Using Art Therapy for the Management of Anxiety in High Distress Cancer Patients

Abstruse

Purpose

While at that place is increasing evidence for the effectiveness of psychosocial support programs for cancer patients, niggling attending has been paid to inventiveness or art as a way of addressing their psychological problems and improving quality of life. This review provides an overview of interventional studies that investigate the effects of art therapy interventions on anxiety, depression, and quality of life in adults with cancer.

Methods

We conducted a literature review with a systematic search. The databases PubMed/MEDLINE, PsycINFO, and EMBASE were searched for articles on fine art therapy among developed (eighteen years and above) cancer patients, published betwixt September 2009 upwardly to September 2019. Search terms were established for each database specifically. A total of 731 publications was assessed for relevance by title and abstract. The remaining 496 articles were examined using three inclusion criteria: interventions were guided past an artist or art therapist, participants were actively involved in the creative process, and feet, depression, and/or quality of life were included every bit outcome measures. Methodological quality of the included studies was appraised using specific checklists.

Results

Seven papers met the inclusion criteria. Data was extracted from iii non-randomized intervention studies and four randomized controlled trials. All studies used a quantitative pattern with validated outcome measures. Iv articles described positive effects of art therapy on feet, depression, or quality of life in adults with cancer.

Conclusion

Fine art therapy could mayhap help decrease symptoms of anxiety and depression, and improve quality of life in adult cancer patients. Nonetheless, because of the heterogeneity of the interventions and limited methodological quality of the studies, further inquiry using stringent methods is needed.

Introduction

Groundwork

Receiving the diagnosis cancer may evoke strong emotions of anger and anxiety and tin can be considered traumatic [1]. When the emotional brunt of being seriously ill stretches beyond patients' ability to cope, it may fifty-fifty issue in mental disorders [two]. Indeed, anxiety and low disorders are common amidst cancer patients [iii, 4], as they bear on 10% and xx% of the cancer population respectively, which is two to 3 times higher compared to the general population [5]. Symptoms that are clinically relevant, but do non meet the DSM-criteria for an feet or depressive disorder, such equally indisposition or distractibility, are even more frequent among cancer patients [6, 7]. These symptoms of depression and anxiety touch on quality of life (QoL) adversely [viii, ix].

The relevance of interventions that address psychological symptoms is increasingly recognized [ten], and several supportive care interventions have been shown to exist constructive among cancer patients [11,12,thirteen]. An example of such a supportive intervention is fine art therapy. Several definitions of art therapy are available, which are partly non-overlapping. The British Association of Art Therapists (BAAT) defined fine art therapy as "a grade of psychotherapy that uses fine art media as its primary way of communication" [14]. Similarly, art therapy is seen past Pamela et al. as a form of psychotherapy, good by trained art therapists, aiming at therapeutic goals [xv]. Rather than an arroyo to enhance cocky-expression, others emphasize the artistic process in art therapy that has healing effects and enhances patients' well-being [16, 17].

A forensic psychiatry study showed the benign utilize of art therapy in the treatment of subversive assailment [18]. Haeyen et al. [nineteen] institute improvements in cocky-expression among patients with personality disorders undergoing art therapy. Some other study highlighted the value of art therapy programs on emotion regulation in agile duty military service members with postal service-traumatic stress disorder and traumatic brain injury [twenty].

In oncology, withal, fine art therapy every bit a supportive care intervention is a relatively new and previous literature studies in this field contain some limitations. For example, Geue et al. [xxx] and Wood et al. [31] use a diversity of report designs, making it hard to draw conclusions because of the heterogeneity of the studies included. Furthermore, Ennis et al. [33] focus on the beneficial effects only, thus, not paying attention to potential negative outcomes. Most importantly, all reviews signal that more research is needed in this field and since upcoming literature about art therapy in cancer care is increasing speedily, more reviews may be relevant. Therefore, the present review provides a systematic literature overview of the available effectiveness of this course of therapy in developed cancer patients.

In this review, we will define art therapy as an art intervention, aimed at decreasing symptoms of anxiety, depression, and/or increasing QoL, which is delivered past someone with expertise in arts (an creative person or professional art therapist). This ensures that there is professional guidance in the apply and making of the art, although this does non necessarily involve professional person psychotherapeutic involvement. An art therapy intervention may include all sorts of disciplines, like singing, cartoon, painting, coloring, sculpting, writing, or poetizing. Our aim is to provide an overview of interventional studies that investigate the effects of fine art therapy interventions on anxiety, low, and quality of life in adults with cancer. We focus on the making of art and will leave out passive forms, such as listening to music or looking at paintings.

Methods

Systematic literature review

We conducted a literature review with a systematic search to provide a summary of the evidence on the utilize of art therapy in cancer care.

Search strategy and inclusion criteria

We performed a search in the databases PubMed/MEDLINE, PsycINFO, and EMBASE, considering we deemed these to exist near relevant to our enquiry topic. We searched for publications from September 2009 up to September 2019 and no restrictions regarding publication type were made at this stage. We but included publications that were available in English language. The search contained the following search terms: "fine art therapy" OR "fine art-making" AND "cancer" OR "oncology". Search terms were adapted for each database specifically and can be establish in Supplementary Material. Using this strategy, we obtained a total of 968 articles. Of this entire search, 280 publications were derived from PubMed/MEDLINE: 256 from PsycINFO and 432 from EMBASE. Later, 237 duplicate articles were removed. Two reviewers (HB and ZB) get-go screened the remaining articles past title and excluded clearly irrelevant articles. The remaining 496 publications were assessed by HB and ZB based on their title and abstract, using the following inclusion criteria: Studies including adults above the age of eighteen with cancer who were involved in art making in the presence of an artist or fine art therapist, employing anxiety, low, and/or QoL as outcomes. To increment the validity of our results, we merely included prospective cohort studies with a controlled design.

Disquisitional appraisal

The Critical Appraisal Tools by the Joanna Briggs Institute (JBI) were used to examine the methodological quality of the studies [21]. For the not-randomized intervention studies, we used the JBI Critical Appraisal Checklist for Quasi-Experimental Studies and for the randomized controlled studies nosotros used the JBI Critical Appraisement Checklist for Randomized Controlled Trials.

Information extraction and assay

The post-obit data was extracted from each written report newspaper: authors, year, report design, number of patients, female person to male person ratio, number of patients in the intervention/control grouping, cancer diagnosis, duration and methods of the fine art therapy intervention, blazon of instructor of the art therapy intervention, outcome measures, and principal findings. A descriptive analysis was performed to evaluate the results.

Results

Overview of manufactures

20-vi articles were read in full text of which xix articles were excluded because they did not see the inclusion criteria, for case, they did not focus on fine art making or did not include an artist or fine art therapist. Hence, vii articles were suitable for farther analysis. These included three non-randomized intervention studies and 4 randomized controlled trials. An overview of our selection strategy can be found in Fig. 1.

Fig. ane

Choice strategy

Full size image

The number of participants reported in the manufactures varied between 24 and 183. Vi out of seven papers included more than 50 patients. Three studies focused on female cancer patients but [22,23,24]. In the remaining articles, patents with a variety of cancer diagnoses were included. In full general, more than women than men participated in the art therapy trials. A complete overview of the sociodemographic characteristics was given in all studies, except for Radl et al. [24] who just reported age and race of the participants. Four articles described the diagnosis of the patients and their clinical characteristics [24,25,26,27].

All studies used a quantitative design with validated outcome measures. The Hospital Feet and Depression Scale (HADS) and the EORTC-QLQ C-30 were used most oft as outcome measures. One report added a qualitative questionnaire to explore the satisfaction with the art therapy intervention [26].

Critical appraisal

The not-randomized controlled trials were assessed based on nine questions virtually the methodological quality of the studies (Table ane). In all articles, the examined causes and effects were clear. The measurements were psychometrically robust and were applied both before and after the interventions. However, the patients in the control group were only similar to the patients in the intervention grouping in i study [26]. For instance, in one study, the control grouping consisted of patients who declined participation in the fine art therapy program, which may have acquired option bias [25]. Besides, it was ofttimes unclear whether the command group and the intervention group received similar cancer treatment apart from the art therapy intervention [25, 27].

Table 1 JBI critical appraisal¹

Full size table

The checklist regarding randomized controlled trials consisted of twelve questions. In all studies, true randomization was used; nonetheless, blinding the treatment was cocky-evidently not applicable in any of the studies [22, 23]. Porter and McConnell [28] noted that their outcome assessors were blinded. All 7 articles used appropriate statistical analysis. Total elaboration of the answers to the questions on the checklists can be found in Supplementary Material. No studies were excluded based on their methodological quality.

Clarification of the included manufactures

Bozcuk et al. [25]

Bozcuk and Ozcan [25] included participants from the outpatient chemotherapy unit Akdeniz Academy Medical Faculty in Antalya, Turkey. Patients were classified based on their previous exposure to painting art therapy and were divided into two intervention groups. Patients declining participation served as control group. An fine art therapist with experience in painting fine art therapy worked with everyone individually. First, he provided information about the materials and techniques and and then let the patients make as much watercolor paintings equally they wanted during a chemotherapy date. Afterward, the art therapist encouraged the patients to elaborate on the meaning and subject of their finished work. The number of finished paintings was registered as a representation of motivation.

De Feudis et al. [26]

De Feudis and Graziano [26] provided fine art therapy sessions of ninety min in the Medical Oncology Out-Patient unit of San Paolo, serving a population of adult cancer patients from Puglia, Italy. Each patient participated in i group session. The control group was on a waiting list to receive art therapy and meanwhile received usual care. A psychotherapist skilled in fine art therapy guided the sessions, assisted by a psycho-oncology team. The intervention took place in a room equipped with a large amount of art materials and groundwork music. Groups consisted of a maximum of 8 people, varying in age, gender, and diagnosis. The therapy focused on 3 principles: production of spontaneous artwork, provocation of self-reflection, and sharing experiences with group members. After, all patients were offered the opportunity of boosted psychosocial back up.

Geue et al. [27]

The hemato-oncological patients in the study of Geue and Richter [27] were recruited from the Leipzig University Hospital, Frg. Hemato-oncological patients who lived too far away to participate formed the control group. Twenty-two weekly sessions of ninety min were held under the supervision of an art therapist. The groups included patients of different gender and historic period. The intervention consisted of iii phases: becoming familiar with drawing, assisted by an artist, watercolor painting by oneself, and creating an individual volume to express feelings. All decisions regarding the content or design of the book were made by patients themselves.

Jalambadani et al. [22]

Jalambadani and Borji [22] investigated Neyshabur women with breast cancer visiting the Razavi Hospital of Mashhad Urban center, Iran. They conducted twelve weekly mindfulness-based art therapy (MBAT) sessions, lasting on average 90 min. The control group was on a waiting list to receive art therapy and was provided with usual cancer care. The MBAT-plan focused on the procedure first used in Monti and Peterson [29], involving an introduction to art-making, self-picture assessment tasks, exploration of fine art materials and listen-body human relationship, artistic problem-solving, meditation, costless art-making, and group discussions. The interventions were guided by an artist with psycho-oncological training.

Jang et al. [23]

Jang and Kang [23] examined the effects of mindfulness-based art therapy (MBAT) in women with breast cancer, who had received surgery and radiation therapy at Wonkwang Academy Hospital, South-Korea. The patients in the MBAT-group were provided with twelve weekly sessions lasting 45 min each. The qualified art therapist encourages the patients to express their inner feelings. Both the intervention group and the control group continued to have standard postal service-treatment intendance.

Porter et al. [28]

Porter, McConnell [28] adult music therapy sessions for hospice patients in Northern Republic of ireland with an Eastern Cooperative Oncology Group (ECOG) performance of 2 or lower. The intervention group received a total of six 45-min individual music therapy sessions, twice a week. The control group underwent usual cancer intendance. A trained and registered music therapist provided the program using an interactive arroyo. Patients could participate by singing or listening to known music, simply they also got the opportunity to create something of their own, due east.one thousand., a tune, song, rhythm, or instrumental slice. The music therapist supported the patients in the creative procedure.

Radl et al. [24]

Self-Book fine art therapy was offered by Radl and Vita [24] to female cancer patients undergoing active oncological treatment in a major hospital in Philadelphia, USA. Both the intervention grouping and the control group had access to all bachelor complementary (psychological) therapies, but only the intervention grouping created a Self-Book. The participants worked with an art therapist individually in six sessions ("agreements") of nigh 50 min. The purpose of the art therapy was to create a cocky-reflective book to express 1's feelings and experiences. During the first five sessions, the patients were instructed to make full the pages of their book with creative artwork related to a given subject (safe place, supports, strength and virtues, wishes for loved ones, wishes for oneself). In the final session, the patients were encouraged to decorate the comprehend of the book.

Findings: event on result measures

Anxiety

Out of the iv studies measuring anxiety, ii establish a significant improvement. De Feudis and Graziano [26] reported a meaning reduction in anxiety scores in the intervention group, with the score decreasing from 44.3 to 37.1 (p = 0.002), while the anxiety scores in the control grouping did not significantly alter. However, the study did non observe a significant divergence in anxiety scores between the two groups. In the study of Jang and Kang [23], anxiety scores were significantly improved compared to the control group (p < 0.001). Geue and Richter [27] did not notice any significant differences, neither within the invention group nor between the intervention grouping and control group. Bozcuk and Ozcan [25] compared feet scores among two intervention groups and i control group and found that feet scores did not differ significantly between the grouping.

Depression

Three of the seven studies compared low scores between intervention and control groups. Jang and Kang [23] and Bozcuk and Ozcan [25] institute the depression scores in the intervention grouping to significantly improved compared to the control group (p < 0.001 and p = 0.001 respectively). Geue and Richter [27] constitute neither significant improvement in low scores within the groups nor between the groups.

Quality of life

Six studies reported on QoL or QoL related scales, such as well-beingness, of which four institute an improvement in these upshot variables. Bozcuk and Ozcan [25] reported a significant difference in QoL between the intervention groups and the control grouping (p = 0.001). In addition, every bit expected through the regression to the mean principle, patients with lower QoL appeared to take the greatest advantage from painting art therapy program. All participants declared they enjoyed taking part in painting art therapy program. The intervention was likewise establish to be feasible during chemotherapy sessions. Jang and Kang [23] as well reported comeback in quality of life, with the global health status/QoL score increasing from 26.4 to 81.3 (p < 0.001). Pregnant beneficial effects on functional scales, concrete symptoms, and financial difficulties were also noted. None of these changes were found in the control group. Additionally, Jalambadani and Borji [22] showed statistically significant decreases in symptoms of distress in the intervention group compared to the waiting list command grouping. The scores of physical health, psychological symptoms, social relationships, and environmental factors were improved significantly, every bit well as quality of life behavior. Lastly, De Feudis and Graziano [26] reported that 89.3% of the participating patients considered the art therapy program beneficial to their well-being.

Radl and Vita [24] documented no statistically pregnant differences between the Cocky-Volume therapy intervention group and the command group for the principal consequence (emotional distress) or the secondary result (psychological well-existence). However, they did find significant improvement in the spiritual well-existence of the patients taking office in the Cocky-Book art therapy program. Also in the study of Porter and McConnell [28] changes in McGill Quality of Life questionnaire (MQoL) scores, as well as in physical symptoms and psychological and existential well-beingness, from baseline to the kickoff assessment (week i) were not statistically dissimilar between the intervention grouping and the control group [28].

Summary results

In conclusion, of the seven studies, four identified significant results regarding anxiety, depression, or QoL [22, 23, 25, 26]. Of the four studies that studied anxiety, half plant significant improvements in feet scores, the other half did not [23, 26]. Regarding depression, two studies found significant improvement in depression scores and 1 did not [23, 25]. Four out of six studies regarding QoL showed pregnant improvement in QoL afterward the fine art therapy intervention [22, 23, 25]. Hence, three studies did not identify whatever significant results regarding anxiety, depression, or QoL [24, 27, 28]. Nevertheless, all participants considered the feel valuable to their well-being, what came upwards anecdotally besides equally through questionnaires afterwards completion of the intervention. An overview of the results of all studies tin be found in Table 2.

Table ii Written report results

Full size table

Discussion

Main findings

In this systematic review, we plant some positive effects of art making on anxiety, depression, and QoL in adults with cancer. Four out of seven included studies described these benign effects. All studies reported that participants considered the experience valuable to their well-being.

Interpretations

These results partially support the findings of previous non-controlled studies on the effectiveness of art therapy on psychological outcomes in cancer care [thirty,31,32,33]. This is somewhat encouraging, because novel, bear witness-based interventions to meliorate psychological outcomes for cancer patients are urgently needed, particularly in view of the increased life expectancy of this patient population [34], which prolongs the period of being ill. Whereas QoL is considered of main importance by cancer patients [35], psychological needs are still unrecognized and undertreated [36].

In our review, we only considered interventions involving active art making by the patients. Conspicuously, many other forms of art therapy interventions for cancer patients be, from purely passive appreciation of art to more interactive forms such as co-creation, in which an artist creates art while making apply of the patient's narrative [37]. Active creative work is likely to differ in its mental touch from passive art consumption and is therefore best investigated separately.

Strengths and limitations

Strengths

For this review, nosotros did not only search the usually used database PubMed/MEDLINE just also EMBASE and PsycINFO, providing an overview of the literature that is equally consummate as possible. Next, we used a stringent definition of art therapy, focusing on fine art making in the presence of an artist or fine art therapist but. In this way, the studies were highly comparable. We excluded all studies that did not use a command grouping, which increased the validity of our results. Finally, the included studies were from countries across the world, enhancing the generalizability of the results.

Limitations

Despite the strengths of this review, our findings need to be interpreted with caution. The included articles showed several methodological shortcomings. First, three out of seven studies were not randomized, which may have led to selection bias [25,26,27]. Randomization of the participants was only attempted in the RCTs, considering others were afraid that randomization might subtract the willingness of patients to participate. Second, it is not entirely certain that all the effects found in the non-RCTs are due to the art therapy interventions, because the included studies did not address controlling for confounders. For example, it was frequently non clear what the cancer characteristics, such as metastasized or non- metastasized, of the patients were. Tertiary, there was a remarkable imbalance in participation between men and women, every bit 3 out of seven studies did not include male patients at all. Tavani already addresses the low number of male art therapists [38], merely just few studies accept elaborated why men are less likely to participate in art-making programs. This should be investigated further in guild to make art therapy suitable for a full general population. Finally, the widely varying cultural settings of the included studies are likely to have contributed to the heterogeneity of the studies.

Clinical implications and future research

Our findings are supportive for further development of fine art-making approaches in cancer intendance. To improve the clinical evaluation of these approaches, the methodological shortcomings, east.yard., the lack of randomization, demand to be addressed. Outcomes of this review suggest that more randomized controlled trials with larger sample sizes are needed to establish the evidence of art therapy's effectiveness for adults with cancer. We besides recommend developing a protocol to standardize fine art therapy interventions that are as well feasible for clinical exercise and for continuation at abode.

Conclusion

In conclusion, fine art therapy involving a professional person fine art therapist or artist and agile art-making of the patients can possibly have a positive event on anxiety, depression, and QoL in adults with cancer. Yet, further enquiry with stringent definitions of fine art therapy equally an intervention and advisable randomized designs are urgently needed.

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Acknowledgements

This study is office of a larger written report on an fine art intervention for cancer patients. In search of stories, which is funded by the Dutch Cancer Order, grant number 11507.

Availability of data and materials

Not applicable.

Code availability

Not applicative.

Funding

This study was funded past The Young Academy, Royal Dutch Academy of Sciences, and the Dutch Cancer Club (grant number 11507).

Writer information

Author notes

1. J. T. Bosman and Z. M. Bood contributed equally to this work.

Affiliations

1. Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9; D3-312, 1105 AZ, Amsterdam, Kingdom of the netherlands

   J. T. Bosman, Z. M. Bood & H. West. M. van Laarhoven

2. Kinesthesia of Philosophy, Theology and Religious Studies, Radboud University–Nijmegen, Nijmegen, Kingdom of the netherlands

   M. Scherer-Rath

3. University of the Fine art Utrecht, Utrecht, Kingdom of the netherlands

   H. Dörr & N. Christophe

4. Department of Medical Psychology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The netherlands

   M. A. G. Sprangers

Contributions

JTB, ZMB, and HWML designed the study. JTB and ZMB collected and analyzed the data. JTB, ZMB, and HWML wrote the manuscript and all authors participated in manuscript review. All authors approved the final manuscript.

Corresponding authors

Correspondence to Z. M. Bood or H. W. One thousand. van Laarhoven.

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Bosman, J.T., Bood, Z.M., Scherer-Rath, M. et al. The effects of art therapy on anxiety, low, and quality of life in adults with cancer: a systematic literature review. Back up Intendance Cancer 29, 2289–2298 (2021). https://doi.org/10.1007/s00520-020-05869-0

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• Received: 28 July 2020

• Accepted: 29 October 2020

• Published: 13 November 2020

• Effect Date: May 2021

• DOI : https://doi.org/10.1007/s00520-020-05869-0

Keywords

• Cancer
• Oncology
• Patients
• Quality of life
• Art therapy

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Source: https://link.springer.com/article/10.1007/s00520-020-05869-0

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