Art Making/Art Therapy

To determine the effect of drawing and writing technique on the anxiety level of children treated for cancer during hospitalization.

A five-day therapeutic program to reduce anxiety of children in treatment for cancer was implemented to understand the effect of continuous therapeutic play. Drawing, writing, and mutual storytelling techniques were pre-arranged in the child’s room. Drawing supplies were given to the children. The State Anxiety Inventory was administered on the first day. Drawing was implemented on the first and third days. Children were asked to draw a picture of a child in the hospital and to write a self-created story with a beginning, a middle, and an end about his or her drawing. Mutual storytelling was implemented on the second and fourth days. While listening to the story of the child, the researcher analyzes the themes and psychological meaning for the child. The researcher responds with a story that is similar but has a more positive ending. On the fifth day, the State Anxiety Inventory is administered for the second time.

• N = 30   
• AGE: Mean = 12.56 years (range = 9-16)
• MALES: 7 (23%)  
• FEMALES: 23 (77%)
• CURRENT TREATMENT: Chemotherapy, combination radiation therapy and chemotherapy
• KEY DISEASE CHARACTERISTICS: Leukemia, solid tumor, lymphoma
• OTHER KEY SAMPLE CHARACTERISTICS: Had received two or more courses of chemotherapy; child and parent consent to participation

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Gazi University, Ankara, Turkey

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Pediatrics

Quasi-experimental (pre- and postintervention evaluations of a single group)

• Descriptive data collection
• State Anxiety Inventory
• Wilcoxon test

The five-day program was evaluated on the first and fifth day. The State Anxiety Inventory mean score (38.63 [SD = 4.38]) for children after the intervention decreased when compared to the mean beginning score (42.63 [SD = 4.64])  (Z = -4.57, p < 0.05). Only 2 of the 30 children wanted to keep the drawings after the intervention.

Drawing and writing and mutual storytelling techniques can be used to reduce the anxiety levels of children in treatment for cancer. The five-day program time interval and intervention could be implemented in future research.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results
• Other limitations/explanation: No information was provided on who implemented the writing and drawing program, although there is a mention of nursing staff or the "researcher" doing this but it was not made clear who this was and what training he or she had.

Writing and drawing can enable children to express their emotions and fears in an artistic format. Nurses should use these techniques to help uncover the hospitalized child’s anxiety. Training for interpretation and projective techniques in therapeutic communication with children would be helpful in hospital settings.

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.

• 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.

A single-arm, pilot study design was used.

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

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).

• 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.

To test the effect of painting art therapy, provided by a dedicated professional artist, on quality of life and anxiety and depression levels in patients receiving chemotherapy

Patients receiving treatment at an outpatient chemotherapy unit were recruited into the study for 12 weeks. Patients were classified by their exposure to the Painting Art Therapy Program (PATP). One group had prior exposure the the second did not. The third group were patients who declined participation and they were considered the control group. The study investigator who is an experienced art therapist conducted the therapy. Patients participated in watercolor painting and a discussion about the symbolic nature of the paintings, feelings, and thoughts. The investigator artist provided introduction to watercolor. During the chemotherapy infusion, the patient made watercolor paintings. After completions of the painting, patients discussed the meaning and subject of their painting. Patients in the intervention group were also given painting materials for home practice.

• N = 97 (65 in the PATP group and 32 in the control group)    
• AGE: Mean = 50.6 years (range = 22-73)
• MALES: 35%  
• FEMALES: 56%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: 54% metastatic cancer
• OTHER KEY SAMPLE CHARACTERISTICS: In the intervention group, 26 had prior exposure to PATP and 22 did not. The authors did not define what "prior expose" included.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Antalya, Turkey

PHASE OF CARE: Active anti-tumor treatment

Comparative prospective study

• EORTC-QLQ-C30 questionnaire
• Anxiety and depression scores (HADS)
• Analysis of variance (ANOVA) with Bonferroni correction
• Number of paintings finished by a patient (proxy motivation indicator)

All patients reported liking the PATP to some extent. Change in global quality of life and depression scores differed significantly among the three groups (F = 7.87, p = 0.001; and F = 7.8, p = 0.001).  Correlates of change in depression were participation in PATP (F = 7.75, p < 0.001) and baseline depression scores (F = 17.71, p < 0.001). Predictors of the magnitude of change and change in depression were participation in PATP. Patients who had poorer well being showed better improvements by participating in PATP.  Previous exposure to PATP appeared to diminish the benefit obtained by PATP.

The authors showed improved quality of life and relief from depression in patients with the utilization of PATP. They authors demonstrated that watercolor can be an important form of art therapy in maintaining quality of life in patients with cancer. The application is feasible in the outpatient clinic. Patients demonstrated benefit of PATP in close relationship with basal global quality of life and depression scores. Because art is subjective, other forms of art therapy may target different patients more specifically.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results

Art therapy can be an important and feasible intervention for patients on active treatment. Participation in art therapy while receiving chemotherapy treatment can improve quality of life and contribute to decreased depression.

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

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.

• 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.

• Single site
• Inpatient setting
• Kansas

Patients were undergoing active antitumor treatment.

 A crossover pre/post-test design was used.

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

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.

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

• 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.

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.

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

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

A quasi-experimental design was used.

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

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

• 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.

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

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.

• 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.

• Single site
• Outpatient setting
• Sweden

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

Randomized controlled trial with longitudinal analysis

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

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.

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.

• 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.

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.