for the exercise. The art therapist would and then assistance subjects with their choice of subject affair and media, and would choose an appropriate course for the session. For example, when subjects could not use their hands or were not comfy using the art materials, the art therapist would practice the art making under the direction of the subject or they could look at and discuss photographic images that were assembled into a book. The content of the art therapy sessions was individualized according to subjects' goals ranging from light entertaining distraction to investigating deep psychological issues.

Table one Fine art Cart

Art Therapy Supplies
• Cards/envelopes	• Jewelry/beads
• Clay	• Journals/sketch pads
• Collage	• Paper pulp masks
• Fancy papers	• Painting
• Feathers	• Finger paint
• Felt	• Stained glass
• Foam shapes	• Tempera
• Glitter glue	• Watercolor
• Glue sticks	• Rainsticks
• Magazines	• Stained drinking glass lord's day catchers
• Pipe cleaners	• Stamps
• Sequins	• Wooden boxes
• Tissue paper	• Wooden frames
• Yarn
• Drawing
• Charcoal
• Color pencils
• Pastel chalk
• Pencils
• Mark pens
• Oil crayons

• Open tabular array in a new tab

The fine art therapist encouraged the subject to use the art materials in a way that met the goals they had prepare. She attempted to put the subject field at ease by saying things such as "I'm here to help y'all anyway I can. There is no correct or incorrect way to practice this. The process is the healing aspect, not the end product. Tell the critic in your mind to be repose and only permit yourself enjoy doing this. You lot can't exercise this incorrect." When the subject was finished, he or she was encouraged to discuss his or her feelings through questions such as "Were you thinking about anything in detail while you were making this? Practice any of your choices accept special meaning?" At the end of the session, the subject was allowed fourth dimension to talk virtually whatsoever additional issues that arose during the session.

After this discussion was concluded, the art therapist offered to leave some materials with the subject if he or she wanted to go on working on his or her own. Upon the completion of the therapy session and later the therapist exited the room, the research assistant returned to administrate the posttest measures and open-ended qualitative questions.

Assay of Data

SPSS for Windows (Statistical Package for the Social Sciences Version 11, Chicago, IL) was used for data management and statistical assay. Because the variables did not have normal distributions, nonparametric statistical methods were used to clarify these variables. The Chi-squared test of association was done to compare groups with respect to percentages. The Kruskal-Wallis and Mann-Whitney tests were used to compare groups with respect to noncategorical information. The Friedman test was done to evaluate changes after therapy compared to pretherapy values. Means are expressed as mean ± standard deviation. A 0.05 significance level was used for all statistical tests. No i-sided statistical tests were washed.

Results

Of 63 patients who were approached but declined to participate in this study, 35 (55%) stated that they were not interested and did not provide boosted explanation, 9 (fourteen%) were being discharged, 8 (13%) felt too sick, 2 (three%) were experiencing too much pain, one person (2%) stated that his or her hands were too "shaky," and one person had participated in fine art therapy before but did not like the experience.

Fifty subjects were enrolled in this study, almost with leukemia (29.2%) or lymphoma (32.6%), with the bulk diagnosed inside the prior two–3 years (mean ii.fourteen ± 3.0 SD). Additional demographic data regarding the sample are provided in Tabular array ii. No patients dropped out of the written report one time art therapy was started.

Table two Demographic Information

Characteristics	due north	%
Age (hateful ± SD, range years)	51.3 ± xiv.eight (nineteen–82)
Gender
Female	29	58
Male	21	42
Ethnicity
Caucasian	32	65.3
African American	13	26.5
Asian	1	2
Hispanic/Latino	2	4.i
Other	2	4.1
Marital condition
Unmarried	17	34
Married	28	56
Divorced	5	10
Instruction (mean ± SD, range years)	15.3 ± two.8 (10–25)
Diagnosis
Leukemia	fourteen	29.ii
Lymphoma	15	32.half-dozen
Breast cancer	4	8
GI/colorectal cancer	four	8
Gynecological cancer	2	four
Other malignancies	11	xviii.2
Fourth dimension since diagnosis (mean ± SD, range years)	2.1 ± 3.0 (0–15)

• Open table in a new tab

Symptom Burden

There were statistically pregnant reductions in eight of nine symptoms measured past the ESAS, including the global distress score (Fig. 1, Fig. two). Nausea was the singular symptom that did not change every bit a issue of the art therapy session. There were no associations betwixt age or gender and change in the private and global ESAS distress score, although this association was noted with ethnicity (Fig. 3). African American subjects were more likely to have lower post-test ESAS global distress scores when compared with Caucasians (Mann-Whitney or MW; P = 0.037).

In regard to pre- and postintervention anxiety measures, in that location were statistically significant differences in well-nigh of the domains measured by the STAI-Southward (Fig. iv). Yet, responses such as regret, feeling at ease, being worried, and feeling rattled demonstrated no change when comparing scores prior to and after the therapy. At that place were no associations between age, gender, or ethnicity and change in STAI-S scores.

Perceptions of Art Therapy

Well-nigh (44% or 88%) of the subjects had never participated in art therapy prior to this written report and the bulk, 46 (92%), stated that they would similar to do art therapy once again. When asked how they perceived art therapy inverse their overall well beingness, 45 (xc%) stated that the session distracted them and focused their attending onto something positive. Eighteen subjects (36%) responded that the therapy was calming and relaxing, six (12%) felt productive and worthwhile, and 12 (24%) felt that it was a pleasant action. Three (6%) subjects commented that the art therapy had no consequence.

When asked whether they felt comfortable making art, 48 (96%) subjects agreed. Reasons for this comfort included the approach of the art therapist, prior feel with making fine art, or conversely, that making art was a new and interesting experience. Several subjects commented that making fine art gave them a feeling of control and allowed them to express their feelings without words.

Only ii (4%) subjects said that they were not comfortable with making art. Both of them believed that they had no talent or skill and thus did non like what they produced.

Discussion

Pain and other symptoms are common in an oncology inpatient population. Although pharmacologic therapies are essential to provide relief, consumers are interested in supplementing traditional medical approaches with complementary therapies to salve hurting and suffering. Art therapy is 1 complementary therapy that has adept anecdotal support for its efficacy in relieving feet and other emotional symptoms.

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Withal, well-designed studies demonstrating the effectiveness of fine art therapy in an inpatient oncology setting are deficient. This written report was the first to attempt to evaluate the benefits of this intervention on reducing a broad spectrum of symptoms in an empirical style. The results provided farther testify of the benefits of art therapy, as in that location were meaning reductions in symptoms and overall country anxiety after a 1-hour fine art therapy intervention.

Although there was a decrease in most symptoms, a peculiarly surprising finding of the report was the reduction in "tiredness" expressed by these subjects. Despite reporting significant tiredness immediately prior to the therapy (mean score of 4.4 ± 2.7) and using free energy during the therapy session, subjects described pregnant reduction in this tiredness at the end of the intervention (mean 2.ix ± 2.5). Subjects fabricated numerous anecdotal comments that the fine art therapy had energized them. This is the first written report to document reduction in tiredness equally a consequence of art therapy.

Our disability to detect a statistically significant improvement in nausea (ESAS) and several items on the STAI-S (feeling regretful, rattled, or worried) was partially due to a "floor outcome." On average, subjects started with an already low score on these items during the pretest, assuasive footling or no room for improvement. For instance nausea had the lowest ranked pretest value of all of the nine symptoms of the ESAS. To further complicate estimation of changes in this symptom, one patient was given a medication immediately prior to the art therapy intervention that caused her to become very nauseated and vomit during the session. Her information were included in the assay every bit she completed the session.

Regarding the subjects' perceptions of art therapy, this very various patient population, with a wide range of ages, educational and ethnic backgrounds, diagnoses, and length of disease, was very receptive to the therapy. There was no departure in comfort level or interest in standing art therapy past any of these demographic variables. This suggests that art therapy could be appropriate for a broad variety of patients and not to a single homogeneous group. A puzzling paradox to this credence was the large refusal rate while entering patients into the trial, a phenomenon that is common in clinical practice in our institution. A significant pct of individuals on the inpatient oncology units are reluctant to endeavour art therapy. Additional research is needed to empathise the barriers to this acceptance, particularly in light of the outset bear witness for its efficacy and the big number of subjects enrolled in the written report who reported a positive experience.

This study had a number of limitations. First, without control or randomization we were non able to business relationship for a number of variables that might have influenced the result of our written report. This written report was designed to evaluate immediate symptom change after one therapy session, rather than determining the duration of effect or intensity when multiple sessions were offered. While a big percentage of the patients who took office in our study requested and received additional art therapy sessions during the course of their hospital stay, nosotros did not evaluate long-term effects of art therapy on their symptoms. It would be useful to see whether the positive benefits of art therapy tin extend for longer periods of time and also how oftentimes fine art therapy should exist given to extend these benefits. We are currently planning controlled clinical trials with longer follow-up.

This written report provides beginning prove for the efficacy of art therapy in reducing a broad spectrum of symptoms in a diverse sample of cancer inpatients. Art therapy is piece of cake to implement in the hospital setting and was widely accustomed past the participants in this study who found the process distracting and calming. Very few individuals constitute the process uncomfortable and no agin effects were noted. Fine art therapy is a relatively inexpensive intervention, entailing the therapist'due south time and cost of fine art supplies, that may have long lasting furnishings by teaching individuals long-term techniques and cocky-efficacy. As consumers limited greater interest in complementary therapies, techniques such every bit fine art therapy will likely be used with greater frequency. Future inquiry is needed to identify patients who might experience the greatest benefit, the duration of effect of this approach, as well as the optimal number of sessions needed to produce long-term furnishings.

Acknowledgments

The authors wish to give thanks the patients, nurses, physicians, and other staff on the inpatient oncology units at Northwestern Memorial Infirmary, forth with Jackie Medland, Director of Oncology Services at the time this study was conducted. The authors are grateful to the Service League of Northwestern Memorial Hospital for their funding of this trial.

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Article Info

Publication History

Footnotes

This enquiry was supported by a grant from the Service League of Northwestern Memorial Hospital.

Identification

DOI: https://doi.org/10.1016/j.jpainsymman.2005.07.006

Copyright

© 2006 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc.

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