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
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
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
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.
TABLE OF CONTENTS
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 ..
REVIEW OF THE LITERATURE
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 ... ... ... .. ... ...
t oa l . . . a a a a 4 . 10S
. .. . . . . . . . . 25
tionale . . . . . . . . . 210
.. . . . .......25
. . . . . . . . . . 2 5
.*. a . a a . a t . a . . . 27
S S S S S 4 5 5 5 5 a 4 S S S S 5 5 5 5 5 S S 2 8
. . . . 28
. . . . . . 29
. . .9. .*. .S. .S. 38
ing ... . ... .. .44
.. .. .. .. . .. 648
. . . 5 2
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 .....
Tlclian nfthp gtriid;,
. .. . . . . . . .. 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
* S S S* S i St S S S S S S i S i St S 4* a a a S I 4 5 5 4 4* 5 5 a a a a a 67JV
. . . . . . . . . . 67
. . . . . . . . . a . 68
. . . . . . . . . . 70
* 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
. . . 128
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
E INTRODUCTION TO STUDY LETTER-EXPERIMENTAL GROUP ...... 152
F DEMOGRAPHIC QUESTIONNAIRE .................................. 153
G INTRODUCTION TO STUDY LETTER-CONTROL GROUP .. p. ..... 154
H POSTTEST COVER LETTER CONTROL GROUP ........ 155
I POSTTEST INSTRUCTIONS-CONTROL GROUP ....... ....... 156
J POSTTEST COVER LETTER-EXPERIMENTAL GROUP ..... ... 157
K POSTTEST INSTRUCTIONS-EXPERIMENTAL GROUP ... ..... 158
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
THE EFFICACY OF ART THERAPY TO ENHANCE EMOTIONAL EXPRESSION,
AND PSYCHOLOGICAL WELL-BEING OF NEWLY DIAGNOSED
STAGE I AND STAGE II BREAST CANCER PATIENTS
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
depression, and anxiety and may generate feelings of fear, anger, guilt, and emotional
repression. Emotional repression
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
not effective in enhancing the
;pression or the level of spirituality of
this sample. However, participation in the art therapy
decrease negative emotional states and
enhanced positive ones of experimental group
shifts in feeling states indicate that the women were able to
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
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
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 &
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,
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
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.
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.
A breast cancer diagnosis presents an enormous challenge to a woman's
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.
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
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
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
hodv_ one's ancestors, saints. Higher Power or God" (n. 15-16Vl
rituals, sacred scriptures, doctrines, rules of conduct, and other practices"
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
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
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"
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'
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.
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'
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 .
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
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-
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.
The following research questions were addressed in this study:
* Can creative art therapy help enhance newly diagnosed Stage I and Stage II breast
' 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
' 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
REVIEW OF THE LITERATURE
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;
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"
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
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,
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
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"
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
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
= 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
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
nrnuln t csnni~ntnn^+/^- lxrac Arc,1nnr-MoA xi.Aht1-i a k-ir~ti'i/ b~oalnnir fy~ranljznxx/nrlr tn\ Qoccic P^Qflfl'r
& 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"
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
rnmnrnrrl ix/ith thel Prnte`ctant refptrsrnr. -rsnrnuin Thb` rnithnrc rnnn~rthldA* that nnnr,=>1mrnuic?
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
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
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
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
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,
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
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
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'
interpreted them as therapeutic experiences of emotional expressivity and as reflection of
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"
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"
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"
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
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
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
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
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-
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
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,
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.
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
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),
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-
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
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.
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
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
Descriptive Data Analysis
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
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.rw t i-^ hi*/ I .~ fs ^ rr- i^ fvv/ ^ *i + ^/*
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
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.
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
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
mail. A cover letter (Appendix J) and written instructions (Appendix K) were
Delineation of Relevant Variables
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
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.
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
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
= 18.9); anxiety mean
= 32.4 (SD
= 24.5); disgust
= 9.7 (SD
13.3); fear mean
13.0 (SD = 14.5)
= 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,
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
The Paranormal Beliefs (PAR) dimension involves beliefs in scientifically
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
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,
= 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"
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)
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 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.
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