Learning Objectives: After participating in this continuing professional development activity, the provider should be better able to:

1. Describe the various types and mechanisms of art therapy used in clinical practice.

2. Interpret evidence for use of art therapy in patients with cancer-related and chronic pain.

3. Explain art therapy resources that can be incorporated into pain management.

A cancer diagnosis can be life-altering and causes debilitating stress and pain for patients.1 High levels of stress can increase inflammation, affecting the progression of cancer and intensifying pain signaling and perceived pain severity.1 Pain, fatigue, and anxiety are common symptoms of cancer patients undergoing standard medical treatment, such as radiation and chemotherapy. Studies suggest that 80% of cancer patients seek out some form of complementary therapy, alongside standard medical treatment, to manage their pain and other symptoms.2 Previous research has been able to successfully provide evidence on the relationship between art therapy and the relief of symptoms for various medical conditions.

Art therapy is one of these complementary approaches that patients with cancer choose to seek, and there is a body of evidence showing that such therapy aids in managing pain and stress from cancer diagnosis and treatment. This article reviews the existing evidence and describes some of these therapeutic approaches.

The creative process involved in making art is thought to be healing and life-enhancing. Art therapy is used as emotional support while the patient is focused on expressing psychological distress and difficult feelings related to a cancer diagnosis and treatment. Art therapy encourages patients to become aware of and express deep emotions about their illness, hospitalization, experience of pain, and cancer treatment(s). Various forms of art therapy include visual art, dance, and music, and creative visual arts such as painting and drawing.3 Art therapy may also be used by patients to increase their self-awareness, cope with symptoms, and better adapt to the stressful experience of a cancer diagnosis. The goal of this article is to review evidence to date on art therapy and its effects on pain experiences in cancer patients undergoing treatment.

Background and Significance

In 2018, there were roughly 436 new cases of cancer reported for every 100,000 people living in the United States.4 The International Association for the Study of Pain in 2020 defined pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."5 Pain is not only physical, but also psychological, emotional, and spiritual.6 In some cases, physical pain can be managed using opioids and analgesics.7 There are different kinds of pain-breakthrough, emotional, psychological, and spiritual pain-and they are treated in different ways. According to the Centers for Disease Control and Prevention,8 pain is a symptom of cancer and a side effect of many treatments, surgeries, procedures, and tests performed throughout a patient's treatment and recovery.9 Daily living activities can be affected by the frequent or constant pain often experienced by patients undergoing treatments.10 Due to this, scientists and medical professionals are leaning more toward complementary care when treating conditions such as cancer.3

Art therapy is a complementary treatment option, which takes a holistic approach that allows for the expression of emotional, psychological, and spiritual pain.11 Art therapy is thought to allow for a positive expression of emotion and relaxation through the types of self-expression mentioned previously.1 At the same time, art therapy provides an outlet that is thought to redirect the patient's focus away from physical pain.11 Recently, patient care has moved toward a more holistic approach that includes treating not only the physical conditions, but also those of the soul, mind, and spirit.11

It is important to understand how emotional, psychological, and spiritual distress can manifest as pain that is unable to be treated using pharmacologic methods. Research is needed to determine the effectiveness of art therapy in reducing psychological distress related to cancer and its treatment, and alleviating pain and its impact on quality of life. With more knowledge, there is hope for patients to receive more effective and efficient pain management while going through treatment.9 When a patient's pain is managed, the patient is less likely to end up in the hospital with extreme episodes of pain.

Review of the Literature

Several studies have examined art therapy as a complementary modality for pain management related to procedural, general, or cancer-related pain.

A retrospective chart review was conducted to investigate the efficacy of art therapy sessions on pain and psychosocial issues during acute hospitalization.12 Patients in the study were seen by a registered art therapist and asked to rate their perception of mood, anxiety, and pain before and after each session. The study enrolled 195 participants (85.1% female), with at least one art therapy session performed at the patients' bedside.

Art therapy sessions were conducted with an average time frame of 50 minutes. The Rogers Happy/Sad Face Scale was used to measure mood, anxiety, and pain, ranging from a score of 0 (no symptoms) to a score of 4 (worst possible symptoms). The type of art therapy used in the study included acrylic painting on objects, canvas, or paper, and watercolor painting on paper. Beadwork, wood-making, and other craft work were also used.

Data were analyzed using t tests, binomial tests, and [chi]² tests. The results of the study showed that there were significant reductions in pain, mood, and anxiety levels from the start of the art therapy session to the end of it, with a P value < 0.001. Regarding the pain assessment of the study, results showed a significant association with change in pain scores as seen by a greater decrease in pain after art therapy sessions. The results were able to support the study's hypothesis that art therapy sessions performed at the bedside could improve mood, reduce anxiety, and decrease pain.12 A major limitation of the study, however, was the limited time frame used to evaluate the impact of the art therapy on pain and other symptoms.

Other studies have focused on music as a form of art therapy alongside traditional art, such as painting. This was seen in a study examining the effects of music therapy and painting therapy on pain severity, perceived stress, and happiness in adolescents with leukemia.13 The study was conducted because pain is one of the most worrying symptoms of patients with cancer and their families, because pain can cause severe emotional distress.

The study included a convenience sample of 30 participants between the ages of 5 and 12 years who were diagnosed with leukemia undergoing cancer treatment. Participants were randomized into 3 groups: 10 participated in music therapy sessions, 10 participated in painting therapy sessions, and the remaining 10 did not participate in any of the sessions until the study was completed. The study used the Wang-Baker Faces Pain Rating Scale for pain assessment. The Owens Children's Sleep Habit Questionnaire and Quay and Peterson's revised Behavior Problem Checklist were also used in pretest and posttest stages.

Results of the study showed, that after music and painting therapy sessions, pain severity had decreased (P = 0.005 and P = 0.006, respectively). The researchers found a significant difference in pain severity between the pretest and the posttest in both music and painting therapy experimental groups. The authors noted that music therapy was able to reduce pain severity to a greater extent than painting therapy.

Furthermore, sleep quality improved and behavioral disorders decreased post-intervention to a greater extent in the music therapy group compared with the painting therapy group, whereas there were minimal changes in the control group.

The results supported the study hypothesis that either music therapy or painting therapy would reduce pain severity more than if neither of these therapies were employed.

Although this study provides some evidence on the beneficial effects of music or painting therapy, the findings are limited by the lack of description about the music and painting interventions, dosage of the interventions, and mechanisms through which the interventions reduce pain severity. In addition, the short-term outcomes were evaluated, but there is little information on whether there are longer-term benefits of using music or painting therapy to increase self-efficacy in pain and symptom management or the impact on quality of life.13

Multiple studies have assessed the effectiveness of art therapy as a complementary form of treatment in patients undergoing cancer treatments. A quasi-experimental study by Nainis et al2 that demonstrated the effectiveness of art therapy enrolled 50 participants from 19 to 82 years of age. The participants had diverse backgrounds, were diagnosed with leukemia or lymphoma, and were at an inpatient hospital.

The purpose of this study was to explore the effects of art therapy on patients undergoing cancer treatment. The study was conducted in each patient's hospital room over a 1-hour period. The patients were given pretest and posttest evaluations. Each patient was able to choose the form of art they would be participating in-or directing if unable to participate.

The instruments used for the study were the Edmonton Symptom Assessment System (ESAS) and the state portion of the State-Trait Anxiety Inventory (STAI-S) to measure physical and emotional symptoms of cancer. Upon completion of the study, the parti-cipants were asked 3 open-ended questions about their willingness to try art therapy again, their overall well-being after completing art therapy, and if they were comfortable making art.

Based on this information, the researchers found that 8 of the 9 symptoms assessed in the ESAS were significant decreased after the art therapy. Specifically, the results showed that the mean pain severity score decreased from a 1.8 to a 1.2; tiredness decreased from a 4.3 to a 3.9; depression decreased from a 2.2 to a 1.6; and breathlessness decreased from a 2.5 to a 1.9. Along with that, the overall mean of the ESAS scores for distress were reduced from 24 to 11 after the art therapy.

The STAI-S showed significant changes with an increased feeling of security, ease, rest, comfort, self-consciousness, relaxation, content, joy, and pleasure and a decreased feeling of tension, upset, misfortune, anxiety, nervousness, jittery, and high-strung emotion.

When participants were asked if they would use art therapy in the future, 96% said they would. In addition, 90% of participants felt that art therapy helped to distract them in a positive way, 36% said they were relaxed and calm during the experience, and 96% of participants felt that they were comfortable and enjoyed making art.2 The results were able to support the study's hypothesis that art therapy helps to improve the quality of life and patient experiences when undergoing cancer treatments.

A qualitative study by Reilly et al14 explored the experience of performing art therapy among patients with cancer. This exploration was carried out among patients with breast cancer in a tertiary care center. Using a qualitative method combined with a cross-case comparative approach, the authors enrolled 10 women diagnosed with various stages of breast cancer, treatment, and different backgrounds. The women were between the ages of 41 and 67 years. The women were chosen to participate in the study through convenience sampling from those completing treatments at the breast cancer clinic.

The women were asked to participate in a 9-week open studio art therapy study that lasted for 2 hours every week. Data were collected using a semi-structured and open-ended question-based interview that occurred after the completion of the 9-week art therapy course.

The findings for this study were broken down into different themes. The first theme identified was existential growth, which was based on responses in which participants found that art therapy helped provide more control, authenticity, community, and purpose.

Another theme that emerged during art therapy was that of posttraumatic growth. The participants described this growth as feeling empowered to face challenges in the future, developing a greater level of empathy, allowing for new experiences, having greater appreciation of life, and connecting or reconnecting with their inner self. Using art therapy, the women involved in the study were not only distracted from the cancer diagnosis at hand, but also expressed and explored their feelings, allowing for positive emotional growth.14

Bozcuk and colleagues15 conducted a comparative study to test the effects of a painting art therapy program (PATP) on anxiety, depression, and quality of life in patients undergoing chemotherapy. The authors reported a significant improvement in global quality of life (F = 7.87, P = 0.001) and depression scores (F = 7.80, P = 0.001) in the PATP group compared with the control group.

In another interesting study conducted by Ho and colleagues16 to understand the experience of breast cancer patients, pre and postintervention drawings on the theme of "my cancer" were collected from 67 patients with breast cancer. Two creative art therapists engaged participants in drawings inspired by the theme of cancer and compared the art using the body, mind, and spirit element. The researchers counted and compared numbers of pre- and postintervention drawings and the presence of each element in these 3 dimensions.

Upon comparing the drawings, the researchers identified many changes between pre- and postintervention drawings. Use of color, space, and multiplicity increased from 12% to 17%. Images of negative emotions were greatly reduced from 52% to 3%. Images of positive emotions increased from 28% to 93% in post-drawings, and images of breasts decreased as well. Investigators reported these changes as a representation of moving toward a more peaceful and hopeful attitude.16

Mechanisms Underlying Art Therapy

Art therapy is a mind-body interaction, based on the changes that have been identified in areas involving brain functions associated with image formation and physiology of emotion.17 Researchers are attempting to understand the details of the mechanisms underlying art therapy's effectiveness in patients. They are studying mechanisms such as brain wave changes and changes in hormones and neurotransmitters.17,18 There are studies to show the relationship between the processes of art expressions and brain functions and its connections to emotional states, the formation of memories, and the processing of somatosensory, motor, and visual information.18

Some studies have shown electroencephalogram (EEG) changes, such as increase in gamma power of the right medial parietal lobe during drawing, along with decreased right medial frontal gamma power and elevated theta power while clay sculpting.19 Art therapy also offers the capability of addressing the basic sensory building blocks in the processing of information and emotions, and some of the processing is guided by cognition.20 As knowledge advances in understanding the mechanisms by which structures and functions of the brain integrate art therapy, there may be more precise and sophisticated methods of using art therapy for symptom management.

Discussion

Summary of Data

To summarize, studies have demonstrated art therapy to be beneficial in helping patients, and there are some mechanisms that might potentially explain how art therapy is effective to manage pain and associated symptoms in cancer.

The selected studies discussed here have many similarities and differences that make their respective research unique. Three studies2,12,13 reported a decrease in pain levels during and after the use of various forms of art therapy. Art therapy in its various forms has been shown to help patients as a form of distraction. Three studies2,13,14 report the use of art therapy as a positive distraction of thought and noted that use of art therapy brought changes in mood and feelings. Two studies12,14 showed improvement in pain levels, but also in mood and levels of anxiety after the completion of art therapy.

Some studies even reflected on increases in quality of life, purpose, and community. Unlike the other studies that were reviewed, one study reported that patients experienced an improvement in their overall quality of life after engaging in art therapy.2 Another study demonstrated that art therapy was viewed as a tool for positive emotional growth that allowed participants to grow in community, empathy, connection with their inner self, and appreciation of life.14

Some weaknesses across the studies were observed, in that most of the study designs were pre- and posttests, with overall lack of diversity in the sample populations in terms of sex, race, and ethnicity. The studies reviewed were also relatively small, ranging from 10 to 195 participants, with most of the studies having fewer than 60 participants. However, a strength of these studies is that they were done within populations that vary in age and diagnosis.

Limitations and Recommendations for Future Research

The present review acknowledges multiple limitations with existing published studies and provides recommendations for improvement.

Pain severity level was the primary focus of most of the studies reviewed in this article, although it is important to recognize that pain is multidimensional. Because pain is an emotional and physical experience, it is important to measure the multiple components of pain rather than to focus on the single dimension of physical bodily pain. Cancer pain, specifically, is a multidimensional experience, with patients reporting emotional, social, and spiritual components.7 Art therapy can be seen as a holistic approach that, alongside a physical pain experience, influences the nonphysical dimensions of pain, which makes it important to incorporate in future studies.

Second, an individual patient's reporting pain is entirely subjective and can introduce bias in a research study.12 Some participants may want to report improvements because they feel the need to please the art therapist. Rather than relying solely on self-report scales, future studies could seek multimodal or alternative forms of measuring pain or pain outcomes (such as analgesic use) to reduce the risk of bias. One suggestion for adding an objective pain measure would be to use EEG monitoring of cortical activity. Imaging studies in humans have been able to successfully display the multiple cortical areas that are activated in response to painful stimuli.21 One study was able to successfully demonstrate the cortical activity changes using EEG before and after undergoing art-making and rote motor movement sessions.22 Using neuromonitoring technologies, bias can be greatly minimized in future research studies.

Another limitation of the present research was the wide variety of art therapy forms and differences in the intervention format in timing (duration of the art therapy), individual versus group sessions, and number of sessions. With a wide interpretation of what constitutes art therapy, it can become difficult to identify the form of art therapy that is the most effective. Art therapy can include music, painting, dancing, crafting, and many more activities. Some studies have been able to show that art therapy in the form of music is more effective in reducing pain severity levels than art therapy in the form of painting.13 With the availability of such a wide variety of art forms, a suggestion for future research is to identify the methods of art therapy that are most effective for improving pain and symptom management. With more research specifying which methods and forms of art therapy are more effective for certain patient populations or medical complications, clinicians will be better able to select more appropriate, well-reasoned art therapy interventions.7

Clinical Significance and Collaboration

Research shows that art therapy tends to decrease the pain experiences in patients undergoing cancer treatment. Past studies have demonstrated that pain is more than just a physical experience, but also emotional and spiritual in nature.7 The research studies reviewed on the use of art therapy for cancer pain and other symptoms tended to show improvements to one's pain, quality of life, and well-being, and feelings such as anxiety and depression. With this information, the review findings are clinically relevant due to its potential to improve the pain experiences of patients with cancer using complementary methods such as various forms of art therapy.

Based on the studies selected for and reviewed in this article, it is apparent that the use of art therapy can be an important complementary method for decreasing pain experiences. Physicians and other health care providers should consider including recommendations for the use of art therapy when discussing pain management options with their patients undergoing cancer treatments. Physicians, nurses, and therapists should encourage patients to use various forms of art therapy to find one that is most effective for them. There is further need of collaboration among medical professionals to determine the most effective forms of art therapy and other effects art therapy can have on patients overall.

Clinical Application

The concept of art therapy is not new in oncology. Benefits of art therapy are multifold, whether offered pre-treatment, during treatment, during hospitalization, or after treatment. Several studies have shown the effectiveness of including art therapy to manage not only physical but also psychological problems faced by patients undergoing treatment for cancer.

A recent systematic review concluded that art therapy reduces pain, anxiety, depression, fatigue, and quality of life in women diagnosed with breast cancer.23-25 Several benefits have been reported by patients who engaged in art therapy during chemotherapy, such as helping with relaxation and providing a creative outlet. Some stated that it helped them express their emotions and feel listened to. And some also mentioned that it helped them search for meaning in life.26

Among many therapies, music therapy has been shown to be most effective in alleviating cancer pain. In another systematic review that included 19 trials evaluating 1548 patients, music therapy was found to be more effective for decreasing anxiety, depression, and pain.27

There are many forms of art therapy including music, drawing, painting, knitting, crocheting, poetry, dance/movement therapy, and other expressive arts. More recently, mindfulness-based art therapies are also showing health-related benefits and can be incorporated into any of these art formats. Because art therapy can be initiated at any time and without needing many resources, nurses can provide tips on how to engage in art therapy for their patients. Some tips include:

1. Start with a drawing pad and a simple set of colored pencils or watercolors if the patient is interested in drawing or painting.

2. If the interest is to learn a new form of art such as sculpture or knitting, local resources where such beginner classes are taught can be provided.

3. Encourage patients to look at online resources such as You Tube videos that might teach start-up techniques for the various forms of art.

4. Patients who are interested in poetry can write their poems and share with support groups and others who might also be interested in the art of creative writing.

5. Contact local community park districts, libraries, and arts organizations about donating free supplies and/or coordinating classes that could be offered to patients and families.

6. Some local hospitals might also sponsor art programs and events to engage patients and families during the treatment of cancer.

7. Conducting art events for cancer patients by friends and families and communities can also help the patient feel supported.

Health care professionals can be trained in educating patients with cancer on how to incorporate art therapy in their daily lives. Art therapists can also be included as team members in the health care team along with physicians, psychologists, nurses, mental health counselors, and marriage and family counselors to bring a multimodal approach to clinical practice. Patient education on the benefits of art therapy might also encourage patients who are hesitant to view art as therapy. Such education can give them the context and perspective to consider it as a nonpharmacologic approach for alleviating psychological distress, which is very common in patients undergoing cancer treatment. Pamphlets can include the potential benefits and resources and can be distributed in person during clinic visits or using social media.

Editor's Note

Reading the intriguing article by Dr. Saravanan and colleagues on the positive effects of art therapy reminded me of a program that I participated in many years ago.

At the time, I was a junior anesthesiologist at the Albert Einstein College of Medicine in the Bronx, New York. It was a time when hospital stays tended to be much longer than they are now. It was not unusual for a patient undergoing a hysterectomy to be hospitalized, in bed, for 10 to 14 days. Moreover, visiting hours were restricted to perhaps 2 to 3 hours in the evenings. Television was available but expensive. Not surprising, loneliness contributed to pain and depression.

Working with the social services department, a group of us volunteered to form a rolling art display, rather like the library carts that used to take books to patients' rooms. During down times, for example when I was on call and staying in the hospital or if my operating room had finished early, I would volunteer to round on patient rooms with the cart, which was quite cumbersome, as we had collected an assortment of pictures, pastoral scenes, animations, abstracts, and caricatures, among other styles.

Patients would choose the picture that best suited their mood. Within the next day or two, I would return to see whether another scene was preferred and it often was. Perhaps it was the visit and chat about the art, perhaps the involvement in the pictures, but patients really seemed to enjoy the ability to see changing art. Their moods improved.

As unwieldy as that big cart was, I and my fellow volunteers felt it was worth the effort.

-Elizabeth A.M. Frost, MD

Resources

The following are some art therapy resources available that nurses and other health care professionals can provide to patients who might be undergoing unpleasant symptoms such as pain and other psychological symptoms during and after their cancer treatment and survivorship:

1. Founded in 1969, the American Art Therapy Association educates the public about the use of art therapy in health care and is responsible for setting standards. The organization's website has many resources for those interested in learning about art therapy for health (https://arttherapy.org/).

2. Caring Arts is a nonprofit organization that donates art supplies and connects patients to heal using art therapy. There are several patients who have entered their art in the "Oncology on Canvas" contest (https://www.caringarts.com/).

Conclusion

Because the benefits of art therapy are multifold, it is important for nurses and other health care professionals to provide information to patients about the availability of nonpharmacologic interventions such as art therapy. This can be particularly useful for patients with cancer who like a quiet creative outlet. For some patients it can be useful to bring one's experiences into a creative expression and that might be a safe and supportive environment to explore their feelings about the illness. In addition, it can help patients to improve their confidence and manage their stress and anxiety. Art therapy can also distract from pain. All of these effects can help improve physical and psychosocial well-being.

References