The efficacy of art therapy to enhance emotional expression, spirituality, and psychological well-being of newly diagnos...


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The efficacy of art therapy to enhance emotional expression, spirituality, and psychological well-being of newly diagnosed stage I and stage II breast cancer patients
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xi, 183 leaves : ill. ; 29 cm.
Puig, Ana
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Counselor Education thesis, Ph. D   ( lcsh )
Dissertations, Academic -- Counselor Education -- UF   ( lcsh )
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )


Thesis (Ph. D.)--University of Florida, 2004.
Includes bibliographical references.
Statement of Responsibility:
by Ana Puig.
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University of Florida
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aleph - 003163574
oclc - 726711491
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Full Text





"Hope i.

s the

thing with


in the


And sings the tune
Without the words



at all. '"


This dissertation is dedicated to my mother,
Miltho Lady Figueroa de Puig, a clinician in her own right
and the woman who planted the seed of this calling in my heart
whence it now blossoms,


To the memory of my father, Hector Enrique Puig Alfonzo, the man
who always introduced me as his daughter "the doctor."
have finally earned the title you bestowed upon me so many years ag
)w your spirit smiles and lays blessings upon me from wherever you
I miss you, Papi


And to my beautiful, steadfast, and faithful partner,
Rebecca Anne Fields. I have achieved this goal, in no small way,
because of your support and encouragement. For having you in my life,
I am the luckiest woman I know.


The doctoral studies journey is filled with seemingly endless challenges,

opportunities, and possibilities. As I near the end of this academic exercise, I am acutely

aware of the intricate web of human beings that have blessed me with their support,

encouragement, commitment, and dedication. Their contributions have been invaluable.

First, I want to express my gratitude to the women who volunteered for this study.

In the face of overwhelming and frightening challenges they chose to explore the

uncharted territory of their psyche and open their minds and hearts to my research

partner, Dr. Lyn Goodwin, and to me. Each exemplifies a courageous and giving spirit,

joining this research not only to empower themselves but also to make a contribution to

the lives of others who might benefit from its outcomes. They have my profound

admiration and respect.

Without them, this study would have never come to fruition.

I am also grateful to the breast cancer survivors I met through the American

Cancer Society's (ACS) support network, especially Martha Psarras and Nancy

Mackintosh, who provided useful input and encouragement. Margaret Shaw and Jackie

Krill of the ACS's

Winn-Dixie Hope Lodge showed commitment and appreciation for

this endeavor and were instrumental in helping advertise the study. Local oncology

practices of Dr. Robert Carroll, Dr. Barbara Shea, and Dr. Earl Pickens were key referral

sources. I am especially indebted to Debbie Crom, Barbara Hitchingham, Ms Dorothy

supporting my process. These individuals are the anchors that newly diagnosed patients

rely on and, undoubtedly, beacons in their healing journeys.

Elspeth Keller and Mary Ann Burg from the Women's Health Research Center

provided steadfast support and information as I navigated the Gainesville healthcare

community. They initiated the SUNNA Center for Women to offer free, complementary,

and supportive therapies to cancer patients; their efforts are commendable.


Edmons of the ACORN Clinic and Julia Howell of the Shands Anesthesia Preoperative

Clinic also provided referrals and suggestions. Because of the support and expertise of

these individuals, I was able to reach the community of breast cancer patients that were

the focus of this research study.

I have been blessed with the most supportive, open, encouraging, and flexible

dissertation committee any student could hope for. Dr. Peter A. D. Sherrard provided

invaluable guidance, insights, challenges, and all-around stimulating conversations; the

gifts born of his nurturing, wise spirit will always be a part of me. Dr. Ellen Amatea kept

me on my toes through her challenging inquiries and exemplified commitment to the

scholar practitioner model that now informs my work. Her keen mind, curious stance,

and classroom discourse (especially in systemic and postmodern thought) helped inform

my study's theoretical framework. Dr. Mary Fukuyama took me under her wing and

opened up the world of spirituality, health, and multicultural counseling and research.

She spent countless hours supporting a group of graduate students interested in

spirituality and health research. Best of all, she listened, encouraged, supported, and

challenged me ever sten of the wayv I am indebted to her kind. entle snirit for enduring

analyses assistance. She was affirming of my ability to take on this task and offered

useful suggestions throughout the data analysis and evaluation process. She is a superb

teacher, making what can be a complex and obscure subject easier to grasp and, dare I

say, enjoyable!

A few individuals from various disciplines provided much needed assistance,

support, and mentorship. Tricia Sample kindly shared her art therapy skills and resources

as I conceptualized the treatment intervention. Dr. David Miller's timely consultations for

vexing statistical questions coupled with his open-door policy saved me more than once.

His kindness, approachability, and no-nonsense advice were priceless. Dr. James Archer

and Dr. Mirka Koro-Ljungberg became steadfast supporters and cheerleaders; providing

insights so I could see more clearly.

When the wind left my sails and I found myself

drifting, they were always there to say the right words of encouragement so I would set

on the right course once again. They have become friends, and I will always cherish their

presence in my life. Candy Spires and Patty Bruner are the beating heart of the

Department of Counselor Education. They provided tactical and technical help and

selflessly worked to facilitate whatever task I engaged in. I could not have accomplished

this without their ongoing support.

My doctoral studies would mean nothing to me without the love, support,

encouragement and unconditional love of my friends and family. Dr. Lyn Goodwin

provided not only selfless practical research support and assistance; she was an

inspiration to me. I watched her blaze the trail before me and fell to the contagion of her

qnirited Inohter She war myv very nwn eheerleandino n aad and will alwavw he a nriked

Ed husband," provided crucial research support and has become a favorite research

partner. My Jewish community, especially Rabbi Shaya Isenberg, Renee Hoffinger, and

Robin Nuzum were inspiring and supportive spiritual travelers throughout my journey.

Karen Spicer, Lauren Pasquarella Daley, Kitty Fallon, Elaine Casquarelli, Marie

Bracciale, Mikki Sauceda, Kelly Aissen, and my D.G. and poker posse kept me focused,

sane, and centered. I will always love them, not only for who they are but also for making

my life so much fun to be in.

My mother, Miltho Lady Figueroa de Puig, was a source of nourishment when I

needed it most. She and my baby sister, Maria Puig Jordan, provided needed respite

many a Friday night so I could pull away from the intellectual grind and laugh a little.

My brother Hector Gabriel Puig and sister-in-law, Dr.

Yi Zhang Puig, passionate

admirers of creative and artistic endeavors, provided stimulating conversation and

indulged my process as I considered creative art therapy as this study's therapeutic

intervention. My sisters Margarita Puig King and Zaida Puig Montiel checked in to gauge

my progress and were always there for me. My nieces and nephews (Gaby, Tony,

Paloma, Ana Yi, Lucas, and Leia) are bright rays of sunshine in my heart. Finally, I thank

my steadfast, patient, and

loving partner, Rebecca Anne Fields, who stood by me, held

me, supported, and unconditionally loved me, sometimes in spite of myself. I love her

more than words can say, and many have been uttered here. Everything good to come of

this process belongs to her.








a a a a a a S 4 S S S S S S 5 5 4 S 4 5 S S 4 4 5 a S 4 4 4 S *

. .. .4 . .. .

Scope of the Problem .... ..
Theoretical Framework and Ra
Need for the Study .......
Purpose .. .. .... ... ....
Research Questions .....
Definition of Terms .....
Organization of the Study ..



Research on Cancer Patients and Emotional Expression
Research on Cancer Patients and Spirituality .....
Research on Cancer Patients and Psychological Well-be
Research on Creative Art Therapy and Cancer ...
Research on Creative Art therapy and Breast Cancer ..
Conclusion ... ... ... .. ... ...


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. .. . . . . . . . . 25

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4 5 S 4 9 S S S 4 5 5 5 5 S S S 4 5 4 a 9 5 a S S 4 5 S a S S S S a 6

Statement of Purpose

Research Hypotheses . . ..
Description of the Population ..
Data Collection and Attrition ....
Sample and Sampling Procedures
Descriptive Data Analysis .....
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. .. . . . . . . .. 6 5

* a a a S S S S S S S S S S S S S S S S S S S S 4 9 5 4 5 4 S S 4 66
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* a a a a S S S S S 5 a a 4 5 a a a a a S S S S 4 5 4 5 72

4 RESULTS OF THE STUDY .. .. .. . ... ... 92

Summary and Chapter Overview . . . . . . .. . . 92
Results of Hypotheses Tests . . . . . . . . . . 92

Clinical Significance .....
Summary of Findings .... .

. . . . . . . . . . . 10 3
. . . . . . . . . . . 10 6

DISCUSSION ................ . . . ............. . . . .108

Research Sample . . .. . . . . . ... . . 108
Discussion of Results .... . . . . . . . . . . 109
C clinical Significance 123
Limitations of the Study. 123

Implications .....
Qualitative Journal
Conclusion ......

. . . 128

. 139


A EXIT INTERVIEW FORM . . . ... ...... . . .. 141

B RELEASE OF INFORMATION ... p ...... ..... ... .. .... 142

C RESEARCH ANNOUNCEMENT FLYER ............................ 143

D INFORM ED CONSENT .N.. a .. .5.5.5. ..a . f a a a .a. . p a a a p a a 145


F DEMOGRAPHIC QUESTIONNAIRE .................................. 153






L ART THERAPY INTERVENTIONS .. .... .................... 159


. . . . . a. *. a. . a. . a. t. .. . .. 16 3

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy






Ana Puig

December 2004

Chair: Peter A. D. Sherrard
Major Department: Counselor Education

Breast cancer is the most common type of cancer among women in the United

States. The psychological impact of the disease may include

adjustment disorders,

depression, and anxiety and may generate feelings of fear, anger, guilt, and emotional

repression. Emotional repression

Emotional expression

has been linked to women with breast cancer.

has been linked to better psychological adjustment and a higher

quality of life. Existential issues raised by a cancer diagnosis

spirituality to cancer research,

highlight the integration of

which has documented the beneficial role of spirituality in

alleviating existential anxiety evoked by a cancer diagnosis. The

was to determine the efficacy of a

purpose of this study

complementary art therapy intervention to enhance


expression, spirituality, and psychological well-being in newly


Forty-four women with Stage I and Stage II breast cancer agreed

to participate in

this study. Subjects were randomly assigned to an experimental art therapy group or a

control group of delayed


treatment. Forty-one women completed the study in which they

offered individual art therapy sessions once weekly for four weeks. A total of 39

women were included in the final sample.

Multiple analyses of covariance and paired t-tests were used to

results, which indicated that the intervention was

emotional approach coping style of emotional ex

analyze the

not effective in enhancing the

;pression or the level of spirituality of

subjects in

this sample. However, participation in the art therapy

intervention helped

decrease negative emotional states and

enhanced positive ones of experimental group

subjects. These

shifts in feeling states indicate that the women were able to

process and

express feelings during session in productive ways, a finding that is congruent with

anecdotal clinical observations.


Additionally, the creative art therapy intervention

psychological well-being of women in this sample by decreasing

tension-anxiety, depression-dejection, anger-hostility, and confusion-bewilderment;

affective aspects of this construct.

effect changes in the

Finally, as hypothesized, the intervention did not

physiological aspects of psychological well-being: vigor-activity

and fatigue-inertia.




Breast cancer, second only to nonmelanoma skin cancers, is the most common

type of cancer among women in the United States. An estimated 211,000 women will be

diagnosed with the disease in 2003 (National Cancer Institute [NCI], 2003).'A breast

cancer diagnosis can have a profound impact on a woman's life and the lives of her

significant others.

Women struggling with the disease "may worry about caring for their

families, keeping their jobs, or continuing daily activities. Concerns about tests,

treatments, hospital stays, and medical bills are also common" (NCI, 2003).

Researchers have also documented the psychological impact of the disease;

adjustment disorders, depression, and anxiety affect breast cancer patients'

ability to deal

with everyday life stressors, and may generate feelings of fear, anger, guilt, and

emotional repression (Glanz & Lerman, 1992; Razavi & Stiefel, 1999; Tapper, 1999; van

der Pompe, Antoni,

Visser, & Garssen, 1996).

Emotional repression has been linked to

women with breast cancer (Greer & Watson, 1985; Lilja, Smith, Malmstrom, & Salford,

1998; Watson et al.,

1991). Recent research found that recurring major depression

predicted a higher incidence of breast cancer (Penninx et al., 1998). Depression and

hopelessness have also been shown to predict mortality (Spiegel,

A tr^onron ann rKc'tr'otnan in th1 fans, af [kraiact nainnerl 10

2001 a). Spiegel added

Ararnnn It jcnlata, vnn


The psychosocial issues at play in breast cancer patients' lives warrant attention

by medical professionals providing treatment. Ignoring these psychosocial variables may

hinder medical science from achieving its ultimate goals of reducing cancer-related

mortality and improving quality of life and psychological well-being (Glanz & Lerman,


The scientific discipline of psycho-oncology, which began over 40 years ago

(Greer, 1999), focuses on the psychosocial aspects of oncology treatment (Hosaka,

Sugiyama, Tokuda, & Okuyama, 2000), including the study of complementary, mind-

body, and psychological therapies that may help cancer patients adjust to and cope with

the physical, psychological, and emotional effects of cancer and its treatment. The

National Center for Complementary and Alternative Medicine (NCCAM) defines

complementary medicine as "a group of diverse medical and health care systems,

practices, and products that are not presently considered to be part of conventional

medicine. [Adding that] mind-body medicine [a form of complementary medicine] uses a

variety of techniques designed to enhance the mind's capacity to affect bodily function

and symptoms" (National Institute of Health [NIH], 2002).

In addition to the conventional medical treatments for the disease, an estimated

33% to 85% of breast cancer patients reportedly use complementary, mind-body

therapies (Jacobson & Verret, 2001; Maskarinec, Gotay, Tatsumura, Shumay, & Kakai,

2001; Richardson, Post-White, Singletary, & Justice, 1998). Technological and medical

advances in cancer detection and diagnosis, and increasingly intensive treatments, have

1992) and have also helped breast cancer patients become "the largest single category of

cancer survivors" (Jacobson & Verret, 2001, p. 307).

Multiple research studies have explored the benefits of psychological and/or

complementary, mind-body interventions on breast cancer patients'


expression, psychological well-being, quality of life, and adjustment to the disease; these

have included individual therapy (Lev & Owen, 2000; MacCormack et al., 2001),

supportive psycho-educational group therapy (Edmonds, Lockwood, & Cunningham,

1999; Fukui, Kugaya, & Okamura, 2001; Greenstein & Breitbart, 2000; Helgeson,

Cohen, Schulz, & Yasko, 1999, 2001; Montazeri et al., 2000), supportive expressive

group therapy (Giese-Davis et al.,


Goodwin et al.

,2001; Gore-Felton & Spiegel,

1999; Spiegel, Bloom & Yalom, 1981; Spiegel et al., 1999), supportive cognitive-

behavioral group therapy (Antoni et al.,


Bloch & Kissane, 2000; Cunningham et

al., 1998; Edelman, Lemon, Bell, & Kidman, 1999; Kissane et al., 1997; Watson, Fenlon,


& Fernandez-Marcos, 1996), and mixed modalities group therapy, including

psycho-education, stress management, guided imagery and/or hypnosis (Spiegel &

Moore, 1997

Fawzy et al., 1990; Fukui, Kugaya, & Okamura, 2001; Hosaka et al., 2000;

Simpson, Carlson, & Trew, 2001; Richardson et al., 1997

Spiegel & Bloom, 1983;

Spiegel, Bloom, Kraemer, & Gottheil, 1989).

Critical reviews of the effects ofpsychosocial interventions on cancer (Andersen,

1992, 2002; Fawzy, Fawzy, Arndt, & Pasnau, 1995) and breast cancer patients (Glanz &

Lerman, 1992; Tapper, 1999; van der Pompe et al., 1996) have also been done. A small

nt n'vl'.ar flC C /ia~l; a tic'+^ rh *i jn, cvQC nim? n~/linAr- 4tlbo I-oni- t c,=-< nC t1l'a nnrnnvt~l cn~vani~tortr yirit


Cruze, 1998; Predeger, 1996) and we found one mixed (qualitative and quantitative)

study on the subject (Dibbell-Hope, 2000).

Due to the existential issues raised by a cancer diagnosis, the importance of

integrating spirituality in cancer research has been underscored (Kristeller, Zumbrun, &

Schiling, 1999; Mytko & Knight, 1999). A number of studies have focused on the lived

experience of spirituality (Chiu, 2000) and the role of spiritual well-being on quality of

life and psychological adjustment of breast cancer patients (Brady, Peterman, Fitchett,

Mo, & Cella, 1999; Cole & Pargament, 19,99; Cotton, Levine, Fitzpatrick, Dold, & Targ,

1999; Feher & Maly, 1999; Gall, Miguez de Renart, & Boonstra, 2000; Mickley, Soeken,

& Belcher, 1992).

The American Cancer Society [ACS] (2001) has acknowledged the value of a

holistic approach to treatment, including the exploration and inclusion of complementary,

mind-body, and psychological therapies to the conventional treatment regimen, and has

encouraged cancer patients to "learn how a good attitude and healthy spirit may have

positive physical effects.

Attending to and helping to alleviate breast cancer patients'

psychological distress "results in improved medical outcomes, reduced health care costs,

and increased quality of life" (Payne, Hoffman, Theodoulou, Dosik, & Massie, 1999,

p. 65). In addition, effectively treating depression symptoms in cancer patients "results in

better patient adjustment, reduced symptoms, and may influence disease course"

(Spiegel, 1996, p. 114). The purpose of this study was to determine the efficacy of a

complementary, mind-body, creative art therapy intervention to enhance emotional

expression, spiritual connectedness, and psychological well-being in newly diagnosed,

Scope of the Problem

One of every eight women is at risk to receive a breast cancer diagnosis in her

lifetime (ACS, 2001).

Breast cancer is the second most common form of cancer,

"accounting for nearly one of every three cancers diagnosed in American women,

" with

African-Americans more likely to die from the disease than Caucasians (ACS, 2002).

The incidence of breast cancer by race and ethnicity (1996-2000) per 100,000 persons is

140.8 White (92.7 White Hispanic and 148.3 White Non-Hispanic); 121.7 Black; 97

Asian/Pacific Islander; 58 American Indian/Alaska Native; and 89.8 Hispanics of other

races. Mortality rates (1996-2000) per 100,000 persons are

White (18.3 White

Hispanic and 27.4 White Non-Hispanic); 35.9 Black; 12.5 Asian/Pacific Islander; 14.9

American Indian/Alaskan Native; and 17.9 Hispanics of other races (NCI, 2003).

Greer and Morris (1975) reported a statistically significant association between a

breast cancer diagnosis and unhealthy release of emotions (extreme suppression and, less

commonly, extreme expression).

Watson et al. (1991) reported an association between

emotional control and a fatalistic attitude about breast cancer. They also found a

predicted low but significant association between helplessness and the control of anger

and anxiety. Greer and Watson (1985) and Watson et al. (1991) have described a Type C

behavior pattern associated with cancer patients, where suppression of anger is the

predominant characteristic.

Watson et al. reported that research has shown "women with

breast cancer are more likely to control emotions than those with benign breast disease or

healthy controls" (p. 51). The Type C personality is further described as characteristic of

individuals who avoid expression of needs and feelings (i.e., believe it is useless to

fatalistic attitude toward the cancer diagnosis and the tendency to control negative

emotions" (p. 53) (e.g., anger, anxiety, and depression) in Stage I and Stage II breast

cancer patients. Lilja et al. (1998) also found confirming evidence that "inhibition and

denial of aggression, probably associated with inability to set boundaries and lack of self-

expression, was generally seen in this patient group" (p. 302).

Fernandez-Ballesteros, Ruiz, and Garde (1998) confirmed that in addition to

emotional suppression, breast cancer patients are "ready to sacrifice their needs in order

to achieve and maintain harmonious interpersonal relationships"

(p. 41). Emotional

suppression, the tendency to neglect personal needs, and attempts to harmonize

relationships appear to contribute to the psychological distress of breast cancer patients.

However, some researchers have indicated "there is not enough evidence that

psychological factors like 'ways of coping'

or 'non-expression of negative emotions'

play a significant role in breast cancer" (Bleiker & van der Ploeg, 1999, p. 201).

Depression and adjustment disorders are common in this patient population and

effective treatment for these psychiatric disorders has been shown to produce better

psychological adjustment, reduction in unpleasant symptoms, such as pain, and longer

survival time (Spiegel, 1996). However, research results are inconclusive about whether

the Type C personality commonly associated with emotional suppression, preexisting

emotional and/or psychiatric disorders, or psychological adjustment increases a woman's

risk of developing breast cancer or whether a breast cancer diagnosis affects emotional

expression (i.e., leads to suppression of emotions), emotional or psychiatric morbidity

and nsvcholomical adjustment.

elicit a need to address spirituality (Cole & Pargament, 1999; Moadel et al., 1999). The.

spiritual domain is thought to provide "important and unique information, with both

clinical implications and explanatory power [and] this information is lost when the

spiritual domain is overlooked" (Brady et al., 1999, p. 426). Research that explored the

role of spirituality in cancer patients'

experience of adjusting and coping with the

disease, although increasing, remains limited.

Mickley et al. (1992) researched the roles of spiritual well-being, religiousness

and hope on the spiritual health of women with breast cancer. Subjects classified as

intrinsically religious (i.e., those who internalize and follow a religious creed faithfully)

were found to have significantly higher scores on spiritual well-being than did

extrinsically religious ones (i.e., those for whom religion is utilitarian: to provide security

or as a social outlet).

Hope scores were similar for both groups. The authors determined

that "existential well-being, a component of spiritual well-being, was the primary

contributor of hope" in the women (p. 267). The researchers concluded that both groups

"may have been using religiousness in a functional manner, i.e., something to help them

cope" (p. 272).

Smith et al. (1993) explored spiritual awareness, psychosocial distress and

perceptions about death and dying in cancer patients. Research findings indicated a

significant negative correlation between the level of spiritual development (based on a

theoretical model of transpersonal development) and psychosocial distress. The authors

suggested increased development of clinical strategies that facilitate spiritual growth in

patients is needed. Carr and Morris (1996). who studied oncolov social workers, echo


involve active listening and use of self to help patients explore .. questions regarding

life and death" (p. 71).

Moadel et al. (1999) researched spiritual and existential needs among an

ethnically diverse cancer patient population and also underscored the importance of

attending to spiritual beliefs and practices. Their research confirmed previous findings

that as many as 33% (with ranges of 25%-51%) of cancer patients report their spiritual or

existential needs go unmet in the course of treatment. The researchers also reported that

ethnicity, proximity to diagnosis, and whether the subject is in partnership or married, are

all related to the "existential plight in cancer,"

defined as "a concern with life and death

issues characteristic of the first few months after diagnosis" (p. 383).

Cotton et al. (1999) studied the relationships among spiritual well-being, quality

of life, and psychological adjustment in women with breast cancer. The authors stated

that subjects who reported high feelings of spiritual wellness also reported higher quality

of life and better psychological adjustment. Feher and Maly (1999) studied the role of

religious faith for women diagnosed with breast cancer in later life (n

= 33, age 65). The

authors reported that religious/spiritual belief and practice remained the same or

increased post-diagnosis. The women indicated religion fulfilled three functions:

providing emotional support to cope with the cancer (91%), social support (70%), and

meaning-making ability (64%) during the experience of dealing with the disease.

Chiu (2000) explored the lived experience of spirituality in women with breast

cancer. This hermeneutic phenomenological study sought to document themes emergent

in the lived experience of Taiwanese women facing a breast cancer diagnosis and

Eastern versus Western definitions of spirituality, and identified significant existential ,
issues that face women with breast cancer through an Eastern perspective. Four larger

themes emerged: Living Reality (pertains to facing the cancer diagnosis, accepting

responsibility for healing, and appreciating life'

opening up to awareness of life'

gifts); Creating Meaning (pertains to

purpose, finding ways to reframe the cancer experience

and learn from it, embracing spirituality/religion as a way to cope); Connectedness: Self,

Others, God (pertains to sensing personal and transcendental relationships and

connecting with the empowerment resulting from these)

and Transcendence (pertains to

acceptance of suffering as part of life, surrender and liberation resulting from acceptance,

and opening up to life and death as natural paths of the spirit). Chiu underscored the

importance of approaching patients holistically and keeping cultural context at the


The role of religion in long-term adjustment to cancer has also been studied (Gall

et al., 2000). Results indicated that religious coping behaviors and relationship with a
Higher Being (e.g., God) are valuable resources in breast cancer survivors' long-term

adjustment. The authors reported women who held a benevolent image of God reported

lower levels of psychological distress. Additionally, women who experienced God'

presence in their lives and felt a sense of God being in control of the relationship reported

higher levels of optimism.

Cole and Pargament (1999) have developed spiritual, psychotherapeutic

interventions for cancer patients geared toward spiritually oriented individuals.

Preliminarv flndincz nf an nntenmr .tudv ntilimino this intervention annear "nrnmisino"


(G. Aldridge, 1996; Predeger, 1996) and one mixed method study explored psychological

adaptation (Dibbell-Hope, 2000), we found no experimental studies that examined the

efficacy of art therapy interventions on breast cancer patients' spirituality or the role of

spirituality on their psychological well-being and/or adjustment to the disease. This is a

worthy area of inquiry that remains unexplored.

G. Aldridge (1996) contended for women with breast cancer "faced with

expressing overwhelming feelings, challenged with adjusting to a new, radically altered

future, the process of bringing their feelings into conscious form without any immediate

verbal label may be a significant step on the road to recovery"

(p. 220). Mental health

counselors are in a unique position to contribute by assessing breast cancer patients'

ability to express difficult, negative emotions (e.g., anger, depression, and anxiety),

providing creative art therapy interventions that may facilitate healthy emotional

expression, and assisting women to cope with and adjust to the stressors associated with a

breast cancer diagnosis and its treatment. Engagement in creative art therapy

interventions may also help women to access personal spirituality as a way of coping

with the disease (Samuels & Lane, 2000).

Theoretical Framework and Rationale

Holistic Healing: Body, Mind, Emotions, and Spirit

Weil (2002) defined health as a state of "wholeness and balance, an inner

resilience that allows [one] to meet the demands of living without being overwhelmed"

(p. 13). All aspects of self (i.e., body, mind, emotions, and spirit) play a role in the

experience of functional health.

Weil defined the process of healing as "restoring a state

toward wholeness, a recalling of things forgotten, an embracing of things feared, an

i opening of what is closed, a learning to trust life, a transcendence to an experience of the

divine" (p. 31).

This study and our creative art therapy intervention embraced a holistic

approach to breast cancer patients

experience of healing.

Greer (1999) underscored the importance of "delineation, measurement, and

psychophysiology of positive states of mind [that] have been sorely neglected [and

represent] a promising area for future research" (p. 236).

a positive focus on breast cancer patients

This research study maintained

personal strengths. As researchers, we

attempted to help subjects access these strengths through creative art therapy

interventions that may facilitate emotional expression, spirituality and psychological


Thus, guided by a holistic approach to the treatment of breast cancer patients,

the conceptual backdrop to this study was the newly emerging field of positive

psychology, in general, and Csikszentmihalyi's (1990a, 1990b, 1996, 1997) theory of

flow, specifically. Conceptual and research literature on the relationship of spirituality

and health also informed our line of inquiry.

Positive Psychology

Positive psycholo

has recently emerged as "a science of positive subjective

experience, positive individual traits, and positive institutions [that] promises to [help]

improve" the quality of human lives (Seligman & Csikszentmihalyi, 2000, p. 5). Positive

psychology emphasizes individual strengths and the belief in the human potential for

growth and change. This relatively new framework underscores the positive meanings

inherent in the emotional, psychological, and spiritual challenges individuals face in

every day life. In the words of its chief proponents, Seligman and Csikszentmihalvi


The field of positive psychology at the subjective level is about valued subjective
experiences: well-being, contentment, and satisfaction (in the past); hope and
optimism (for the future); and flow and happiness (in the present). At the
individual level, it is about positive individual traits: the capacity for love and
vocation, courage, interpersonal skill, aesthetic sensibility, perseverance,
forgiveness, originality, future mindedness, spirituality, high talent, and wisdom.
(p. 5)

A breast cancer diagnosis presents an enormous challenge to a woman's

sense of

her self, her mind, her emotions, and her spiritual life (Cole & Pargament, 1999). Clinical

oncology, which focuses on the physiological aspects of cancer diagnosis and treatment,

has been increasingly collaborative with psycho-oncologists, who attend, additionally, to

the emotional and psychological morbidity of breast cancer patients (Greer, 1999).

Mental health counselors committed to the positive psychology paradigm may

play an integral role in the implementation of the complementary interventions that

psycho-oncology explores. Traditionally, the fields of psychology and mental health

counseling have almost exclusively focused on psychopathology and the medical model
of psychiatric and psychological care (Seligman, 2002). In a departure from this model of

care, this experimental study explored whether focused, creative art therapy interventions

promote breast cancer patients' individual creativity, access to personal strengths,

emotional expression (e.g., emotion-focused coping), spirituality, and psychological


Creativity and Flow

Applied positive psychology encourages creativity and spirituality, and suggests

that these traits can enhance an individual's overall quality of life. Creativity is similar to

the concept of flow as defined by Csikszentmihalyi (1990a); it refers to an autotelic

Lifts the course of life to a different level. Alienation gives way to involvement,
enjoyment replaces boredom, helplessness turns into a feeling of control, and
psychic energy works to reinforce the sense of self, instead of being lost in the

service of external goals.

(p. 69)

The experience of being present is what engagement in the creative process

awakens. Individuals focused on an act of creativity (e.g., painting, drawing, writing)

describe moments of transcendence wherein their consciousness of time and place

disappears and they experience an allegorical release from the stress of current life

challenges, unresolved emotions, and internal conflicts, and sense a connectedness to all

people and things (e.g., see Spaniol, 1995). These moments of transcendence encompass

what Csikszentmihaly defined as the creative experience of flow.

Csikszentmihaly (1990b, 1996, 1997) has researched and written extensively on

the subject of creativity. He stated that these explorations have led him to the conclusion

"that in order to understand creativity one must enlarge the conception of what the

process is, moving from an exclusive focus on the individual to a systemic perspective

that includes the social and cultural context in which the 'creative' person operates"

(1990, p. 190). It is important to make a distinction between a creative process that is

rooted in cognition, intellect, and/or giftedness (Wallas, 1926, as cited in Solso, 1991;

Torrance, 1995) and a creative process that may facilitate emotional expression, spiritual

connectedness, and psychological well-being in clients. Our experimental research study

focused on the latter.

Csikszentmihaly (1990b) credited the work of Magyari-Beck, a Hungarian

researcher who developed a model of creativity research that takes into account


(p. 209). This research study focused on the second form (process), as related to the

counseling intervention of creative art therapy. Csikszentmihaly (1996) studied the

creative process as it revealed itself in the work of creative individuals who represented a

breadth of professional spheres (from scientists to writers, composers to fine artists).

These in-depth interviews produced insights into the personally transforming aspects of

the creative process and the experience of flow.

Based on his interviews, Csikszentmihaly (1996) identified nine elements that

constitute the conditions of flow:

In flow, we always know what needs to be done; we know how well we are
doing; we feel our abilities are well matched to the opportunities for action; our
concentration is focused on what we do; we are aware only of what is relevant
here and now; we are too involved to be concerned with failure; we are too
involved in what we are doing to care about protecting the ego; we forget time,
and hours may pass by what seem like a few minutes; and, whenever most of
these conditions are present, we begin to enjoy whatever it is that produces such
an experience. (p. 111-113)

The poet Mark Strand described his flow experience with these words: "you're right in

the work, you lose your sense of time, you're completely enraptured, you're completely

caught up in what you're doing, and you're sort of swayed by the possibilities you

see in

this work" (as cited in Csikszentmihaly, p. 121). His words captured the sense of

timelessness inherent in the experience of flow. Csikszentmihaly proposed that an

optimal experience of flow helps individuals make meaning of their life experiences,

helps enhance the quality of their lives, and their psychological well-being.

According to Csikszentmihaly (1990a), individuals bring "order to the contents of

the mind by integrating one

s actions into a unified flow experience" (p. 216). Creating

intentionality into a congruence of thoughts, feelings and actions that create a sense of

harmony for the individual.

"Purpose, resolution, and harmony unify life and give it

meaning by transforming it into a seamless flow experience" (p. 218). This experimental

study examined the way the creative art therapy process facilitates the experience of flow

and emotional expression. Our functionalist view of emotional expression as a goal

oriented (Campos, Mumme, Kermoian, & Campos, 1994), emotion-focused coping

strategy (Stanton, Danoff-Burg, Cameron, & Ellis, 1994) is congruent with

Csikszentmihaly' s

conceptualization of the experience of flow as described herein.

Spirituality and Health

More than 90% of individuals living in the United States believe in the existence

of a Higher Power (e.g., God; Kroll & Sheehan, 1989). Stanard, Sandhu, and Painter

(2000) described spirituality as "a pervasive force in contemporary American society

[that] is deeply influencing several helping professions such as counseling, education,

medicine, nursing, psychology, [and] social work" (p. 204). Assessing and understanding

the role spirituality plays in clients' lives has been deemed an important part of mental

and physical health care delivery (Fukuyama & Sevig, 1999; Kelly, 1995; Stanard et al.

2000; Woods & Ironson, 1999).

Griffith and Griffith (2002) defined spirituality as "a commitment to choose, as

the primary context for understanding and acting, one's relatedness with all that is,

[adding that] with this commitment, one attempts to stay focused on relationships

between oneself and other people, the physical environment, one's

heritage and

traditions, one's

hodv_ one's ancestors, saints. Higher Power or God" (n. 15-16Vl


rituals, sacred scriptures, doctrines, rules of conduct, and other practices"

Worthen, 1997

(Anderson &

as cited in Rivett & Street, 2001, p. 460). The terms are used

interchangeably in much of the literature. The medical community, in research and

practice, is paying increased attention to spirituality and attempting to understand its

relationship to health and healthcare provision (Cook & Hetrick, 2001; Thoresen, 1999),

a trend giving greater credence to research endeavors in this area.

Thoresen (1999) reviewed literature addressing spirituality and health and

reported that there is "empirical evidence based on over 300 studies that demonstrated in

many, but not all cases, that a positive relationship exists between spiritual, or religious

factors, and health" (p. 294).

He cautioned that correlation does not imply causality, and

emphasized that attempts must be made to operationalize these constructs. His review of

the literature presented physiological and psychological evidence that offers promise and

possibility for further exploration of these relationships. Thoresen concluded with a note

that "something called spiritual and/or religious seems to be often related positively to

health status"

and it is well-worth pursuing (p. 298).

Cook and Hetrick (2001) explored the relationship between religion, spirituality

and health by conducting a meta-review of existing literature. Their primary focus was

on religiousness as an aspect of spirituality. In keeping with our positive psychology

framework, only findings pertaining to spirituality and health (not psychopathology) are

highlighted. Cook and Hetrick begin with an analysis by Miller and Thorensen (1999)

(who summarized work by Larson, Swyers, and McCullough, 1997) and reported the

following: "when spiritual and religious involvement has been measured (even poorly), it

said with some confidence that religion is positively associated with a sense of well-

being, healthier self-esteem, and better personal adjustment"

(p. 96). George, Larson,

Koenig, and McCullough (2000) noted significant relations between religion and the

delayed onset of several physical problems and also noticed that religion tends to be

associated with longevity and better recovery from physical illness. Attendance to

religious activities was often the strongest predictor of positive physical and mental

health variables.

George et al. (2000) summarized three mechanisms by which religion might

benefit health: (a) Religion leads to healthy behaviors, which in turn leads to better

physical and mental health (accounts for 10% of variance); (b) participation in religious

activities brings potential benefits of increased social support (accounts for 5%-10% of

variance); and (c) the coherence hypothesis, which proposes that "religion benefits health

by providing a sense of coherence and meaning so that people understand their role in the

universe, the purpose of life, and develop the courage to endure suffering"

(p. 11).

Koenig, McCullough, and Larson (2001) reported that religiousness was beneficially

related to a variety of physical health conditions (including lower incidence of cancer) as

well as mental health variables (including higher sense of well-being, happiness, life

satisfaction, hope, and optimism); McCullough, Hoyt, Larson, Koenig, and Thoresen

(2000) completed a meta-analytic review of data from 42 independent studies and

reported that "religious involvement was significantly associated with lower mortality"

(p. 211). A salient point of this literature review is the call for research endeavors that use

quantitative design and methods so causal relationships can be evaluated.


and spiritual beliefs and practices may provide physiological, affective, behavioral, and.

cognitive mechanisms for coping with illness and distress [adding that] cancer patients

describe their religious beliefs as providing a profound method of coping with the'


(p. 447).

Creative art therapy interventions may help clients reconnect with

themselves holistically and make meaning of their current life'

struggles. In recursive

fashion, engaging in the creative process may enhance holistic healing, facilitate

emotional expression, improve psychological well-being, and nurture personal

spirituality and the optimal experience of flow. Our experimentally controlled study

sought to explore these relationships.

Emotional Expression

The processing and expression of emotion as an adaptive function in the face of

distressful events have received empirical support (Stanton, Kirk, Cameron, & Danoff-

Burg, 2000). Stanton and Danoff-Burg (2002) added there is both experimental and

correlational evidence providing "preliminary support for the important role of emotional

expression for individuals who confront a cancer diagnosis" (p. 45). The idea of

emotionally expressive coping is derived from a functionalist view of emotions (Stanton,

Parsa, & Austenfeld, 2002) and represents a departure from the traditional view of

intense emotional expression as dysfunctional and irrational (Averill, 1990, as cited in

Stanton et al., 2002). A functionalist view of emotions holds that emotions are relational

and contextual (i.e., they cannot be understood alone or as intra-psychic processes;

Campos et al., 1994). Levenson (1994) presented a functionalist outlook of emotions as

short-lived psychological-physiological phenomena that represent efficient modes


muscular tonus, voice, autonomic nervous system activity, and endocrine activity
to produce a bodily milieu that is optimal for effective response. Emotions serve
to establish our position vis-A-vis our environment, pulling us toward certain
people, objects, actions, and ideas, and pushing us away from others. Emotions
also function as a repository for innate and learned influences, possessing certain
invariant features along with others that show considerable variation across
individuals, groups, and cultures..(p. 123)

Stanton et al. recommended "distinguishing, both conceptually and empirically,

among the emotion-focused strategies that involve active movement toward (e.g., active

acceptance, emotional expression, positive reappraisal) versus away from (e.g., mental

disengagement) a stressful encounter" (p. 151). The authors also emphasized the need for

more accurate operationalization of emotional approach coping, and increasing the focus

on its adaptive potential.

In order to improve the operationalization of emotional approach (i.e., emotion-

focused) coping, Stanton, Kirk, et al. (2000) developed a scale to measure emotional

approach coping and have tested it on breast cancer patients (Stanton, Kirk, et al., 2000;

Stanton & Danoff-Burg, 2002). They noted that emotional approach coping is comprised

of two factors and both are assessed in the measure: emotional processing and emotional

expression. Our selective focus on emotional approach coping will obviate the extensive

body of extant literature pertaining to other adaptive coping approaches (e.g., Carver et

al., 1993; Lazarus & Folkman, 1984). Stanton and Danoff-Burg (2002) contended that

"the best known research on psychological intervention with cancer patients involves an

explicit emotional expression component"

(p. 37) that has been deemed central to


Research literature on emotional expression and cancer has addressed two

who confront a cancer diagnosis?" (Stanton & Danoff-Burg, 2002, p. 32). Servaes,


Vreugdenhil, Keunig, and Broekhuijsen (1999) researched inhibition of

emotional expression in breast cancer patients as compared to healthy controls and

concluded that cancer patients' "inhibited behavior is a reaction to the disease rather than

a reflection of a personality characteristic predisposing an individual to breast cancer"

(p. 23). Stanton and Danoff-Burg (2002) cautioned researchers to "take great care in

concluding that personality factors are relevant in light of the potential for victim


(p. 45). This research study addressed the potential role of emotional

expression in enhancing psychological well-being, not its hypothesized role on initiation

or progression of the disease.

Some correlational (longitudinal and cross-sectional) research studies have

reported poorer psychological adjustment (Compas et al., 1999) and emotional well-

being (Cohen, 2002) may occur in subjects who experienced intense discharge of

negative emotion. Research studies have been conducted that implemented supportive-

expressive group therapy to encourage and facilitate emotional expression in cancer

patients (Giese-Davis et al., 2002; Goodwin et al., 2001; Gore-Felton & Spiegel, 1999;

Spiegel, Bloom & Yalom, 1981; Spiegel et al., 1999).

We found no research studies that

used individual therapy interventions to explore the role of emotional expression or

emotional approach coping on the psychological well-being of breast cancer patients.

The multi-center study of Spiegel et al. (1999) of Stage I and Stage II breast

cancer patients receiving supportive-expressive group therapy yielded significant positive

results, including a 40% decrease in total mood disturbance scores of the Profile of Mood


Hospital Anxiety and Depression Scale (HADS). The authors concluded that supportive-

expressive group psychotherapy resulted in reduced overall distress.

Gore-Felton and Spiegel (1999) conducted a literature review on the effectiveness

of supportive-expressive group psychotherapy and concluded "there is a growing body of

evidence suggesting that support groups for women with breast cancer are successful at

improving psychological, social and physiological well-being"

(p. 284). The authors also

reported that a crucial component of supportive-expressive group therapy is the

encouragement of open emotional expression about the disease.

Stanton et al. (1994) argued that current research results on the role of emotional

expression in cancer adjustment were confounded by the researchers'

use of

instrumentation that includes psychopathology- or psychological distress-related items.

In response to this problem, Stanton et al. (2000) developed a new scale to measure

emotion-focused coping (the Emotional Approach Coping Scale) that is reportedly not

confounded with extraneous variables. Using the newly developed instrument to research

the influence of emotion-focused coping on women's adjustment to breast cancer, the

authors reported positive psychological adjustment in cases involving intentional efforts

to emote. The authors also reported that patients who expressed emotions about the

cancer diagnosis and treatment at the beginning of the study reported increased self-

perceptions of physical health and vigor, decreased stress, and fewer medical

appointments for cancer-related complaints, such as pain, than did the less expressive


Finally, Stanton et al. (2002) proposed "coping through emotional

nrocessing and expression is an important area of inauirv for positive nsvcholov"


and enhance psychological well-being in newly diagnosed, Stage I and Stage II breast .

cancer patients.

Creative Art Therapy

The relationship between spirituality, creativity, and healing has been

conceptually and theoretically explored in the psychotherapy and health (physical and

mental) disciplines with increased frequency (Cook & Hetrick, 2001; Thoresen, 1999).

Creativity and spirituality have been named as two positive individual traits that can

potentially enhance the quality and well-being of human lives (Seligman &

Csikszentmihalyi, 2000). Rivett (2000) reported both spirituality and creativity as

significant emergent issues in a thematic review of family therapy journals. Our research

study explored the relationships among these constructs and their role in breast cancer

patients' experience of the disease.

Innovative treatment interventions are being proposed, developed, and researched

that transcend the realm of traditional psychotherapeutic practices and address the role of

spirituality in emotional and psychological healing (Katra & Targ, 2000). The use and

application of creativity through art therapy is one such treatment option. Promoting

creativity and the experience of flow through an art therapy intervention may facilitate

breast cancer patients' emotional expression and enhance self-reported levels of

spirituality and psychological well-being.

Art therapy as a counseling discipline has been evolving within and outside the

counseling field since the 1940s when Naumburg, a psychoanalyst, began exploring art

as a way of analyzing clients' unconscious material (Wadeson, 1980). Creative art

The creative process that art therapy facilitates has been described as a way to

"uncover memories and recover feelings [and] a process of self-expression that allows

[one] to act out painful emotions, attain a cathartic sense of release, and experience a

repertoire of varied emotions"

(Spaniol, 1995, p. 227). The process of art making has

been described as a healing journey and as more important than the final product; the

process itself is described as a healing experience and often includes a reference to

spirituality as a significant contributing factor (Farrelly-Hansen, 2001; Spaniol, 1995).

Creativity in the form of painting, drawing, making music, dancing, and writing

(i.e., journaling prose or poetry) may serve as a vehicle for the expression and

management of difficult emotional states and offer relief for clients receiving

psychological counseling and/or medical treatment for life threatening illnesses. Stanton

and Danoff-Burg (2002) have reported beneficial outcomes in research with breast cancer

patients using the standard expressive writing paradigm (Pennebaker & Beall, 1986) for

intentional emotional expression and release. Creative art therapy interventions may help

decrease ego defenses that keep intense emotions suppressed within the individual and

allow for their expression in non-linear, non-verbal ways; some art therapists have also

emphasized "the integrative and healing properties of the creative process itself, which

does not require verbal reflection"

(Wadeson, 1980, p. 13).

Creative art therapy interventions have been shown to enhance emotional

expression, spiritual connectedness, and psychological well-being of breast cancer

patients (G. Aldridge, 1996; Cruze, 1998; Dibbell-Hope, 2000; Predeger, 1996; Stanton

& Danoff-Burg, 2002).

Creative art therapy may facilitate the autotelic experience of


assimilated, and experienced, an optimal experience of flow may enhance emotional ,

expression, self-reported levels of spirituality and psychological well-being.

Need for the Study

Greer (1999) underscored "the challenge for psycho-oncology and mind-body

medicine is to develop effective, scientifically based psychotherapeutic methods that will

make a significant contribution to patient care and become an integral part of clinical
practice" (p. 242). Review of the literature indicated a relative absence of research

studies that utilized experimentally controlled testing of individual creative art therapy as

a treatment intervention for breast cancer patients.

Counseling interventions should be informed by sound theory and research

(Greer, 1999).

believe a holistic, positive-focused, creative approach is ideal for

counseling women with breast cancer struggling with physical, emotional, and

psychological stressors and existential dilemmas resulting from the cancer diagnosis and

its treatment. Clinicians attending to this population must also address the spiritual,

social, and systemic variables affecting the women's lives. Traditionally, counseling has

been a 'talking cure' for people in distress. Creative art therapy may offer a nonverbal

adjunct to the intentional exploration and expression of difficult emotions.

The efficacy of the complementary, mind-body intervention of creative art

therapy on breast cancer patients' experience of healing (Predeger, 1996), emotional

expression (G. Aldridge, 1996; Cruze, 1998; Predeger, 1996), and psychological

adaptation (Dibbell-Hope, 2000) has been studied; its efficacy on breast cancer patients'

emotional expression, spirituality, and psychological well-being had yet to be


Qualitative studies of breast cancer patients that received creative art therapy

interventions reported the women describing the experiences as powerful, connecting,

moving (Cruze, 1998; Predeger, 1996; Samuels & Lane, 2000), deeply spiritual (Samuels

& Lane, 2000), and beneficial in several ways: facilitated active coping (G. Aldridge,

1996), emotional release (Cruze, 1998; Predeger, 1996), increased self-control (Cruze,

1998; Predeger, 1996), and enhanced psychological well-being and adjustment (Dibbell-

Hope, 2000).

The relationships among these constructs had yet to be explored using

rigorous, experimental design and methodology.


The purpose of this experimental study was to determine the efficacy of a

complementary, mind-body creative art therapy intervention in enhancing emotional

expression and self-reported levels of spirituality and psychological well-being in newly

diagnosed, Stage I and Stage II breast cancer patients.

Research Questions

The following research questions were addressed in this study:

* Can creative art therapy help enhance newly diagnosed Stage I and Stage II breast

cancer patients

' emotional expression

Can creative art therapy help enhance newly diagnosed Stage I and Stage II breast
cancer patients' self-reported levels of spirituality?

Can creative art therapy help enhance newly diagnosed Stage I and Stage II breast

cancer patients

' psychological well-being?

Definition of Terms

Creative art therapy is a psychotherapy modality wherein clients use various art


Emotional expression is an individual's functional, goal-oriented coping strategy

that allows for the intentional, active processing and expression of emotions as measured

by the Emotional Approach Coping Scale.

Flow is an autotelic, optimal state of consciousness marked by deep engagement

and concentration in the present moment on whatever activity the individual is focused


Holistic healing is an approach to healing that encompasses and attends to the

individual's body, mind, emotions, and spirit.

Positive psychology is a recently emergent humanistic psychology that

emphasizes individual strengths and the belief in the human potential for growth and

change and underscores the positive meanings inherent in the emotional, psychological,

and spiritual challenges individuals face in every day life.

Psychological well-being, for the purposes of this study, is defined as the absence

of psychological distress in the forms of depression and anxiety as evidenced by subjects'

scores in the Profile of Mood States-Short Form

Spirituality, for the purposes of this study, is defined as a commitment to choose,

as the primary context for understanding and acting, one's relatedness with all that is, as

measured by the Expressions of Spirituality Inventory-Short Form.

Stage I breast cancer, for the purposes of this study, is defined as a tumor 0-2

centimeters (cm.), without lymph node involvement (no evidence of cancer cells in the

lymph nodes), and without metastasis (Love, 2000).

Stage II breast cancer, for the purposes of this study, is defined as a tumor 0-2


without lymph node involvement, and without metastasis; or, a tumor larger than 5 cm.,

without lymph node involvement, and without metastasis (Love, 2000).

Organization of the Study

Relevant literature is reviewed in.Chapter

All aspects of research

methodology, including a statement of the purpose of the study, hypotheses, description

of the population, description of the sample and sampling procedures, design of the

study, delineation of relevant variables, instrumentation, data analysis, and

methodological limitations are outlined in Chapter 3.

analyses of the data are reported in Chapter 4. The re

The results of the statistical

results of the analyses, the

implications for theory and practice, the limitations of the study, and suggestions for

future research are addressed in Chapter




The purpose of this chapter is to review existing literature related to the emotional

expression, spirituality, and psychological well-being of breast cancer patients. Cancer

research studies that have explored these constructs are discussed. Qualitative and

quantitative studies that have utilized the complementary, mind-body intervention of

creative art therapy on breast cancer patients are examined. Implications of findings of

this review of the literature vis-a-vis future research conclude this chapter.

Creative art therapy is a psychotherapy modality wherein clients use various art

media to explore expression of emotional and psychic material, to help generate

meaningful insights about their inner and outer life experiences (Wadeson, 1980).

Originally, art therapy was used as a diagnostic tool; however, engaging in art therapy

exercises has been recognized as an autotelic experience for individuals in emotional or

psychological distress (Spaniol, 1995). Patients of all ages, ethnicities and races may

benefit from art therapy interventions delivered in individual, couples, family, and group

psychotherapy formats. The production of aesthetic material has been described as "one

of the most common of ways to divert ourselves from problems, to get relaxed and in

touch with others [and] to express feelings"

(Levick, 2001, p. 25). Art therapy techniques

anAa ,ym1irarpA (Cl no XI hc'r 1 OQ nny- tZ22_IZ-4A\ P? cac'^ -i l-bt onnyf


music, dance, painting, drawing, sculpting, journal, poetry or prose writing (e.g., see D.

Aldridge, 1998; G. Aldridge, 1996; Haegglund, 1976; Pennebaker & Beall, 1986;

Wadeson, 1980).

Our review of the literature revealed that research studies exploring the effects of

creative art therapy on breast cancer patients are scarce (G. Aldridge, 1996; Cruze, 1998;

Predeger, 1996). For purposes of this review, studies that utilized creative art therapy

interventions with various types of cancer patients are included; studies that utilized

creative art therapy interventions on breast .cancer patients are reviewed in greater detail.

In order to uncover creative art therapy outcome studies on cancer patient populations,

the following databases were searched: CAM on PubMed, EBSCOHOST, MedLine and


Research on Cancer Patients and Emotional Expression

The issue of health care professionals ignoring patients'

emotional reactions in

the face of medical diagnoses that may have a deleterious effect on patient prognosis has

been raised in the literature (Goleman, 1995). Goleman contended

The problem is when medical personnel ignore how patients are reacting
emotionally, even while attending to their physical condition, [health care
providers are] neglecting a growing body of evidence showing that people's
emotional states can play a sometimes significant role in their vulnerability to
disease and the course of their recovery (p. 165).

Goleman went on to suggest that the medical profession as a whole is lacking in

emotional intelligence, and underscored the importance of minding both the body and the

emotions of individuals struggling with physical disease diagnoses. He reported evidence

that ciioaapctQ relntinnchin eyvict between nhvinral Qvmntnmr and ditrecf1l a1mntions

Researchers have demonstrated a positive association between emotional

expression and an individual'

health status (Pennebaker, 1989; Pennebaker & Beall,

1986). Lilja et al. (1998) reported cancer patient studies have demonstrated an

association between emotional inhibition, including suppression and repression of

aggression and anger, and incidence of cancer diagnoses. They specifically noted several

studies have "found that patients with malignant tumors are more likely to suppress

aggression than women with benign breast disease"

(Greer & Morris, 1975; Morris,

Greer, Pettingale, & Watson, 1981; Scherg, Cramer, & Blohmke, 1981; Watson',

Pettingale, & Greer, 1984; Wirsching, Stierlin, Hoffman,

Weber, & Wirsching, 1982, as

cited in Lilja et al., 1998, p. 292).

Cancer research has extensively explored the role of emotional suppression,

emotional processing, and emotional expression on a number of psychosocial and

treatment outcome variables, for example, psychological adjustment (reported levels of

distress and well-being) (Classen et al., 2001; Classen, Koopman, Angell, & Spiegel,

1996; Cohen, 2002; Compas et al., 1999; Helgeson et al., 2001; Payne et al., 1999;

Spiegel, 1996; Spiegel et al., 1999; Stanton, Danoff-Burg, et al., 2000; Stanton et al.,

2002; Watson, Greer, Rowden, Gorman, Robertson, Bliss et al. 1991), emotional self-

efficacy (Giese-Davis et al., 2002), quality of life (Gore-Felton & Spiegel, 1999;

Helgeson et al., 2001),

incidence and recurrence of disease (Spiegel & Kato, 1996), and

survival and mortality (Derogatis, Abeloff, & Melisaratos, 1979; Watson, Haviland,

Greer, Davidson, & Bliss, 1999; Weihs, Enright, Simmens, & Reiss, 2000). The role of

these tersonalitv factors on the etioloav and incidence of disease dianosis represents

Emotional Expression and Cancer Incidence

The relationship between emotional suppression and incidence of breast cancer

diagnosis has been researched and results indicated there is no significant association

between a cancer outcome and emotional suppression when the patient's

age, a highly

significant variable, is controlled for (O'Donnell, Fisher, Irvine, Rickard, & McConaghy,

2000). The authors added that although the "results suggest that suppression of emotion

may not be relevant to the development of breast cancer ... its role in the progression of

existing disease requires clarification"

(p. 1079).

In a retrospective study, Femandez-Ballesteros et al. (1998) compared emotional

expression (using Rationality/Emotional Defensiveness and Need for Harmony scales) of

women with breast cancer with that of healthy women. The authors stated that women

diagnosed with breast cancer "reported that they did not express emotions, and tried to

get along in stressful social situations even when others hurt them or acted against their

needs or desires" (p. 47). They added that the women with breast cancer were older on

average than the healthy women and hypothesized their findings may be explained by

differences in age between groups. The researchers emphasized they are not inferring a

causal link between personality variables and cancer; however, concluded that "with a

very high level of probability, [their] results show that emotional expression is a good

predictor for discriminating healthy women from those with breast cancer" (p. 48). A

similar study comparing healthy women (n = 49) with breast cancer patients (n


yielded slightly different conclusions (Servaes et al., 1999).
is *rr-. 4 ***- ^ *** *


in a woman's risk of developing breast cancer (Bleiker, van der Ploeg, Ader, van Daal, '&'

Hendriks, 1995). Researchers are uncertain whether the tendency to suppress emotions,

preexisting emotional or psychiatric disorders and psychological adjustment increase a

woman's risk of developing breast cancer or whether the actual breast cancer diagnosis

affects a woman's pattern of emotional expression, her emotional or psychiatric

morbidity and her psychological adjustment. Research evidence also remains

inconclusive about whether psychological factors such as a woman'

coping style and/or

tendency to suppress negative emotions play a significant role in her breast dancer

diagnosis, her response to treatment and/or long-term prognosis (Bleiker & van der

Ploeg, 1999).

Stanton and Danoff-Burg (2002) have clearly cautioned against the potential for

victim blaming associated with research about the role of personality factors (i.e.,

abnormal emotional expression associated with the Type C personality) on a cancer


We reiterate our research study addressed the potential role of emotional

expression in enhancing psychological well-being, not its hypothesized role on initiation

or progression of the disease.

Emotional Expression and Psychological Well-Being

Research results on the relationship between emotional control,

adjustment to

cancer, and depression and anxiety in early stage breast cancer patients indicated a highly

significant association between subjects' tendency to control emotional reactions and a

fatalistic attitude about the disease (Watson et al., 1991). Additionally, the authors

discovered (with rather low huit iaonifieant eneffitientsi "a nredicted assoiation between

between the Type C personality trait of emotional control and a fatalistic attitude about

cancer and, to a lesser extent, feelings of helplessness; adding that these variables were

related to increased feelings of depression and anxiety, thus negatively affecting breast

cancer patients'

psychological morbidity.

Psychological distress may take the form of a psychiatric diagnosis in up to 50%

of cancer patients (Spiegel, 1996).

Spiegel has researched the incidence of clinical

depression in cancer patients and suggested that treatment options include,, among others,

interventions to facilitate emotional expression:

Cancer elicits strong affects, including fear, anxiety, sadness, depression, and
anger. Such feelings become less overwhelming and more manageable when dealt
with directly in therapy. Many seriously ill individuals feel isolated with their fear
and sadness, unable to discuss it with health professionals, family or friends.
Ironically, expression of such emotion seems to reduce rather than increase
depressive symptoms. Patients often find that psychotherapy organizes their
dysphoria by providing a time and place to deal with it effectively. (p. 111)

Spiegel emphasized that a growing body of evidence indicates psychiatric therapy for the

physically ill is an essential and important aspect of health care delivery.

Servaes et al. (1999) also studied personality factors at play in this population and

reported: "the image of the breast cancer patient as it emerges in the present study is that

of a woman who has conflicting feelings about expressing her emotions, is reserved and

anxious, is self-effacing, and represses aggression and impulsiveness" (p. 27). The

ambivalence to express emotions, the authors contended, resulted from their conscious

attempt to appear strong and avoid being burdensome to others. According to the

researchers, the breast cancer patients chose to control their emotions, suggesting a

rnnrhcinhlc nnA rl =rat( atrt rather thnn n nevrnhnlnornl defence merhanicnm hevnnd thlir


given the stressfuilness of a cancer diagnosis. The authors hypothesized this may be part

of the breast cancer patients' attempt to appear in control of their situation and not show

their real feelings to others. Servaes et al. concluded that the breast cancer patients'

display of "cancer-prone characteristics are a consequence of confronting a life-

threatening disease rather than reflecting premorbid personality features"

(p. 27).

Emotion-Focused Coping

Emotion-focused coping involves the active processing and expressing of

emotions and is considered a significant coping strategy in breast cancer patients'

approach to diagnosis and treatment of the disease (Stanton et al., 2002). Stanton, Kirk, et

al. (2000) researched the effects of emotion-focused coping, which involved purposeful

emotional processing and expression, on psychological adjustment to cancer and reported

that "women who expressed emotions surrounding cancer at study entry had fewer

medical appointments for cancer-related morbidities (e.g., pain), enhanced self-perceived

physical health and vigor, and decreased distress during the subsequent 3 months relative

to less expressive women" (Stanton & Danoff-Burg, 2002, p. 34).

One study on a homogeneous sample of Israeli (Jewish) women reported that

emotion-focused coping had a deleterious effect on emotional well-being and predicted

higher levels of depression in patients with breast cancer recurrence (metastatic

malignancy or local recurrence) (Cohen, 2002). Historically, groups of patients enrolled

in randomized controlled trials tend to be relatively homogeneous in demographic

composition (Richardson et al., 1998). Stanton and Danoff-Burg (2002) cautioned

reQenreher' to cnn5ider whether rennrted nntemrne differ 2mnno canner natients a2 a

Stanton and

Danoff-Burg (2002) have also addressed the benefits of explicit

experimental emotional expression through expressive writing on cancer patients. They

conducted a randomized experimental expressive writing intervention on 60 women

(mean age

= 50 years; mean time since diagnosis duration

= 28 weeks) diagnosed with

Stage I and Stage II breast cancer (Stanton et al., 2002). Their goals were to (a) test the

effects of expressive writing on psychological and physical health-related outcomes and

(b) assess the effects of encouraging subjects to write about the positive aspects of their

cancer diagnosis and experience. Subjects were randomly assigned to one of three

writing conditions and completed four, 20-minute writing sessions within a 3-week

period. Trained research assistants read instructions from prepared scripts.


conditions were as follows:

The experimentally induced expressive disclosure group was instructed to write
about their deepest thoughts and feelings related to the cancer experience.

The control group subjects were instructed to write about facts of their cancer

The benefit-finding group was induced to write solely about the benefits (positive
aspects) of the cancer experience.

Writing samples were transcribed and an independent judge reviewed the samples and

assigned them to their respective writing conditions with a reported 95% accuracy.

The authors hypothesized that the groups induced to expressive disclosure about

positive and negative aspects of cancer would experience positive effects on

psychological well-being (defined as positive effects on quality of life and affect) and

positive effects on overall physical health (defined as self-report of uncomfortable


would vary "as a function of participants' self-reported avoidance of cancer-related

thoughts and feelings, reasoning that women low on avoidance might benefit more from

emotional disclosure than would high-avoidant women, for whom induced emotional

disclosure might be difficult" (Stanton & Danoff-Burg, 2002, p. 40).

The experimentally induced expressive disclosure group and the control group

subjects reported significantly greater distress immediately after the written exercise

ended than did the benefit-finding group. The authors indicated this type of finding is not

uncommon in the expressive writing literature. Although described by the stibjects as a

painful and difficult process, most reported that ultimately, the exercise was insightful

and helpful. The positive results of this experience did not hold for any group at 1-month

and 3-month follow-up assessments. The authors reported that women who self-reported

as low-avoidance experienced less distress than women in the high-avoidance category.

The latter group benefited most from the benefit-finding writing condition.

An important finding of this study is that women do not have to write about

painful thoughts and feelings in order to benefit from expressive writing. Subjects in the

experimentally induced expressive disclosure group and the benefit-finding group had

fewer medical appointments in the subsequent 3 months than did control group subjects.

The experimentally induced expressive disclosure group experienced the greatest degree

of benefit regarding overall physical health-related outcomes (less cancer-related medical

appointments and less overall cancer-related physical symptoms). Regarding long-lasting

positive effects, self-perceived enhanced understanding of their experience, and value of
.1 1 1 1 1 /^* a^- 1" I 1* 1 .1 1 r^ 1


of thoughts and emotions surrounding cancer appeared to yield maximal benefit in this

sample [and] the relative risks and benefits of various forms of expressive writing require

further investigation" (p. 44). Stanton and Danoff-Burg (2002) concluded "both

correlational and experimental evidence [reported thus far] provides preliminary support

for the important role of emotional expression for individuals who confront a cancer

diagnosis" (p. 45).

Stanton, Danoff-Burg, et al. (2000) have explored whether emotionally expressive

coping predicts psychological and physical adjustment to breast cancer. The researchers

studied Stage I and Stage II breast cancer patients (n

= 92) with a mean age of 52 years

= 10.33; age range 28 to 76 years). The subjects completed several measures: a

coping measure with the emotional-approach coping scales (emotional-processing and

emotional-expression) embedded; a hope scale, a social receptivity scale; a psychological

adjustment scale, the Profile of Mood States pomsS); a health status questionnaire, and

written documentation of medical visits over time. These instruments were given to

subjects 20 weeks after medical treatment was completed and again 3 months later.

The researchers reported divergent findings related to the two aspects of

emotional-approach coping measured.

Women who coped through emotional expression

experienced better outcomes than those who used coping through emotional processing.

Emotionally expressive coping was "associated with decreased distress, increased vigor,

improved self-perceived health status, and fewer medical appointments for morbidities

related to cancer and its treatment" (p. 84-85). Emotionally expressive coping improved
-t_ __ 1t.. r i 'e ___-__-_-------------Ct AA_ 1 *i _.- -- ^ ^ - - i i- -- L-L c--s" --


emotional processing experienced increased distress. The authors hypothesized that the .

mental rumination component of emotional processing may play a role in this finding.

The researchers underscored the importance of context, citing the work of
Pennebaker et al. (1997), which demonstrated positive results in the experimentally

controlled use of written emotional disclosure processing. The researchers concluded:

"training in coping skills designed to facilitate emotional expression may bolster

adjustment and health status for women when confronting breast cancer"

(p. 88). Finally,

a result of this study labeled as 'curious' by the authors indicated that spiritual coping

(coping through personal spirituality and/or religious beliefs/faith) and acceptance

predicted positive psychological adjustment but more frequent medical visits. The latter

was interpreted as a proactive measure by subjects to remain in control of their bodies

and their management of the cancer experience.

Research on Cancer Patients and Spirituality

The importance of attending to the spiritual lives of breast cancer patients has

been underscored in the literature (Kristeller et al., 1999; Mytko & Knight, 1999; Shapiro

et al., 2001). Researchers have cautioned against ignoring the crucial role spirituality may

play in a patient's experience of healing and suggested multi-disciplinary, collaborative

and holistic approaches to patient care and healthcare research (Carr & Morris, 1996;

Carroll, 2001; Wirth, 1995). A number of conceptual articles have discussed and

explored the role of health care providers in facilitating the emotional, physical,

psychological, and spiritual healing of cancer patients. (Carr & Morris, 1996; Carroll,

2001; Cole & Pargament, 1999; Damianakis, 2001; Kristeller et al., 1999; Wirth, 1995).


adjustment of breast cancer patients (Brady et al., 1999; Cole & Pargament, 1999; Cotton

et al., 1999; Feher & Maly, 1999; Gall & Comrnblat, 2002; Gall et al., 2000; Mickley et al.,

1992). Shapiro et al. (2001) contended that "spirituality may buffer against negative

effects of life stressors" including the struggle with a breast cancer diagnosis (p. 506).

Brady et al. (1999) argued for the inclusion of spirituality in quality of life measures and

for the use of a biopsychosocial/spiritual model of cancer patient care.

Quasi-experimental and qualitative studies have been conducted on cancer


experiences of religiosity (Feher & Maly, 1999) meaning making (Mickley et

al., 1992) and hope (Mickley et al., 1992; Moadel et al., 1999). These studies involved

the use of questionnaires, interviews, and self-report measures. All researchers reported

findings indicating that spirituality played an instrumental role in the experience of

coping with a cancer diagnosis. Moadel et al. cautioned that as many as 33% of cancer

patients reported spiritual or existential needs were unmet in the course of conventional

medical treatment.

Mickley et al. (1992) examined the roles of spiritual well-being, religiousness,

and hope in spiritual health and indicated that physical health status is independent of

spiritual health. This supports the notion that cancer patients may experience spiritual

well-being even when facing a poor prognosis. Existential well-being, an aspect of

spiritual well-being, was shown to contribute to patients' experience of hope as did

maintaining a social support network and the presence of religious beliefs in the subjects'

spiritual life. Feher and Maly (1999) conducted research on the role of religious faith in


Spiritual well-being has been reported to contribute greatly to a cancer patient's

quality of life (Thomson, 2000). Thomson's study surveyed the lived experience of

hospice palliative care for a group of patients over a six-month period of time. Spiritual

well-being and subjective distress (Smith, Stefanek, Joseph, & Verdieck, 1993), and

anxiety (Kaczorowski, 1989) have also been studied. Both Smith et al. and Kaczorowski

found an inverse relationship between spiritual well-being and subjective distress and


Brady et al. (1999) administered questionnaires to a large sample of inulti-ethnic

patients (n =1610) diagnosed with HIV/AIDS or cancer to test their hypotheses:

(a) quality of life and spiritual well-being are positively associated, (b) individuals

reporting high levels of spiritual well-being will also report higher life enjoyment, and (c)

there is a unique relationship between spiritual well-being and quality of life. The

researchers found that both spirituality and physical well-being were equally associated

with quality of life. They also stated that spirituality and quality of life were uniquely

correlated; furthermore, individuals who reported high spirituality were able to enjoy

their lives more.

Cole and Pargament (1999) developed a pilot psychotherapy program and named

it: Re-Creating Your Life: During and After Cancer.

The authors made a case for

integration of spirituality in psychotherapy programs aimed at addressing existential

dilemmas raised by a cancer diagnosis. The program addressed four existential concerns

believed to affect cancer patients: control, identity, relationships, and meaning. The

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& Auerbach, 1988 as cited in Cole & Pargament, 1999). The authors concluded "a

program that explicitly integrates spiritual resources into the psychotherapy process may

hold considerable promise for this population [and] the benefits of such a program may

even exceed those offered by traditional psychotherapy"

(p. 405).

The role of spiritual factors on long-term adjustment to breast cancer has also

been explored (Gall & Comrnblat, 2002). The researchers asked a sample of 39 women,

long-temrn breast cancer survivors, to write in their own words how spiritual and religious

factors played a role in their understanding of and coping with the disease. Content

analysis of transcripts was conducted and the following religious/spiritual themes

emerged as significant contributing factors: relationship with God, social support,

meaning, and life affirmation/growth. Relationship with God became a source of

emotional support, faith in self, greater inner strength, and lessening of emotional

distress. Talking to God through prayer served as a source of comfort and self-soothing

that helped reduce anxiety, depression, and anger. Life affirmation and growth included a

positive attitude, inner strength, inner peace, and connectedness to others. The authors

stated that the concept of faith was a common thread interwoven among the religious and

spiritual factors uncovered:

Faith represented a basic trust in the goodness and greater purpose in life.


trust grounded these women, providing them with a solid sense of purpose and
place, [informing] most spiritual aspects of their adjustment such as their
meaning-making around the cancer experience. (p. 533)

The authors acknowledged the limitations of a retrospective study based on one

question answered by a relatively small sample and suggested that a longitudinal


The role of religion on breast cancer survival has also received attention (Roud,'

1989; Van Ness, Jones, & Kasl, 2001). Roud explored the spiritual dimensions of

extraordinary survival of terminal cancer patients. He conducted in depth interviews (and

domain/content analysis of transcripts) with individuals who, after terminal diagnoses of

various types of cancers and beyond comprehension by their attending physicians, went

into full remission from their disease. (In follow up check-ins, all but one of the

participants (n = 8) were alive and well; five years after the initial interviews were

conducted). The author discovered that these individuals assumed full responsibility for

their disease and recovery from it, let go of fears, expectations, and worries, and

developed a sense of spiritual connectedness and transcendence that brought them great

comfort and improved their quality of life. One of the participants reported that music

was a healing intervention for him, allowing him to let go of stress and increase the

experience of relaxation. All reported that they consciously increased their expression of

two key emotions: anger and love; finding this liberating. According to Roud, the healing

process is a coming to terms with death through a personal choice to live fully; spiritual

awareness greatly enhanced this process.

Van Ness et al. (2001) explored the following religious variables and their impact

on survival: religious denomination, attendance to religious services, religious social

network, religion as a source of comfort, and subjective religious identity.

Denominational preference was the only variable that yielded statistically significant

results with the Pentecostal denomination showing a possible protective effect when

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Thomas and Retsas (1998) designed a qualitative, grounded theory study to

explore the spiritual dimensions of people making sense of and coming to terms with a

terminal cancer diagnosis. They were interested in the meanings that these individuals

ascribe to everyday experiences of life with the disease. They found that cancer patients

"transact self-preservation' in three phases: "taking it all in, getting on with things, and,

putting it all together" [and viewed spirituality as] "an inherent aspect of the individual

self incorporating a source of strength developed through a person's

God and/or another Higher Being"

faith in self, others,

(p. 191). The spiritual dimensions of patients'

experiences evolved, as they moved from transaction to transaction, as follows: taking it

all in (responding to the crisis and questioning 'why?'); getting on with things

(mobilizing resources and connecting spiritually and emotionally with self and others);

and putting it all together (creating meaning out of the experience of life with the disease

and discovering self in new ways). Becoming spiritual, transcending self, and expanding

consciousness were all important aspects of managing the diagnosis in healthy ways. The

authors called upon nurses and other health care practitioners to help instill a sense of

hope and positive expectation in patients; they underscored that in order to accomplish

this task, health care providers must be in touch with their own sense of spiritual


Many of the studies discussed here emphasized the need for further research

exploring useful interventions to assist diverse groups of patients manage the physical,

emotional, and spiritual challenges that cancer brings into their lives. They underscored

the fact that spirituality was a crucial variable in cancer patients' lives and must not be


emotional, and physical health, and quality of life have been conducted (Mytko &

Knight, 1992; Sherman & Simonton, 2001).

Mytko and Knight concluded more studies are needed to further explore the role
of spirituality in relation to psychological adjustment (well-being and distress) and

quality of life of cancer patients, in order to enhance our understanding of the integration

of body, mind, and spirit in future research and treatment of this population. Sherman and


findings concurred; in summary

General religious orientation and cancer-related religious coping have both been
modestly associated with various dimensions of quality of life, including
emotional distress, life satisfaction, social functioning and sometimes, physical
symptoms. Spiritual well-being has also been tied to several important aspects of
quality of life (p. 185).

Sherman and Simonton concluded that the data gathered to date suggests that spirituality

and religiousness are tied to significant health outcomes for cancer patients and the

psycho-oncology research community has only just begun tracing these connections.

Research on Cancer Patients and Psychological Well-being

Psychological adjustment to cancer is indicated by levels of psychological

(mental and emotional) distress and well-being that patients experience as they face

disease diagnosis and treatment choices (Stanton et al., 1998). A diagnosis of cancer has

been described as a "jarring, life-altering experience for most patients and their families

[with] taxing treatments, disrupted functioning, and uncertainty about survival among the

burdens they face"

(Sherman & Simonton, 2001, p. 167). Approximately 20% to 30% of

breast cancer patients report experiencing severe psychological distress a year after initial

diagnosis (Irvine, Brown, Crooks, Roberts, & Browne, 1991). Cancer patients'



decision-making period and almost half of early stage cancer patients (including those

with relatively good prognosis) have been found at risk for moderate to severe

psychological distress (Bleiker, Pouwer, van der Ploeg, Leer, & Ader, 2000).

The research literature has documented a number of negative psychological

consequences of a cancer diagnosis, including clinical depression and anxiety (Bleiker et

al., 1995; Payne et al., 1999; Razavi & Steifel, 1999; Spiegel, 1996). Breast cancer

patients also struggle with performing daily physical, occupational and/or social activities

with a considerable number (20-46%) suffering from moderate to severe emotional

morbidity (van der Pompe et al., 1996).

Spiegel (1996) reported even though about 50%

of all cancer patients have a psychiatric disorder (e.g., adjustment disorder with

depression) "comorbidity of psychiatric with medical illness is a common and under-

recognised problem; [emphasizing that effective treatment of depressive symptoms]

results in better patient adjustment, reduced symptoms, reduced costs of care, and may

influence disease course" (p. 109). Antoni et al. (2001), on the other hand, cited several

studies that researched and reported positive consequences of a cancer diagnosis. The

authors contended:

Although diagnosis and treatment for cancer are distressing and disruptive, there
is an increasing awareness in both research and clinical communities that the
cancer experience often has sequelae that patients view as positive or beneficial.
A substantial number of patients report experiences such as improvement in
personal resources and skills, an enhanced sense of purpose, enhanced
spirituality, closer relationships with significant others and changes in life
priorities. (p. 21)

These findings emphasize the diversity of adjustment responses that may be found across

this nonulation.


chemotherapy, which may affect body image, femininity, sexuality, and fertility (in

women of child-bearing age) and metastatic breast cancer patients struggle with

existential issues such as fear of death and dying, pain, concern for family members they

may leave behind, and the knowledge that their life will be shortened by the disease (van

der Pompe et al., 1996). Razavi and Steifel (1999) also underscored that the type of

cancer, type of treatment, course of illness,

"the patient's personality, gender, and age;

and the quality of social support are all factors that should be taken into account" when

performing cancer research exploring the efficacy of psychological interventions (p.


Extensive critical reviews of the literature have been conducted about

psychological interventions on cancer patients, in general (Andersen, 1992, 2002) and

breast cancer patients, specifically (Glanz & Lerman, 1992; Tapper, 1999). Problems of

conceptualization and confounding have been addressed in psycho-oncology research

(Stanton et al., 1994).

A common admonishment underscored the need for careful

scrutiny and interpretation of the highly heterogeneous sets of extant data from research

done on multiple types of cancer, cancer stages, demographic variables, and

psychological interventions (Andersen, 2002; Tapper, 1999).

Our review of the literature yielded multiple studies pertaining to outcomes of

psychological interventions on breast cancer patients'

emotional expression and

psychological adjustment, including psychological distress and well-being; recall these

studies have utilized interventions as follows: individual therapy (Lev & Owen, 2000;

MacCormack et al., 2001), supportive psycho-educational group therapy (Edmonds et al.,


2001; Bloch & Kissane, 2000; Cunningham et al., 1998; Edelman et al., 1999; Kissane et

al., 1997

Watson et al., 1996),

and mixed modalities (including psycho-education, stress

management, guided imagery and/or hypnosis) group therapy (Spiegel & Moore, 1997

Fawzy et al., 1990; Fukui et al., 2001; Hosaka et al., 2000; Richardson et al., 1997

Simpson et al., 2001; Spiegel & Bloom, 1983; Spiegel et al., 1989).

A number of research studies have explored the efficacy of supportive expressive

group therapy on cancer patients'

emotional expression (Giese-Davis et al., 2002),

psychological adjustment (Classen et al. 1996), distress (Classen et al., 2001; Spiegel et

al., 1999), and survival (Goodwin et al., 2001). It should be noted that supportive

expressive group therapy does not usually incorporate art media in its interventions; the

disciplines of expressive arts therapy and creative arts therapy most commonly do

(Malchiodi, 2003).

Supportive expressive group therapy specifically geared toward emotion-focused

coping has been shown to help women with metastasized breast disease to express their

emotions more openly and freely without becoming hostile (Giese-Davis et al., 2002).

Classen et al. (1996) reported emotional expressiveness and adoption of a fighting spirit

approach to coping (Friedman, Nelson, Baer, & Lane, 1990) were associated with better

psychological adjustment. Supportive expressive group therapy that emphasized

provision of support and helping subjects manage the stress caused by the cancer and its

treatment was found useful in reducing psychological distress in women with

metastasized disease (Classen et al., 2001).

Spiesel et al. (1999) also researched breast cancer patients receiving supportive-


Goodwin et al. (2001) reported that participation in supportive expressive group therapy

by women with metastasized breast cancer did not prolong survival in the treatment

group; however, it helped to improve mood and perception of pain,

"particularly in

women who [were] initially more distressed" (p. 1719). Finally, a review of the literature

on the overall efficacy of supportive-expressive group psychotherapy, including emotion-

focused interventions, concluded that overall results suggested these support groups

helped enhance psychological, social and physiological well-being of breast cancer

patients (Gore-Felton & Spiegel, 1999).

Research on Creative Art Therapy and Cancer

An increasing number of oncology patients receiving medical treatment for a

wide range of cancers have opted to participate in art therapy experiences to help them

cope with the physical, emotional and mental stressors that such a diagnosis brings (Lane

& Graham-Pole, 1994). According to Malchiodi (2003) "some practitioners see art

therapy as part of a larger discipline referred to as expressive arts therapy (the therapeutic

use of art, music, dance/movement, music, drama and poetry/writing) and intermodal or

multimodal (moving from one art form to another) approaches" (p. 106). Creative arts

therapy and expressive arts therapy may be aimed at enhancing emotional expression,

spiritual connectedness, and psychological well-being of cancer patients.

Research exploring the efficacy creative art therapy on cancer patients has

primarily focused on qualitative methods (D. Aldridge, 1998; Davis, 2000; Dreifuss-

Kattan, 1990; Haegglund, 1976; West, 1995).

These researchers have addressed how

engagement in the creative arts can be a healing experience for individuals suffering from

D. Aldridge (1998) explored Life as Jazz, a metaphor for bringing hope and

' meaning to individuals facing life-threatening illness. According to the author, creative

musical improvisation can enhance an individual's ability to tap into inner sources of

strength and resilience. His study focused on'multiple patients dealing with a wide

variety of medical diagnoses, including breast cancer. The author concluded that music

enhanced his client'

lived experience of spirituality and fostered a sense of hope while

facing disease. Music therapy has emerged as a distinct discipline from art therapy;

however, it was included herein to demonstrate the increased use of creative therapies in

cancer patient treatment and research.

Davis (2000) developed a book that offers cancer patients a structured writing

intervention to guide the emotional expression of thoughts and feelings as they come to

terms with and learn to cope with their disease. Dreifuss-Kattan (1990) provided

psychooncological and psychoanalytical overviews of subjects'

experience of cancer and

reported that multimodal creative art therapy helped enhance their emotional and

psychological well-being.

Haegglund (1976) conducted a psychoanalytic study addressing the relationship

between creativity, the death and dying experience, and attitudes of cancer patients. The

author contended that poetry writing may appease and help soothe the pain of loss and

mourning often associated with a cancer diagnosis. Haegglund conducted a literature

review and its findings supported his original hypothesis (that a relationship among these

constructs does exist). The author illustrated his point by presenting five cases studies of

individuals suffering from cancer who used poetry writing as a way to face feelings of


transition into death was also explored. The author concluded that poetry writing, per

patients' self-report, was a healing experience.

West (1995) conducted a case study of a 77-year-old female patient diagnosed

with terminal cancer. She discussed the role music therapy played in the subject's

experience of anticipatory grief as she began to die from the disease. The author

examined the beneficial outcomes of music therapy and concluded that it can serve to
enhance an individual's quality of life and level of comfort in the dying process.

Three studies reviewed explored the use of personal journal writing, including the

crafting of poetry and prose, as a way of documenting the emotional and psychological

experience of living and dying with cancer (Philip, 1995; Smith, 1995; Wyatt-Brown,


They revolved around Claire Philip, a social worker who struggled with and

ultimately died from cancer, seven years after initial diagnosis. Philip (the cancer patient)

chose to document her emotional and psychological process of grief through journal
entries that included poetry, prose, and reflections on creativity, spirituality, and

connectedness. These were published in scholarly journals in her field. She emphasized

the importance and value of being able to express thoughts and feelings to herself

(through writing) or to others (through conversation). Philip equated this form of

expression with the creative flow itself and experienced it as a connecting with and

transforming of the self.

Smith (1995) and Wyatt-Brown (1995) examined Philip's

divergent perspectives. Smith hypothesized that Philip's

writings from two

poetry was another form of

revealing thoughts and feelings that may not be clear to the therapist in session but

with the loss of identity, the loss of loved ones, and the meaning of death and dying


Wyatt-Brown approached Philip's work as an exploration of the themes of

creativity and professional identity. She conceptualized Philip's

writing and self-

disclosure process as a way of coming to terms and wrestling with the experience of

dying. (Philip moved from secrecy the first 3 years after diagnosis to broad self-

disclosure via journal publications the last year of her life).

Wyatt-Brown suggested this

choice to write and express her thoughts and feelings in a public professional forum was

an emotionally healing experience for Philip.

One study explored the roles of spirituality and creative art therapy in mental

health care practice (Greenstein & Breitbart, 2000).

Greenstein and Breitbart proposed a

group intervention to help cancer patients address the challenges that their disease brings.

They developed sessions focusing on aspects of meaning, including a sense of

transcendence, spirituality, responsibility, values, priorities, and personal creativity. The

group intervention incorporated aspects of the creative arts by exposing patients to

instances of meaning, which can be found through the appreciation of beauty in nature or

works of art. According to the authors: "whether pursuing creative goals and experiential

values or reframing one's attitude, [individuals] may attain a sense of meaning in part

through transcendence" (p. 497), a spiritual experience of connectedness with others or

with a universal, larger whole beyond ourselves. In their qualitative explorations of

spirituality and creativity in healing, the authors concluded that creative art therapy

enhanced patients'

ability to ooenlv express painful emotions, including the experience


Our review of the literature uncovered no experimental studies that explored the

efficacy of creative art therapy interventions on breast cancer patients'

levels of spirituality or the role of spirituality on breast cancer patients'



well-being and/or adjustment to the disease. As previously stated, this area of inquiry

remains unexplored. Our study investigated the efficacy of art therapy on these constructs

utilizing a quantitative research methodology.

Research on Creative Art therapy and Breast Cancer

A very small number of qualitative studies have examined the benefits of creative

art therapy on breast cancer patients (G. Aldridge, 1996; Cruze, 1998; Predeger, 1996).

We found one mixed (qualitative and quantitative) study on the subject (Dibbell-Hope,


G. Aldridge (1996) conducted a case study of a 35-year-old female patient

diagnosed with breast cancer. The participant began a music therapy experience after

undergoing radical mastectomy of one breast. The therapy was geared to provide a

vehicle for melodic expression and a forum to reflect upon the emotional experience of

managing her disease. The author defined creative music therapy as "an approach that

actively pulls the client into the process of performing music-the therapeutic

gestalt-[and] exerts an influence on the abilities of the patient to express herself'

(p. 213). G. Aldridge explored the melodic flow of the subject'

improvisations and

interpreted them as therapeutic experiences of emotional expressivity and as reflection of

the subject's

emotional healing process. The author contended that spontaneous musical

improvisation assisted his client to access her creative power, a potential source of


creativity and creative strength to cope with their crisis and maintain coherence through

their illness ... within a culturally accepted form"

(p. 221-222).

Cruze (1998) provided a case study of the breast cancer experience by reporting a

subjective, personal account of her struggle with the disease and the healing she

experienced through a collaborative creative process. Cruze, a physician, was diagnosed

with breast cancer in 1991 and underwent a mastectomy and chemotherapy treatments.

Four years prior to her diagnosis she had attended a presentation by sculptor Christiane

Corbat, who helps cancer survivors make plaster sculptures of their torsos after

mastectomies. These artistic pieces, named the Amazon torsos, tour the United States and

serve as symbolic representations of the women's

stories of tragedy and triumph. Cruze

and Corbat met and discussed this artistic process after Cruze had finished her cancer

treatment. The author was surprised to hear Corbat indicate that she had a hard time

finding women who could bring out the positive aspects of their cancer experience. Cruze

reported she also felt unable to see anything positive in her struggle. After this exchange,

Cruze realized that her future happiness and well-being depended upon her ability to

view the experience with breast cancer and surgery in a positive light. Cruze decided to

have Corbat complete a sculpture of her torso. She described her experience thus:

The plaster cast made me think that I was broken and being reset in order to heal.
My plaster exoskeleton became a warm chrysalis and my soft bug bits solidified
as my pupa matured to imago. As I wriggled out of my hard shell I remembered
having watched a monarch butterfly pump its moist crumpled wings out full and
shapely and dry. I mimicked the movement and made as if to take flight. I felt
transformed! (p. 402)

Corbat completed a sculpture of Cruze's plaster torso and named it Night Light.

of happiness and optimism and, ultimately, gaining the ability to reframe her cancer

experience. Cruze concluded that looking at the sculpture makes her feel "triumphant,

victorious over [her] disease for the first time"

(p. 402).

Predeger (1996) conducted qualitative research using the feminist process

method, a feminist esthetic cooperative inquiry, described as purposeful authentic

collaboration and shared meaning that allows the power of collectivity to emerge.

Predeger and her co-researchers named this process Womanspirit: A journey into healing

through art in breast cancer. A convenience sample of 18 women (ages 39 to 70) from

diverse backgrounds and representing various disease stages, participated in this research

for a 6-month period. The women used artistic expression in the form of painting,

photography, collage, and writing. Collaborative reflection among the coresearchers was

central to the feminist esthetic framing the study. The study

method is described as

evolving within a group session format that "followed a deliberate structure of centering,

art experience, reflection, and action"

(p. 51).

The centering part of the group session

began with a check-in, or an opening-up, where participants became present to each

other. A question was then posed to encourage centering and reflection. The women

proceeded to choose a favorite art medium and to utilize the creative process as vehicle

for describing the breast cancer experience. Sharing among group members took the form

of synthesizing and interpreting the observation of images. Analysis of emergent themes

ended each session. In order to secure data, each session was audio taped and transcribed;

transcripts were discussed and analyzed collectively during later sessions. Additional

data sources came from participants'

reflections about their art, researchers' field notes,

process where emergent themes were discussed and would be revisited in subsequent

sessions, thus deepening the coanalysis of the experience. Leadership, group direction,

individual and group insights occurred throughout the research process.

The guiding research questions were (a) what is the meaning of healing through

the expressive arts for women living with breast cancer and (b) what are the processes

and outcomes of women cocreating personal and collective knowing? Predeger (1996)

chose a holistic nursing paradigm to guide the inquiry. This paradigm affirms multiple

ways of knowing and multiple healing perspectives. The author chose a participative

worldview lens whereby the lived experience of the women's

reflections of healing

through art and group work could be viewed. Predeger described her research

methodology as "open, reflective, dialogic and engaging whatever methods best meet the

aims of the study" (p. 50).

The following themes on personal and collective healing emerged:

* Actualizing the need to express
* Losing and gaining control
* Illuminating a changing perspective
* Transcending and becoming braver
* Connecting with sisters
* Creating a safe harbor
* Fueling the creative spark
* Celebrating the feminine
* Womanspirit.

Actualizing the need to express refers to the women's contention that being able

to express their feelings and thoughts through art was viewed as timely and opportune.

The ability to express became more important than the media used or the final product

itself. The sharing deepened as the group sessions progressed.


regain control. This paradoxical process of surrender and empowerment also deepened,

and became easier with time.

Illuminating a changing perspective refers to their reframing of the breast

cancer experience. Art is described as a pathway toward healing and meaning making

that transcended prior interpretations of the struggle with the disease. The women were

able to focus on the goodness in their lives rather than the negative aspects of struggling

with cancer.

Transcending and becoming braver refers to the wish to move beyond their

own struggle and reach out to assist others facing the disease. Becoming proactive

emerged as an important aspect of healing for the women; this took the form of political

involvement, expressing thoughts and feelings assertively, or reframing themselves from

victims to survivors.

Connecting with sisters refers to the collective engagement in feminist research

and embracing an ideology that promotes support and encouragement of women. The

experience of sisterhood provided companionship and warmth that reduced feelings of

alienation or loneliness.

Creating a safe harbor refers to the women's

framing their art-making process

as a place of rest and replenishing. The time spent together provided needed relief from

everyday worries.

Fueling the creative spark refers to the power of the collective to inspire the

women to explore their thoughts and feelings through the creative process. Some of the

women reported a reawakening of their creative selves they had long neglected.

Celebrating the feminine refers to the experience of making art within a feminist

Womanspirit underlies the spirit of women reaching out and bravely
transcending their own boundaries in their quest for healing; [it] captures the
process of knowledge cocreated from experience, exploration, expression, and
empowerment of the women realized within the collective methodology....
Women, connected in spirit, are finding their own way. (p. 57)

Predeger (1996) concluded that the voices of personal and collective healing, as

experienced by the women through their artistic creative process, must be heard; health

care practitioners and researchers "would benefit by collaborating with women in a

nonhierarchical participative model where dialogue of experiences and possibilities are

uncovered" (p. 57).

Dibbell-Hope (2000) explored the use of dance/movement therapy in the

psychological adaptation to breast cancer. The study was an attempt to address the lack

of systematic, quantitative, controlled approaches to clinical therapy research. Authentic

Movement was chosen as the clinical intervention and is described as a therapeutic

process based on the Jungian concept of active imagination. The dancer is encouraged to

move at her own pace, in her own time, within her physical limitations and is always in

control of the process. The dancer is also encouraged to attend to her inner experience by

closing her eyes and listening to her body, learning to trust herself, and opening up to


witnessing of her process. This therapeutic dance "may facilitate healing from the

emotional effects of breast cancer by reinforcing a sense of internal trust ... and by

encouraging active participation in the healing process, which can lead to a better

medical prognosis and improved quality of life" (p. 53). The ultimate goal of this

approach is to help the dancing client develop awareness of, give form to (through

improvised dancing), and integrate conscious and unconscious material; her feelings

about her body and her self.


The research questions were (a) can an Authentic Movement group help women

with breast cancer increase their level of psychological adaptation to the disease and its

treatment and (b) can that increase be sustained over time? Research hypotheses were

(la) Participation in an Authentic Movement treatment group will improve '
psychological adaptation of women with breast cancer significantly more than
waiting for treatment.

(1 b) Improvement will be sustained over time.

(2) Women who show the most improvement will be older, have had earlier stage (I
or II) cancer diagnosis, less invasive medical treatment, more time elapsed since
the end of treatment, and more past experience with physical activities (i.e., sports
or dance).

Inclusion criteria were as follows:

* Diagnosed with Stage I or Stage II breast cancer.
* Treatment completed 6 to 60 months prior to the study.
* No prior breast cancer diagnosis.
* No active psychiatric symptoms (i.e., hallucinations, delusions, severe psychiatric
* No history of inpatient psychiatric treatment.

The treatment consisted of 3 hours of Authentic Dance sessions held weekly over

a 6-week period. The group therapists were reported to be well-known, experienced,

Authentic Dance professionals who taught and published on the subject widely.

Participants were recruited via letters, with assistance from the San Francisco Bay Area's

Alameda County American Cancer Society. Interested respondents were contacted by

phone, after inclusion criteria were verified a face-to-face was interview scheduled.

During the first in-person interview, pretreatment qualitative data was gathered regarding

the subject's personal experiences with cancer diagnosis and treatment, including how it

affected her feelings about her body or her self. A paper-and-pencil packet of

questionnaires was administered to measure pretreatment levels of psychological


image and self esteem scores in the Borscht-Walker-Bohrnstedt Body Image Scale


After the interviews and questionnaires were completed, the women were

separated by geographical area: from the Northern Bay Area (Group 1: where the

population was characterized as urban, sophisticated, and heterogeneous) and the

Southern Bay Area (Group 2: where the population was characterized as suburban,

conservative, and homogeneous) and randomly assigned to a treatment or control group

of 10 to 12 women each.

The treatment subjects were 33 women (ages 35 to 80; mean age



sessions were held at two area churches. Control group subjects were told they would be

contacted in 6 weeks to begin treatment. After the 6-week treatment period, both groups

were assessed for psychological adjustment using the same instruments described in

pretreatment measures. Qualitative data (post-treatment clinical interviews) was also

gathered from the treatment group subjects. Quantitative data from experimental and

control groups was compared to determine treatment effect. Qualitative data were used to

compare objective and subjective aspects of subjects'

experiences of psychological

adaptation. Three weeks post-treatment, both control and treatment group subjects were

again assessed for psychological adaptation using the same instrumentation as before.

The third testing was conducted to offset the possibility of halo effect from the end of the

treatment and to determine whether obtained benefits remained over time. Comparisons

of psychological adaptation were made between control and treatment groups at

pretreatment, post-treatment, and delayed post-treatment.

After delayed post-treatment,

members of the treatment group completed a written evaluation to rate (on a Likert-type


Dibbell-Hope reported that only the control group subjects from the Northern San

Francisco Bay area accepted the delayed treatment; adding that subjects from the

Southern group were no longer interested and had met their psychological and emotional

needs through other support groups. For hypothesis l a, Analyses of Co-Variance

(ANCOVAS) were used to compare effectiveness of treatment against no treatment.

Repeated measures Analyses of Variance (ANOVAS) were used to measure changes

over time, at post-treatment and delayed treatment. In order to measure within group

changes over time for both treatment and control groups paired t-tests were used.

The treatment groups showed significant improvement over control groups in

Vigor, Fatigue and Somatization (p

< .05) when post-treatment scores were compared

with post-wait scores of the control groups. Significant regional differences appeared in

the results: the Northern group showed lower level of psychological adaptation after

treatment than did the Southern group. The Southern group reported overall better

improvement than the Northern group whether in the treatment or control groups. The

Northern group reported higher levels of Fatigue and Total Mood Disorder in the POMS

< .05) than did the Southern treatment group. The Northern group also had higher


evels on the SCL-90R (p

.001) and greater dissatisfaction with body image in

the BWB (p

< .05) than did the Southern treatment group. The Northern control group

also showed higher overall mood disturbance, distress, and dissatisfaction with body

image. The Southern treatment group reported statistically higher levels of body image

.05) than did the Southern control group. Statistical testing of interaction of

treatment by region was done and no significant interaction effect was found.

Dibbell-Hope concluded that Hypothesis l a was generally unsupported. ANOVA

improvement in Fatigue,

Vigor and Somatization was not sustained over time.

Hypothesis I b was not supported. The'Authentic Movement therapy group showed
minimal improvement when compared to the control group and the improvement was not

sustained over time. The author noted that the areas where small improvement was

reported related to the physical body (Fatigue,

Vigor and Somatization) and hypothesized

that Authentic Movement might have contributed to a sense of physical well-being in the


Hypothesis 2 was tested through a step-wise multiple regression procedure to

if the demographic factors selected (age, stage of cancer, type of treatment, time since

treatment, and experience in sports and dance) may predict level of psychological

adaptation. The stage of breast cancer was the most frequent predictor of mood and

distress. Age was the most significant predictor of satisfaction with body image and self-

esteem. Hypothesis

was largely supported.

Qualitative data from the interviews and written evaluation were analyzed within

a phenomenological framework "in order to capture the nature of each woman's

individual experience, to point out any common elements or themes and to summarize

descriptively and succinctly the essence of the experience"

(p. 62). Most women,

according to the author, reported that the Authentic Movement dance therapy experience

was positive and healing, assisting them to resolve issues related to their breast cancer

struggle, especially disturbances in mood, negative feelings about their bodies, and social

isolation. The author acknowledged that subjectively perceived improvement in distress,

mood, self-esteem, and body image after the therapeutic dance experience cannot be

interpreted as a direct causal relationship since she made no attempt to correlate or track


data. She concluded that further qualitative phenomenologicall) and quantitative research

is needed in this area.

Dibbell-Hope reported considerable differences were found between quantitative

and qualitative data collected.

While the quantitative data showed a few changes in mood

and distress, none were shown in self-esteem and body image. On the other hand,

qualitative data indicated noticeable improvements in self-esteem and body image while

improvements in distress and mood were minimal. She believes instrumentation and

response bias may be responsible for the discrepancy between objective and subjective

results. Dibbell-Hope suggested that future research include correlations between

objective and subjective measures of change.

Methodological limitations were acknowledged: demographics, treatment

duration, variations in leadership styles, sample size, and group composition may have all

affected the outcome of this study. A noteworthy qualitative finding came through the


written evaluations and recommendations. Dibbell-Hope reported the women

wished the treatment were offered at diagnosis time, during or immediately after

treatment when distress is highest and the benefits may be greater and recommended that

future therapy interventions incorporate other types of expressive arts therapies, i.e., art,

music, and drama.

In the diverse explorations about the efficacy of art therapy interventions on

cancer patients, the majority of research reviewed herein reported qualitative evidence

that art therapy interventions may assist patients to openly express painful emotions,

explore the existential spiritual dilemmas raised by their struggle with the disease and by

facing their own mortality, and enhance overall psychological well-being. Controlled,



Lerner and Remen (1987) have reported their personal experiences in a residential

treatment program for cancer patients. Their holistic approach incorporated yoga,

meditation, health education, and support groups. The authors contended that

complementary therapies, including art therapy are beneficial to psychological and

physical recovery from various types of cancer. Engagement in these interventions, by


self-report, helped decrease their feelings of fear, sadness, distress, and

isolation, and provided an increased sense of personal control. The multimodal art

therapy approach to treatment proposed in this research study provided creative

techniques "through which individuals [may] express thoughts and feelings,

communicate nonverbally, achieve insight, and experience the curative potential of the

creative process" (Malchiodi, 2003, p. 117).

Review of extant literature indicated a relative absence of rigorously controlled

experimental studies focusing on the efficacy of structured, creative art therapy

interventions, delivered in individual sessions, on breast cancer patients'


expression, self-reported levels of spirituality, and psychological well-being. Qualitative

findings reported in this literature review appear promising and have shown

psychological benefits associated with engagement in creative arts therapy. Research

studies about the efficacy of art therapy on patients with various types of cancer have

included music therapy (D. Aldridge, 1998

West, 1995),

structured and unstructured

journal writing, including poetry and prose (Davis, 2000; Haegglund, 1976; Philip, 1995;

Smith, 1995; Wyatt-Brown, 1995), art appreciation (Greenstein & Breitbart, 2000), and

multimodal art therapy (Dreifuis-Kattan, 1990). Research studies about the efficacy of art

collaborative sculpting (Cruze, 1998), multimodal art therapy (Predeger, 1996), and

dance therapy (Dibbell-Hope, 2000).

Dibbell-Hope's (2000) study about the efficacy of dance therapy on the

psychological adjustment of breast cancer patients was the only one to use both

quantitative and qualitative measures. No treatment effect was found for post-treatment

or delayed treatment variables measured quantitatively. Subjective assessments, however,

showed post-treatment benefits, as have the other qualitative studies reviewed here

(G. Aldridge, 1996; Cruze, 1998; Predeger, 1996).

A number of studies found, which examined the efficacy of experimentally

induced expressive writing, music therapy or creative art therapy,

reported positive

findings (e.g., enhanced emotional expression and psychological well-being) that were

also described (by the authors and/or the subjects) in spiritual language and overtones

(e.g., D. Aldridge, 1998; Philip, 1995; Predeger, 1996; Stanton & Danoff-Burg, 2002).

Although not directly exploring spiritual or religious factors, these studies suggest that

cancer patients' experiences of psychological and/or emotional healing may be

subjectively appraised as spiritual ones; thus underscoring the value of a holistic

approach to health care practices and research.

Clearly a diagnosis of breast cancer presents great challenges to a woman's


mind, emotions, and spirit. Creative art therapy may prove a viable and beneficial

intervention to assist women in facing this life-threatening challenge. The pretest/posttest

control group design experiment described herein examined the efficacy of the

complementary, mind-body intervention of creative art therapy on breast cancer patients'

emotional expression, self-reported levels of spirituality, and psychological well-being.


Statement of Purpose

The psycho-oncology literature contains a number of qualitative studies focused

on the efficacy of creative art therapy interventions on emotional expression

(G. Aldridge, 1996; Cruze, 1998; Predeger, 1996), spirituality (Chiu, 2000), spiritual

well-being (Brady et al., 1999; Cole & Pargament, 1999; Cotton et al., 1999; Feher &

Maly, 1999; Gall et al., 2000; Mickley et al., 1992) and/or psychological variables (e.g.,

psychological well-being, psychological adjustment, quality of life) (Brady et al., 1999;

Cole & Pargament, 1999; Cotton et al., 1999; Feher & Maly, 1999; Gall et al., 2000;

Mickley et al., 1992) in breast cancer patients; however, we found only one that utilized,

in part, an experimental methodology (Dibbell-Hope, 2000). Experimental studies of

potentially effective "psychotherapeutic methods that will make a significant contribution

to [cancer] patient care and become an integral part of clinical practice" remain

challenging and scarce (Greer, 1999, p. 242). The purpose of this study was to determine

the efficacy of a creative art therapy intervention to enhance emotional expression,

spiritual connectedness, and select aspects of psychological well-being in newly

diagnosed, Stage I and Stage II breast cancer patients.

This chapter describes the research hypotheses, population, data collection

including attrition). samnile and samnlin, procedures. design of the study. including


relevant variables, instrumentation, and data analysis. Methodological limitations of this

research study are also discussed.

Research Hypotheses

The following research hypotheses were evaluated in this study.

Ho(l): There is a significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on emotional expression,

as measured by the Emotional Approach Coping Scale (EACS) in newly diagnosed,

Stage I and Stage II breast cancer patients.

Ho(2): There is a significant difference between the experimental group's


post-session scores on positive and negative emotional expression/states as measured by

the Emotional Assessment Scale (EAS) in newly diagnosed, Stage I and Stage II breast

cancer patients.

Ho(3): There is a significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on spirituality, as

measured by the Expressions of Spirituality Inventory-Revised (ESI-R),

in newly

diagnosed, Stage I and Stage II breast cancer patients.


There is a significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on the psychological well-

being subscale, Tension-Anxiety, as measured by the Profile of Mood States pomsS), in

newly diagnosed, Stage I and Stage II breast cancer patients.

Ho(5): There is a significant difference between the experimental group of

creative art theranv and the rnntrnl oranii nfrlelaverl treatment nn the ncvrhnlnokal uaill.-


Ho(6): There is a significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on the psychological well-

being subscale, Anger-Hostility, as measured by the Profile of Mood States pomsS),

newly diagnosed, Stage I and Stage II breast cancer patients.

Ho(7): There is no significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on the psychological well-

being subscale,

Vigor-Activity, as measured by the Profile of Mood States.(POMS), in

newly diagnosed, Stage I and Stage II breast cancer patients.

Ho(8): There is no significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on the psychological well-

being subscale, Fatigue-Inertia, as measured by the Profile of Mood States pomsS), in

newly diagnosed, Stage I and Stage II breast cancer patients.

Ho(9): There is a significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on the psychological well-

being subscale, Confusion-Bewilderment, as measured by the Profile of Mood States

pomsS), in newly diagnosed, Stage I and Stage II breast cancer patients.

Description of the Population

The population was comprised of newly diagnosed breast cancer patients. The

subjects were diagnosed with Stage I or Stage II breast cancer within 12 months of being

referred to the study. The sample was recruited from women recently diagnosed with

breast cancer who reside in the North Central Florida area and were receiving treatment

+lnw^Birn-l it l-%a d~f nnaryr^ na~r at ilCl. ani le ~n-^' L-Jnot o1--rri +l-in no nnor n- a ntnrf i M at N/^nrtln 171 ^yrlr A a P oa nn 1

The U

Census Bureau (2001) estimates that the North Central Florida area,

which includes Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,

Lafayette, Levy, Madison, Marion, Putnam, Suwanee, Taylor, and Union counties, has

about 936,700 residents with 47% being female. North Central Florida area's population

breakdown by race/ethnicity is 79% Caucasian, 17% African-American, 4% Hispanic,

0.6% Asian, and 0.5% Native American. Alachua County, where this experimental study

took place, has about 218,800 residents with 51% being female. Alachua County's

population breakdown by race/ethnicity is reported as follows: 74% Caucasian, 19%

African-American, 8% Hispanic, 4% Asian, and 0.2% Native American.

According to the American Cancer Society (ACS, 2002) 211,300 new cases of

invasive breast cancer and 55,700 in situ breast cancer cases among women are expected

in the U.S. in 2003; of these cases, 39,800 deaths are expected.

Breast cancer is the

second most common form of cancer, "accounting for nearly one of every three cancers

diagnosed in American women,"

with African-Americans more likely to die from the

disease than Caucasians (ACS, 2002). In the state of Florida, the incidence of female

breast cancer is 18.0 (In situ) and 110.0 (Invasive) with mortality rate of 23.2 per

100,000, age-adjusted to the 1970 U.S. standard population (ACS, 2002).

Data Collection and Attrition

This study was conducted from November of 2003 through July of 2004; all data

was collected throughout that time. In order to advertise the study, research flyers were

posted in parking garages at Shands Hospital at the University of Florida (including the

1~~~ C, i. I Ii 1 I l In .1 ci Ir A ir1I-


radiology, and oncology surgery, and at the local American Cancer Society's


Lodge and related support groups. Social work, counseling, nursing and oncology care

personnel at Shands Cancer Center and the aforementioned oncology offices were also

given flyers and they referred subjects who qualified and expressed interest to participate

in the study.

Table 1 outlines the referral sources of women who participated in the

study. Most of the subjects were referred by local oncology physicians (41.0%), or by

friends, who knew about the study (30.8%), designated as "Other"

in the demographic

questionnaire. Shands Hospital at UF, specifically Shands Cancer Center personnel

(20.5%) and American Cancer Society support group members (7.7%) referred the rest of

the subjects who participated.

Table 3-1.

Referral sources

Referral sources Treatment group (%) Control group (%) Total (%)
Private physician 10 (50.0%) 6 (31.6%) 16 (41.0%)
Shands Hospital 2 (10.0%) 6 (31.6%) 8 (20.5%)
American Cancer Society 2 (10.0%) 1 (5.3%) 3 (7.7%)
Other 6 (30.0%) 6 (31.6%) 12 (30.8%)
Total 20(100.0%) 19(100.0%) 39(100.0%)

Once contact was made with a potential research subject, the primary investigator

explained details of the study to her. If the woman chose to participate, she was randomly

assigned to the experimental or control group. Experimental and control group subjects

received an appointment to meet with their randomly designated counselor following

completion and receipt of all pretest documents, pretest measure, and informed consent.

Experimental group subjects began individual art therapy treatment at the appointed time.

Control group subjects met with one of the study's

counselors at the end of the four-week


Forty-four women volunteered to participate and 41 completed the study. Two Of

the women who initially wanted to participate changed their minds and never completed

the informed consent form or other pre-test documents. Of the twenty women in the

control group, seven did not complete the delayed treatment offered to them, after

completion of post-test measures. Three women indicated their lives were too hectic to

commit to weekly sessions and three others did not offer an explanation for declining the

treatment. Messages left by the designated counselor, in an attempt to schedule the first

session, were not returned. Finally, another woman discontinued treatment after two

sessions because of sudden plans to relocate out of the area with her family.

Although 41 women completed the study, the final total sample consisted of 39

women. During the statistical data analyses, we discovered two outliers, one in the

control group and another in the experimental group. The control group subject

encountered a crisis about two weeks into the delayed treatment wait period. She phoned

her designated counselor and a discussion ensued that lasted approximately 15 minutes.

Subsequently, this subject exhibited enhanced psychological well-being on post-test


We hypothesized that this brief contact may have influenced her post-test scores.

The experimental group subject reported an accidental death by drowning in her

immediate family between sessions two and three and her psychological well-being post-

test scores appear to reflect the emotional repercussions of this loss. Data collected from

these outliers was eliminated due to the aforementioned circumstances and probable

effects on post-test scores.

V a^ ni on si' Co nt i-tin a r arl. ne^^~vf


participated in this study was 39. In orderto participate, the woman was diagnosed with

Stage I or Stage II breast cancer within .12 months prior to entering the study. A Release

of Information for the subject's

treating oncology physician was obtained (Appendix A)

to ascertain that the subject met inclusiofi criteria. All women in this research study were

voluntary participants.

The subjects were recruited from Shands Hospital and North Florida Regional

Medical Center's cancer treatment centers, from the Suwanee Valley Cancer Center in

Lake City, and from oncologists'

private practice offices in the Gainesville and Lake City

communities. A research announcement flyer was used to disseminate research

recruitment information to subjects who met the research eligibility criteria

(Appendix B). Some subjects were recruited from the local ACS support network. The

subjects were adult women, 18 years of age and older, who volunteered and signed an

informed consent for participation in the study. Posted notices at Gainesville area

community bookstores and worship centers were also utilized. The subjects called a

designated contact number and left a message expressing interest in the research project.

The primary investigator talked to the callers and screened them according to outlined

criteria with verification occurring after receipt of the subject'

signed Release of

Information form and Informed Consent form (Appendix C). Subjects were informed that

they would be randomly assigned, using the flip of a coin, to a control group (delayed

treatment for 4 weeks) or an experimental group (four individual creative art therapy

interventions over 4 weeks).

Control group subjects were informed that they would

r. _

Descriptive Data Analysis


and Table

outline descriptive and demographic variables of the

women who participated in this research study.

Within the treatment group, 3 women

(15.0%) were African American, 14 (70.0%) were Caucasian, and 3 (15.0%) were

Hispanic. Eight (40%) of the women in the treatment group had a high school education,

none (0%) had an associate degree,

master degree or above.

(25.0%) had a bachelor degree, and 4 (20.0%) had a

Three women (15.0%) in the treatment group marked "other,

indicating they received vocational training in office administration, marketing, and

graphic arts.

Within the control group, one (5.3%) was African American, 16 (84.2%) were

Caucasian, and one (5.3%) was Hispanic. Six (31.6%) of the women in the control group

had a high school education,

Bachelor degree, and

(10.5%) had an associate degree, 6 (31.6%) had a

(15.8%) had a master degree or above. Two women (10.5%) in

the control group marked "other,"

indicating they received certification in nursing

assistance and sales.


Descriptive data for race

Race Treatment group (%) Control group (%) Total (%)
African American 3 (15.0%) 1 (5.3%) 4 (10.3%)
Caucasian 14 (70.0%) 16 (84.2%) 30 (76.9%)
Hispanic 3 (15.0%) 1(5.3%) 4(10.3%)
Native American 0 (0%) 1 (5.3%) 1 (2.6%)
Total 20(100.0%) 19(100.0%) 39(100.0%)

Table 3-3. Descriptive data for educational level
Educational level Treatment group (%) Control group (%) Total (%)
High school diploma 8 (40.0%) 6 (31.6%) 14(35.9%)
Associate degree 0(0%) 2(10.5%) 2(5.1%)


Data pertaining to age by groups is presented in Table 3-4. The mean age for the

creative art therapy group was 51.8 years with a standard deviation of 13.0 years. The

mean age for the control group of delayed treatment was 50.9 years with a standard

deviation of 10.7 years.

Table 3-4. Age
Age Treatment group (n=20) Control group (n=19) Total (n=39)
Mean 51.8 50.9 51.4
St. D 13.0 10.7 11.88



and Table 3-6 delineate descriptive data regarding participants' breast

Within the treatment group, 14 women (70.0%) were diagnosed with Stage I

breast cancer and six women (30.0%) with Stage II.

Within the control group, six women

(31.6%) were diagnosed with Stage I breast cancer and 13 women (68.4%) with Stage II.


Stage of breast cancer

Stage of breast cancer Treatment group (%) Control group (%) Total (%)
Stage I 14 (70.0%) 6 (31.6%) 20 (51.3%)
Stage II 6 (30.0%) 13 (68.4%) 19 (48.7%)
Total 20(100.0%) 19(100.0%) 39 (100.0%)

The type of treatment prescribed for Stage I and Stage II breast cancer is seldom

singular; therefore, table six delineates the most common treatments and combinations

thereof for the 39 women who participated in this study.

Within the treatment group, for

type of surgery, 15 women (75.0%) underwent a lumpectomy, one (5.0%) a partial

mastectomy, and four (20.0%) a mastectomy. Four women (20.0%) reported receiving

chemotherapy, six (30.0%) received radiation therapy, and five (25.0%) received both

chemotherapy and radiation therapy. Two women (10.0%) reported receiving
A~ ~ L4/h^ ^^1^ ^-wir/- 4- / t i-^ hi*/ I .~ fs ^ rr- i^ fvv/ ^

had not received chemotherapy, reported they expected to receive medication therapy

(e.g., Tamoxifen, Femara) over

years posttreatment(s). No other women in the

treatment group indicated they expected to receive medication therapy post-treatment(s).

Within the control group, for type of surgery, 11 women (57.9%) underwent a

lumpectomy, none (0.0%) a partial mastectomy, and 8 (42.1%) a mastectomy. Six

women (31.6%) reported receiving chemotherapy,

2 (10.5%) received radiation therapy,

(26.3%) received both chemotherapy and radiation therapy. Two women (10.5%)

reported they received chemotherapy and expected to also receive medication therapy

(e.g., Tamoxifen, Femara) over 2 to 5 years posttreatment(s). An additional four

women (21.1%), who had not received chemotherapy, reported they expected to receive

medication therapy (e.g., Tamoxifen, Femara) over 2 to 5 years posttreatment(s). No

other women in the treatment group indicated they expected to receive medication

therapy posttreatment(s).

Table 3-6. Treatment for breast cancer
Types of treatment Treatment group (%) Control group (%) Total (%)
Lumpectomy 15 (75.0%) 11 (57.9%) 26 (66.7%)
Partial mastectomy 1 (5.0%) 0 (0%) 1 (2.6%)
Mastectomy 4 (20.0%) 8 (42.1%) 12 (30.8%)
Chemotherapy 4 (20.0%) 6 (31.6%) 10 (25.6%)
Radiation 6 (30.0%) 2 (10.5%) 8 (20.5%)
Chemo/radiation 5 (25.0%) 5 (26.3%) 10 (25.6%)
Drug(s) with chemo 2 (10.0%) 2 (10.5%) 4 (10.3%)
Drug(s) without chemo 3 (15.0%) 4 (21.1%) 7(17.9%)


* Multiple responses

The lapsed time since diagnoses at enrollment into the study is summarized in


Within the treatment group, nine women (45.0%) were diagnosed 1-3 months

women (26.3%) were diagnosed 1 to 3 months prior to enrollment into the study, five

women (26.3%) 4 to 6 months, four women (21.1%) 7 to 9 months, and five women

(26.3%) 10 to 12 months.

Table 3-7

Time since diagnosis at enrollment

Time from diagnosis Treatment group (%) Control Group (%) Total (%)
1-3 months 9 (45.0%) 5 (26.3%) 14 (35.9%)
4-6 months 6 (30.0%) 5 (26.3%) 11 (28.2%)
7-9 months 1(5.0%) 4 (21.1%) 5(12.8%)
10-12 months 4 (20.0%) 5 (26.3%) 9 (23.1%)
Total 20 (100.0%) 19 (100.0%) 39 (100.0%)

Design of the Study

The experimental study involved a pretest/posttest control group design and

included the random assignment of subjects to a treatment group (independent variable of

individual creative art therapy intervention) or a control group (delayed treatment for 4


Women recently diagnosed with Stage I or Stage II breast cancer were included

in the study.

Two mental health counselors conducted the study. They were doctoral

candidates in counselor education at the University of Florida at the study's


One has a Master of Health Science degree in rehabilitation counseling, a Specialist in

Education degree in research and evaluation, and a Doctor of Philosophy degree in

counselor education. She is a licensed mental health counselor in the state of Florida and


years of age at the time of the study. The second counselor has a master's


in counselor education. She is a licensed mental health counselor in the state of Florida

and was 41 years of age at the time of the study. The counselors have over 30 years of


Once a potential research subject was identified, the primary researcher randomly

assigned the individual to the experimental or control group. The primary investigator

contacted each subject randomly assigned to the experimental group, informed her about

the study, and asked if she still wanted to participate. Each experimental group subject

who agreed to be in the study received (via U.S. mail) an introduction to the study letter

(Appendix D), a release of information form, an informed consent form, a pretest

measure (profile of mood states) and a demographic questionnaire (Appendix E) to be

completed and returned via U.S. mail prior to arrival for the first therapy appointment.

Experimental group subjects received an appointment, to meet with their designated

counselor, following completion and receipt of the release of information, informed

consent, pretest measure, and demographic questionnaire.

The primary investigator contacted each subject randomly assigned to the control

group, informed her about the study, and asked if she still wanted to participate. Each

control group subject who agreed to be in the study received (via U

mail) an

introduction to the study letter (Appendix F), a release of information form, an informed

consent form, a pretest measure (profile of mood states), and a demographic


At the end of the 4 weeks, each control group subject met with one of the study's

counselors to complete the posttest measures (Emotional Approach Coping Scale,

Expressions of Spirituality Inventory-Revised, Profile of Mood States),

and to set up the

first posttest treatment session. If a control group subject was unable to attend the posttest

session, she received a phone call where the counselor instructed her to complete the


stamped envelope was provided so the control group subject could return the completed

questionnaires to the researcher. An appointment to begin posttest treatment sessions was

set up after receipt of the posttest measures. The treatment protocols for the control group

of delayed treatment and for the experimental group were the same.

Individual, creative art therapy sessions for the experimental group subjects were

held in a Gainesville private practice office and in a Lake City private practice office.

Each experimental group subject received four individual therapy sessions, including a

closure session during which posttest measures were completed.

When an experimental

group subject arrived for the initial individual session, the designated counselor reviewed

the informed consent process with her. The subject was given an opportunity to ask

questions about the informed consent, the release of information, the completed

measures, and the research project itself. The counselor then reiterated that participation

in this individual therapeutic experience was strictly voluntary and that the decision to

participate would not affect the services that they received in the individual sessions.

Once a subject agreed to proceed and participate in the research process, the assigned

intervention began. Each individual creative art therapy session lasted approximately 60


If an experimental group subject was unable to attend the final, posttest session,

she received a phone call where the counselor instructed her to complete the posttest

measures (Emotional Approach Coping Scale, Expressions of Spirituality Inventory-

Revised, Profile of Mood States) and an exit interview form (Appendix I) that was sent

via U.S.

mail. A cover letter (Appendix J) and written instructions (Appendix K) were


Delineation of Relevant Variables

Independent Variable

The independent variable used in this study was an individual creative art therapy

intervention. There were a total of four individual therapy sessions over a 4-week period.

Each session lasted approximately 60 minutes. The last session lasted approximately 90

minutes to allow for completion ofposttest measures. The individual sessions consisted

of guided, semi-structured, creative art therapy exercises. The interventions were adapted

from art therapy manuals and texts (Crockett, 2000; Horovitz-Darby, 1994; Lesser, 1999)

and were specifically designed to facilitate emotional expression, spiritual connectedness,

and psychological well-being (Appendix L).

Although the sessions were semi-structured, the counselors took care to attend to

each woman's

emotional and psychological needs at the time of the interventionss. The

women were encouraged to bring into each session whatever issues) of concern were

salient that particular week. The semi-structured interventions were designed to provide a

framework of emotional and psychological exploration and an opportunity for emotional

expression and support. The guiding theoretical framework was positive psychology; a

humanistic psychology that encourages uncovering and building upon clients' strengths

rather than psychopathology. Each woman brought a set of traits and characteristics that

they drew from in the process of adjusting to and managing their breast cancer diagnosis

or any other emergent concerns. Each woman was encouraged to explore their strengths

and ways to engage these in their healing process, including managing difficult emotional

states. The exploration of these themes was done both verbally and through the creative

Each individual counseling session involved the counselor engaging the subject in

semi-structured creative art therapy experiences using pencils, pastels and/or acrylic

painting supplies. The subject completed the creative art experience in available multi-

purpose drawing/painting tablets. The counselor focused the creative experience on

subjective symbols and metaphors of emotional expression, spirituality, and the use of

color to represent salient emotional states. Creative freedom was allowed and encouraged

in order to facilitate the woman's emotional expression, spiritual connectedness, and

psychological well-being. The treatment protocols for the experimental group and for the

control group of delayed treatment were the same.

The individual creative art therapy exercises included exploration of the breast

cancer experience, a guided meditation developed to assist the client increase body

awareness and connection, a spiritual belief questionnaire intended to assist with

exploration of spiritual themes, including the role that a belief in a higher being (i.e., G-d,

Jesus, Allah, Krishna, Buddha) plays in the experience of coping with life problems;

including the breast cancer. The last session included a creative poetry writing exercise

geared toward the exploration of life and death issues through words, imagery, and


The questions guiding session one were meant to elicit meaning making of the

breast cancer experience. As previously stated, a breast cancer diagnosis can raise

existential dilemmas that put women face-to-face with issues of life purpose, meaning,

and death (Spiegel, 1999). Session two underscored the importance of a holistic approach

to health and healing. It provided a guided exploration of body-emotion awareness and


psychoeducational and subjective understanding of each woman's body-mind-emotions

and spirit experiences and connections. The third session was a more structured series of

questions aimed at eliciting awareness of spiritual development over the lifespan,

uncovering places of congruence and incongruence, exploring specific beliefs and

practices that may enhance or hinder spiritual groundings. The women also had an

opportunity to visually represent their idea of a higher power and delineate the ways that

this force has influenced their lives, if at all. Finally, the last session was conducted in a

spirit of playfulness and through the use of creative written and verbal expression. Each

woman was asked to answer a series of questions about themselves that encouraged the

use of active imagination. They were then instructed to write two poems using the words

from a list of answers. The themes were life and death and were meant to assist with the

uncovering of personal meaning and beliefs about each. This session enhanced self-

awareness pertaining to deeply held beliefs about the purpose of life itself and ideas

around death and/or the dying process. All individual sessions were aimed to facilitate

self-awareness, emotional exploration and expression, and the discovery of personal

strengths and potential areas of growth.

Dependent Variables

The dependent variables of this study were emotional expression, including pre-

and possession emotional reactivity for the experimental group subjects, spirituality, and

select aspects of psychological well-being. Emotional expression was assessed by the

Emotional Approach Coping Scale (EACS) (Stanton, Kirk, et al., 2000). Pre- and

postsession emotional reactivity for the experimental group was assessed by the


designated one. This practice, an effort to take care of the experimenter effect, was not

always possible or practical. Spirituality was assessed by the Expressions of Spirituality

Inventory-Revised (ESI-R) (MacDonald, 2000a). Psychological well-being was assessed

by the Profile of Moods States (POMS) (McNair, Lorr, & Droppleman, 1971).


The Emotional Approach Coping Scale (EACS), the Emotional Assessment Scale

(EAS), the Expressions of Spirituality Inventory-Revised (ESI-R), the Profile of Mood

States pomsS), a demographic questionnaire, and an exit interview were used to assess

subjects. The pretest instruments took an average of 10 minutes and the posttest

instruments an average of 20 minutes to complete. The pre- and possession tests of

emotional reactivity (EAS) for the experimental group took about one minute each to


Emotional Approach Coping Scale (EACS)

The Emotional Approach Coping Scale (EACS) was used to assess emotional

expression. The EACS was developed by Stanton, Kirk, et al. (2000) in order to


emotional approach coping, a construct based on a functionalist theory of emotions

(Campos et al., 1994; Levenson, 1994) as potentially adaptive for individuals in distress.

Emotional approach coping involves the active processing "(i.e., active attempts to

acknowledge and understand emotions)" and expression of emotions (Stanton, Kirk, et

al., 2000, p. 1150). The EACS includes subscales measuring emotional processing and

emotional expression. The scale has been used in several studies with breast cancer

patients (Stanton & Danoff-Bure. 2002: Stanton Danoff-Buri. et al.. 2000).


1994). Stanton, Kirk et al. (2000) identified three emotion-focused coping domains:

identification of emotions, emotional processing, and emotional expression. The

preliminary measure tested by Stanton and her research team included a total of 94 items:

33 items generated by Stanton and her research-team members and representative of the

three specified emotion-focused coping domains, embedded in a multi-dimensional

coping-strategies inventory of proven validity and reliability: the COPE, which has 48

items (Carver, Scheier, & Weintraub, 1989).

An additional 13 items, all considered to

contain the confounding factors of distress and self-deprecatory statements, were added

to demonstrate their distinction from the author-constructed items. The EACS used four-

point response options (1= I usually don't do this; 4

= I usually do this a lot) and was

tested in several research studies.

The first study consisted of 400 undergraduate psychology students who

completed the dispositional coping measure and the Emotional Expressiveness

Questionnaire (EEQ; King & Emmons, 1990), an existing measure of positive, negative

and intimacy-related emotional expression. Combined data (male and female scores) of

all 94 items were "submitted to a maximum likelihood factor analysis with promax


(Stanton, Kirk, et al., 2000, p. 1153) that yielded 9 factors: Emotional

Processing, Emotional Expression, Distress-contaminated Coping, Seeking Social

Support, Problem-focused Coping, Alcohol-drug Disengagement, Avoidance, Humor,

and Turning to Religion. The Emotional Identification and Emotional Processing

domains loaded on a single factor.

Using hieh factor loadings and lack of redundancy as criteria, the authors chose

for emotional processing, r = 0.72 and for emotional expression, r = 0.82. Test-retest

reliabilities were emotional processing = 0.73 and emotional expression

= 0.72. The

correlations between the emotional processing scale and the emotional expression scale

and the EEQ were reported as significant (p

< .005). Stanton, Kirk, et al. (2000) reported

"the correlation between the emotional processing and emotional expression scales was

at Time 1 and .65 at Time

< .0001)" (p. 1153). In order to control for self-report

response bias, the researchers conducted another study where students and family

members assessed each other's coping. The researchers reported internal consistencies

for self-reported coping through Emotional Processing as: a

.88 for students, .90 for

mothers, and .80 for fathers; for Emotional Expression they were reported as: a

.92 for

students, .91 for mothers, and .90 for fathers.

The final EACS consists of 16 items measuring the constructs: emotional

processing (eight items) and emotional expression (eight items). Stanton, Kirk, et al.

(2000) suggested that the scales be interpreted separately whenever emotional approach

coping is not the primary variable of interest. Although the authors embedded the

original EACS into other multi-dimensional coping measures, in this study, only the

Emotional Expression sub-scale was used to measure emotional expression.

Emotional Assessment Scale (EAS)

The EAS was designed by Carlson et al. (1989) to measure emotional reactivity.

This 24-item, self-report instrument is used to capture multiple, complex, simultaneous

emotions min individuals. It examines eight emotional states considered consistent across

cultures: anger (items 4. 12. 20). anxiety (items 6. 14. 22). disgust (items

. .

11. 19). fear


23), and surprise (items 1. 10. 18). The instrument has been deemed "very useful... for

measuring momentary levels and changes in emotions" (Fischer & Corcoran, 1994,

p. 203). Each item response ranges from "Least possible" to "Most possible"


state at the moment of scale completion. The test is scored by measuring the number of

millimeters from the left endpoint of the slash mark placed by the subject and located on

00mm line. Three items comprising each emotion are summed up for a score for that


The scale developers chose a visual analogue scale (VAS), used to measure

variations on intensity of pain (Price, McGrath, Rafii, & Buckingham, 1983), and thought

to be particularly useful in evaluation of ongoing and shifting emotional states (Carlson

et al., 1989). Carlson et al. contended that using a VAS in the measurement of emotions

"could be a valuable means of assessing ongoing emotional processes of persons engaged

in therapy or involved in psychological interventions designed to influence emotional


" (p. 315-316). The fact that a metric is used (instead of easily remembered

numbers) also decreases the chances that respondents' posttest ratings will be influenced

by pretest responses.

The EAS was developed on undergraduate psychology students, ages 18 to 34,

62% being female and 38% male. Reported means and standard deviations were as

follows: anger mean

14.6 (SD

= 18.9); anxiety mean

= 32.4 (SD

= 24.5); disgust


= 9.7 (SD

13.3); fear mean

13.0 (SD = 14.5)

guilt mean

12.6 (SD


happiness mean

= 38.8 (SD

= 23.8); sadness mean

= 19.1 (SD

= 19.6); and surprise


= 10.7 (SD

10.4) (Fischer & Corcoran, 1994).

Carlson et al. (1989) reported


The EAS is reported to have very good concurrent validity, with several of the

subscales correlating with existing measures such as the POMS, the Beck Depression

Inventory, and the State-Trait Anxiety Inventory (State form). The subscales are sensitive

to externally induced stress levels, making if particularly useful to measure emotional

reactivity in newly diagnosed breast cancer patients attempting to adjust to and cope with

a highly stressful situation. It is reported that the EAS'

with inter-item reliability for emotion factors ranging fr<

reliability is "good to excellent"

3m .70 to .91 and split-half

reliability of .94 (Fischer & Corcoran, 1994, p. 203).

Expressions of Spirituality Inventory-Revised (ESI-R)

The Expressions of Spirituality Inventory (ESI), developed by MacDonald

(2001), is a measure of spirituality derived from a two-stage factor analytic study of more

than 70 measures of spirituality with about 1,400 subjects (MacDonald,

Kuentzen, &

Friedman 1999). MacDonald created the ESI "to provide a well-designed and validated

measure of spirituality that incorporates existing psychometric conceptualizations into a

coherent organizational framework on which to understand and research the various

elements of the construct" (p. 157).

Spiritual dimensions resulting from the factor analysis were (a) Cognitive

Orientation Towards Spirituality (COS), (b) Experiential/Phenomenological Dimension

(EPD), (c) Existential Well-being (EWB), (d) Paranormal Beliefs (PAR), and

(e) Religiousness (REL).

The Cognitive Orientation Towards Spirituality (COS) dimension refers to

spiritual beliefs that are not expressed through religious affiliation. These may involve


The Experiential/Phenomenological Dimension (EPD) refers to spiritual

experiences that are of a transpersonal and mystical nature.

The Existential Well-being (EWB) dimension involves aspects of spirituality

related to existential facets of human functioning. This dimension appears to include

three main components: meaning and purpose in life, which derives from any number of

sources, a sense if inner strength and perceiving oneself as able to effectively cope with

fundamental aspects of life. The latter includes a relaxed approach to self and to everyday

life challenges.

The Paranormal Beliefs (PAR) dimension involves beliefs in scientifically

unproven phenomena.

The PAR dimension has been associated with higher indices of

pathology, including unusual thought patterns, psychosis, external locus of control, and

suggestibility (MacDonald, LeClair, Holland, Alter, & Friedman, 1995; MacDonald et

al., 1999).

Finally, the Religiousness (REL) dimension involves an intrinsic religious

orientation based on organized religious affiliation and practices. The REL dimension is

comprised of two aspects: (a) nondenominational beliefs about a higher power or being

and (b) religious practices such as prayer, attendance to religious services and meditation.

Extrinsic religious orientation (i.e., religious attendance for social status or gain) is

specifically excluded from the REL dimension.

Respondents of the ESI use a 5-point Likert-type scale (0

= Strongly Disagree,

= Disagree,

= Neutral,

= Agree, 4

= Strongly Agree) to rate agreement or

disagreement with given statements. The long form consists of 98 items (42 reverse

developed test with reasonable reliability and validity that systematically embodies

numerous constructs as tapped by several existing measures of spirituality"

(p. 159).

According to MacDonald (2000a), feedback from research participants and from
other investigators indicated that a 98-item version of the ESI presented problems that

made use of the measure difficult. Specifically, elderly populations reported problems

with the length of the instrument, other respondents complained that the items were

repetitive, and some of the reverse or negatively worded items proved difficult to certain

respondents, especially those for whom English was a second language. In order to

address these issues, MacDonald developed a revised version of the ESI. This study

utilized the revised version of the instrument, to minimize strain on subjects.

The ESI-R consists of 32 items. As in the original ESI, two items at the end were

added to provide face and content validity.

MacDonald (2000a) reported that the ESI-R

is different from the longer version of the test in three ways:

(1) The revised ESI consists of 30 items, six for each dimension; (

) Items were

selected from the 98-item version of the ESI based upon both uniqueness of
content as well as evidence of satisfactory psychometric properties. As such, any
appearance of item repetition is virtually eliminated from the instrument. Further,
the psychometric properties and correlates of the revised ESI are highly similar to
those for the longer version (e.g., all revised dimensions have been found to
produce scores with good reliability and satisfactory factorial validity); and (3)
Reverse worded items are kept to a minimum. (p. 18)

The ESI-R'

alpha coefficients range from .85 for Existential Well-Being to .97

for Cognitive Orientation towards spirituality. MacDonald et al. (1999) reported that

"corrected item-dimension total score correlations range from .40 to .80 for all items"

(p. 158). MacDonald (2000a) reported evidence of factorial, discriminant, convergent,


Profile of Mood States (POMS)

The POMS, developed by McNair et al. (1971), is a 65-item, 5-point Likert-type

scale of adjective ratings that are factored into six mood scores: tension-anxiety,
depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-

bewilderment. Subjects indicate mood states or reactions for the "past week including

today" or for brief periods such as "right now" (Eichman, 1978). Reliability of the POMS

ranges from .84 to .95 and test-retest correlations range from .65 to

.74. This is reported

as a considerable difference; however, congruent with a measure of mood states that are

deemed transient and changeable. Eichman concluded that the POMS "appears to be

optimally reliable and sensitive to change ... and a valid measure of mood states [that] is

simple and easy to use" (p. 1018). Face validity is reported as good (Eichman, 1978).

The POMS are a frequently used product development tool. Scores that form each

of these scales can be combined to yield a total mood disturbance score. Historically, the

scales have been used in research requiring a sensitive measure of affect following a

program of behavior modification, among others. Because of their documented use with

the population of breast cancer patients (Carver et al., 1993; Classen et al., 1996; Dibbell-

Hope, 2000; Goodwin et al., 2001; Hosaka et al., 2000; Spiegel et al., 1999; Stanton &

Danoff-Burg, 2002; Stanton, Danoff-Burg, et al., 2000) and considerable psychometric

properties (Eichman, 1978), the POMS sub-scales'

scores were used as a measure of

psychological well-being in this study.

Demographic Questionnaire

Demographic variables about each woman with breast cancer were obtained by

of breast cancer, medical treatment received for the breast cancer, and previous

experience with art therapy. The questionnaire also included details about the subject'

(in-home or out-of-home) employment situation. Finally, an open-ended question

explored whether the subject wanted to disclose additional information about her self that

had not been included in the questionnaire. The information included in this demographic

questionnaire was used in the final analysis of data.

Exit Interview

An exit interview form was obtained from each research subject in the control and

experimental groups who completed all four creative art therapy sessions. The exit

interview form explored the subjects' assessment of their participation in the study, their

opinions about the helpfulness of the creative art therapy interventions, whether they

would recommend the experience to other breast cancer patients, and suggestions for

health care providers, including mental health counseling practitioners, in general, and

the researchers of this study, in particular. The information obtained in this form was

used as a measure of clinical significance as it reflected each woman's subjective

appraisal of the individual creative art therapy experience, including perceived emotional

and psychological benefits thereof. This information also helped inform

recommendations for future research and clinical practice.

Finally, the main researcher of this study kept a reflective journal of the research

process min an attempt to document issues or concerns pertaining to research design,

subject recruitment, treatment implementation, results, and any other noteworthy items

that could help inform future research and clinical practice. Relevant entries from this