Art Making/Art Therapy

Art Making/Art Therapy

PEP Topic 
Anxiety
Description 

Art therapy encourages participants to express emotions through drawing and is aimed at triggering thoughts and feelings for communication. Trained art therapists assist participants to reflect on and explore the thoughts and feelings exposed in the creative expression. This activity is seen to promote the participant's understanding of him- or herself and the situation encountered. Art therapy has been studied in patients with cancer related to management of anxiety, depression, and fatigue.

Art making is the provision of the opportunity and materials for individuals to create various types of artistic items. Art making can be seen as a diversional activity. It differs from art therapy because it does not involve interaction with a trained art therapist and does not necessarily engage the participant in exploring thoughts and feelings through the creative expression.

Effectiveness Not Established

Research Evidence Summaries

Bar-Sela, G., Atid, L., Danos, S., Gabay, N., & Epelbaum, R. (2007). Art therapy improved depression and influenced fatigue levels in cancer patients on chemotherapy. Psycho-Oncology, 16, 980–984.

doi: 10.1002/pon.1175
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Intervention Characteristics/Basic Study Process:

An anthroposophy art therapy intervention (watercolor painting) in weekly group sessions was administered by an art therapist in northern Israel. Participants chose the amount of time to spend in the session, ranging from a few minutes to more than an hour. Data were collected at baseline and before every session.

Sample Characteristics:

  • The study reported on a sample of 60 oncology inpatients and outpatients who were receiving chemotherapy, radiotherapy, or follow-up care.
  • Patients in the intervention group (n = 19) completed four or more art sessions.
  • Patients in the participation group (n = 41) completed one to three art sessions.

Study Design:

A single-arm, pilot study design was used.

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression Scale (HADS)
  • Brief Fatigue Inventory (BFI)

Results:

A Mann-Whitney U test compared HADS and BFI in the intervention group and the participation group. A Wilcoxon signed-rank test assessed changes in HADS and BFI scores in the two groups. There were no significant difference between the two groups for reducing anxiety (p = 0.2).

Limitations:

  • Anxiety levels at baseline were in the normal range for both groups.
  • The small sample size of unspecified types of cancer and varying treatments, lack of statistically significant findings, and lack of randomization or control group limited this study.
  • A specialized art therapist was needed to administer the intervention.

Lawson, L.M., Williams, P., Glennon, C., Carithers, K., Schnabel, E., Andrejack, A., & Wright, N. (2012). Effect of art making on cancer-related symptoms of blood and marrow transplantation recipients. Oncology Nursing Forum, 39, E353–E360.

doi: 10.1188/12.ONF.E353-E360
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Study Purpose:

To examine the effects of a one-hour art-making session during bone marrow transplantation (BMT) treatment

Intervention Characteristics/Basic Study Process:

Interested patients were randomly assigned to the sequence to receive either the art-making session or the control condition first and were then crossed over to the other condition. Art-making sessions were 40–60 minutes. Patients were provided with a ceramic tile, brushes, and paint to create a tile at no cost. Measurements were obtained pre- and postintervention. Patients waited an average of 6.8 days between the treatment and control conditions.

Sample Characteristics:

  • The study reported on a sample of 20 patients undergoing BMT.
  • Mean patient age was 38.5 years, with a range of 20–68 years.
  • The sample was 50% male and 50% female.

Setting:

  • Single site
  • Inpatient setting
  • Kansas

Phase of Care and Clinical Applications:

Patients were undergoing active antitumor treatment.

Study Design:

 A crossover pre/post-test design was used.

Measurement Instruments/Methods:

  • Therapy-Related Symptom Checklist
  • State-Trait Anxiety Inventory
  • Salivary cortisol measurements collected between 9 am and noon

Results:

Symptoms declined in post-test measures in both conditions, with significant decline post art making (p = 0.01). There was no significant change in anxiety scores. Salivary cortisol levels declined significantly in both conditions. Time between conditions ranged from 1 to 28 days.

Conclusions:

Art making appeared to reduce treatment-related symptoms but had no apparent effect on anxiety.

Limitations:

  • The study had a small sample, with less than 30 participants.
  • The study had risk of bias due to no blinding, no random assignment, and no appropriate attentional control condition.
  • The timing of postintervention measures for each condition is not stated; it is not clear whether these were done immediately after the art-making session, or at what time points they were measured in the control condition. Time between cortisol level measurements also was not stated. In some cases, the time between conditions was only one day, which seems too brief to avoid contamination of effect. 
  • Patients self-selected to participate.

Nursing Implications:

This pilot study showed that the art-making session appeared to have an effect in reducing treatment-related symptoms; it is not clear if the art making specifically was effective, or if any diversional activity would have the same result. Findings do not support an effect of art making on anxiety.

Nainis, N., Paice, J.A., Ratner, J., Wirth, J.H., Lai, J., & Shott, S. (2005). Relieving symptoms in cancer: Innovative use of art therapy. Journal of Pain and Symptom Management, 31, 162–169.

doi: 10.1016/j.jpainsymman.2005.07.006
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Intervention Characteristics/Basic Study Process:

The intervention was a one-hour art therapy session administered by a registered art therapist/counselor.

Sample Characteristics:

The study reported on a sample of 50 adult inpatients with cancer.

Study Design:

A quasi-experimental design was used.

Measurement Instruments/Methods:

  • State-Trait Anxiety Inventory (STAI-S): To measure state anxiety
  • Edmonton Symptom Assessment Scale (ESAS)

Results:

Change in anxiety scores was reported on both the STAI-S and ESAS (no p values were reported).

Limitations:

  • The study reported on a small sample that was not randomized or controlled.
  • The study did not include data on dose, repeated measures, or longitudinal evaluation.
  • The study did not include pharmacologic assessment.
  • The study required specialized training of a registered art therapist/counselor.

Thyme, K.E., Sundin, E.C., Wiberg, B., Öster, I., Åström, S., & Lindh, J. (2009). Individual brief art therapy can be helpful for women with breast cancer: A randomized controlled clinical study. Palliative and Supportive Care, 7, 87–95.

doi: 10.1017/S147895150900011X
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Study Purpose:

To explore the responses, in terms of self-image and psychiatric symptoms, of women with breast cancer to an art therapy intervention

Intervention Characteristics/Basic Study Process:

The art therapy intervention consisted of five sessions in which participants were encouraged to express feelings and thoughts. Participants’ pictures were used as a mode of expression, followed by reflective dialog. Two experienced art therapists conducted interventions and patient interviews, so that the therapist did not function as both interviewer and therapist for the same patient. Art therapy sessions were provided during adjuvant radiation therapy. Study data were collected at baseline, after two months, and after four months.

Sample Characteristics:

  • The study reported on a sample of 41 patients.
  • Median patient age was 59 years, with a range of 37–69 years.
  • All the patients had breast cancer (100% female sample) and had received adjuvant radiation therapy. No other specific diagnostic information was provided.
  • No demographic data were reported (other than age). A few patients in both groups were receiving antidepressants. About 50% of patients had received chemotherapy prior to radiation therapy, and 41% had received hormone therapy.

Setting:

  • Single site
  • Outpatient setting
  • Sweden

Phase of Care and Clinical Applications:

  • Phase of care: active treatment
  • Clinical applications: late effects and survivorship

Study Design:

Randomized controlled trial with longitudinal analysis

Measurement Instruments/Methods:

  • Structural analysis of social behavior
  • Symptom Checklist-90 (provides symptom-subscale scores and measures of general severity)
  • Interview

Results:

At baseline, all participants had similar self-image scores and scores for depression, anxiety, and general symptom severity as a group of females undergoing radiation therapy for breast cancer who are otherwise healthy. Those who received art therapy showed a decrease in symptoms of anxiety and depression (p < 0.01). Control patients’ symptom levels remained essentially stable. Regression analysis showed that surgery, chemotherapy, parenthood, and study group were significant predictors of depression and anxiety as measured at the end of the study (p < 0.05). Axillary surgery and hormonal treatment predicted higher ratings of anxiety. Subjects’ positive and negative self-image scores were not different between study groups and did not differ significantly from healthy controls.

Conclusions:

Participation in art therapy was related to lower patient ratings of depression, anxiety, and somatic symptoms. Axillary surgery and hormonal treatment were predictive of higher levels of anxiety and depression.

Limitations:

  • The study had a small sample, with fewer than 100 participants.
  • No attentional control was provided.
  • It is unclear whether art therapy sessions were provided individually or in groups, a factor that could have affected results.
  • There was an overall drop-out rate of 24% from the initial randomized sample.
  • Baseline scores relating to depression and anxiety were actually lower in study patients than those of a healthy comparison group, leading one to question the clinical relevance of study findings overall.
  • Measurement methods used in the study did not include those commonly used in other research.
  • Authors reported minimal demographic informatio, a factor that may limit generalizability.

Nursing Implications:

Findings suggest that art therapy might be helpful in management of symptoms of depression and anxiety in women with breast cancer; however, the clinical relevance of findings is unclear. Further well-designed research is needed to confirm these preliminary findings.


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