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Title:
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
Creator:
Puig, Ana
Publication Date:
Language:
English
Physical Description:
xi, 183 leaves : ill. ; 29 cm.

## Subjects

Subjects / Keywords:
Counselor Education thesis, Ph. D ( lcsh )
Dissertations, Academic -- Counselor Education -- UF ( lcsh )

## Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 2004.
Bibliography:
Includes bibliographical references.
General Note:
Printout.
General Note:
Vita.
Statement of Responsibility:
by Ana Puig.

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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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University of Florida Theses & Dissertations

Full Text

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

By

ANA PUIG

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

"Hope i.
That

s the

thing with

perches

in the

feathers
soul,

And sings the tune
Without the words

never

stops

at all. '"

Dickinson

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,

I
Ikn

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

o.
are.

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.

ACKNOWLEDGMENTS

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

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.

Wendy

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

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

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

the focus of this research study.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

say, enjoyable!

A few individuals from various disciplines provided much needed assistance,

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

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

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

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

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

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.

pjage

ACKNOWLEDGMENTS

ABSTRACT

CHAPTER

INTRODUCTION

Overview

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

Introduction

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 ... ... ... .. ... ...

3 METHODOLOGY

t oa l a a a a 4 10S
. .. . . 25

tionale . . 210

.. .......25

. . . 2 5
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. 28
. . 29
. .9. .*. .S. .S. 38
ing ... ... .. .44

.. .. .. .. .. 648
5 2
63

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
72
67

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

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

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

. . . 10 3
. . . 10 6

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

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

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

. 128

. 139
139

APPENDIX

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

REFERENCES

. . 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,

SPIRITUALITY

AND PSYCHOLOGICAL WELL-BEING OF NEWLY DIAGNOSED

STAGE I AND STAGE II BREAST CANCER PATIENTS

By

Ana Puig

December 2004

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

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

States. The psychological impact of the disease may include

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

repression. Emotional repression

Emotional expression

has been linked to women with breast cancer.

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

emotional

expression, spirituality, and psychological well-being in newly

diagnosed

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

were

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

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

women were included in the final sample.

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

results, which indicated that the intervention was

emotional approach coping style of emotional ex

analyze the

not effective in enhancing the

;pression or the level of spirituality of

subjects in

this sample. However, participation in the art therapy

intervention helped

decrease negative emotional states and

enhanced positive ones of experimental group

subjects. These

shifts in feeling states indicate that the women were able to

process and

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

anecdotal clinical observations.

enhanced

Additionally, the creative art therapy intervention

psychological well-being of women in this sample by decreasing

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

affective aspects of this construct.

effect changes in the

Finally, as hypothesized, the intervention did not

physiological aspects of psychological well-being: vigor-activity

and fatigue-inertia.

I

CHAPTER 1
INTRODUCTION

Overview

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

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

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

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

significant others.

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

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

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

Researchers have also documented the psychological impact of the disease;

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

ability to deal

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

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

der Pompe, Antoni,

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

Ararnnn It jcnlata, vnn

2

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,

1992).

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'

emotional

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.,

2002

Goodwin et al.

,2001; Gore-Felton & Spiegel,

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

behavioral group therapy (Antoni et al.,

2001

Bloch & Kissane, 2000; Cunningham et

al., 1998; Edelman, Lemon, Bell, & Kidman, 1999; Kissane et al., 1997; Watson, Fenlon,
.4

McV

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

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

Moore, 1997

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

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

Spiegel & Bloom, 1983;

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

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

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

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

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

4

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

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

Breast cancer is the second most common form of cancer,

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

" with

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

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

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

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

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

White (18.3 White

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

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

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

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

commonly, extreme expression).

Watson et al. (1991) reported an association between

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

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

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

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

predominant characteristic.

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

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

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

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

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

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

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

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

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

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

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

to achieve and maintain harmonious interpersonal relationships"

(p. 41). Emotional

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

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

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

psychological factors like 'ways of coping'

or 'non-expression of negative emotions'

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

Depression and adjustment disorders are common in this patient population and

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

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

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

the Type C personality commonly associated with emotional suppression, preexisting

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

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

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

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

8

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 ,
S*
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'

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

forefront.

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"

10

(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

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

well-being.

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

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

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

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

and health also informed our line of inquiry.

Positive Psychology

Positive psycholo

has recently emerged as "a science of positive subjective

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

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

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

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

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

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

12

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

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

sense of

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

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

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

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

Mental health counselors committed to the positive psychology paradigm may

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

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

counseling have almost exclusively focused on psychopathology and the medical model
WI
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

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

well-being.

Creativity and Flow

Applied positive psychology encourages creativity and spirituality, and suggests

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

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

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

service of external goals.

(p. 69)

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

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

describe moments of transcendence wherein their consciousness of time and place

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

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

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

what Csikszentmihaly defined as the creative experience of flow.

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

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

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

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

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

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

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

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

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

focused on the latter.

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

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

14

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

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

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

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

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

the creative process and the experience of flow.

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

constitute the conditions of flow:

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

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

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

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

see in

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

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

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

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

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

the mind by integrating one

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

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

harmony for the individual.

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

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

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

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

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

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

Csikszentmihaly' s

conceptualization of the experience of flow as described herein.

Spirituality and Health

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

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

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

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

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

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

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

2000; Woods & Ironson, 1999).

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

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

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

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

heritage and

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

This

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

Worthen, 1997

(Anderson &

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

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

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

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

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

Thoresen (1999) reviewed literature addressing spirituality and health and

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

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

factors, and health" (p. 294).

He cautioned that correlation does not imply causality, and

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

the literature presented physiological and psychological evidence that offers promise and

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

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

health status"

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

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

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

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

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

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

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

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

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

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

(p. 96). George, Larson,

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

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

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

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

health variables.

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

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

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

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

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

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

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

(p. 11).

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

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

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

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

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

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

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

quantitative design and methods so causal relationships can be evaluated.

18

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'

disease"

(p. 447).

Creative art therapy interventions may help clients reconnect with

themselves holistically and make meaning of their current life'

struggles. In recursive

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

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

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

sought to explore these relationships.

Emotional Expression

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

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

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

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

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

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

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

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

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

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

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

short-lived psychological-physiological phenomena that represent efficient modes

19

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

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

treatment.

Research literature on emotional expression and cancer has addressed two

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

Vingerhoets,

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

blaming"

(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

21

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

expressive group psychotherapy resulted in reduced overall distress.

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

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

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

improving psychological, social and physiological well-being"

(p. 284). The authors also

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

encouragement of open emotional expression about the disease.

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

expression in cancer adjustment were confounded by the researchers'

use of

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

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

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

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

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

authors reported positive psychological adjustment in cases involving intentional efforts

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

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

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

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

individuals.

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

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

22

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

cancer patients.

Creative Art Therapy

The relationship between spirituality, creativity, and healing has been

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

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

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

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

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

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

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

patients' experience of the disease.

Innovative treatment interventions are being proposed, developed, and researched

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

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

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

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

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

spirituality and psychological well-being.

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

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

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

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

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

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

repertoire of varied emotions"

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

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

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

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

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

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

management of difficult emotional states and offer relief for clients receiving

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

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

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

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

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

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

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

does not require verbal reflection"

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

24

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
7i
practice" (p. 242). Review of the literature indicated a relative absence of research

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

a treatment intervention for breast cancer patients.

Counseling interventions should be informed by sound theory and research

(Greer, 1999).

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

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

psychological stressors and existential dilemmas resulting from the cancer diagnosis and

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

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

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

adjunct to the intentional exploration and expression of difficult emotions.

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

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

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

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

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

25

Qualitative studies of breast cancer patients that received creative art therapy

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

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

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

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

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

Hope, 2000).

The relationships among these constructs had yet to be explored using

rigorous, experimental design and methodology.

Purpose

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

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

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

diagnosed, Stage I and Stage II breast cancer patients.

Research Questions

The following research questions were addressed in this study:

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

cancer patients

' emotional expression

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

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

cancer patients

' psychological well-being?

Definition of Terms

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

26

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

upon.

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

27

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

CHAPTER

REVIEW OF THE LITERATURE

Introduction

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

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

29

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

Psychlnfo.

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
.4

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

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

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

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

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

Helgeson et al., 2001),

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

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

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

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

Emotional Expression and Cancer Incidence

The relationship between emotional suppression and incidence of breast cancer

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

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

age, a highly

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

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

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

existing disease requires clarification"

(p. 1079).

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

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

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

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

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

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

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

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

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

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

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

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

=48)

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

32

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

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

preexisting emotional or psychiatric disorders and psychological adjustment increase a

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

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

morbidity and her psychological adjustment. Research evidence also remains

inconclusive about whether psychological factors such as a woman'

coping style and/or

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

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

Ploeg, 1999).

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

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

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

diagnosis.

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

cancer patients'

psychological morbidity.

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

of cancer patients (Spiegel, 1996).

Spiegel has researched the incidence of clinical

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

interventions to facilitate emotional expression:

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

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

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

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

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

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

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

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

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

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

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

34

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

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

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

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

threatening disease rather than reflecting premorbid personality features"

(p. 27).

Emotion-Focused Coping

Emotion-focused coping involves the active processing and expressing of

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

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

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

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

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

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

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

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

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

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

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

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

in randomized controlled trials tend to be relatively homogeneous in demographic

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

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

Stanton and

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

experimental emotional expression through expressive writing on cancer patients. They

conducted a randomized experimental expressive writing intervention on 60 women

(mean age

= 50 years; mean time since diagnosis duration

= 28 weeks) diagnosed with

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

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

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

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

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

period. Trained research assistants read instructions from prepared scripts.

Writing

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
experience.

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

36

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

37

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" --

38

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
a
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).

39

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

patients'

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

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

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

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

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

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

medical treatment.

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

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

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

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

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

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

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

40

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

anxiety.

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

41

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

program that explicitly integrates spiritual resources into the psychotherapy process may

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

even exceed those offered by traditional psychotherapy"

(p. 405).

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

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

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

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

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

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

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

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

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

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

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

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

spiritual factors uncovered:

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

This

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

42

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 Prntectant refptrsrnr. -rsnrnuin Thb rnithnrc rnnn~rthldA* that nnnr,=>1mrnuic?

43

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

connectedness.

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

44

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
i1
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

Simonton's

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'

needs,

45

decision-making period and almost half of early stage cancer patients (including those

with relatively good prognosis) have been found at risk for moderate to severe

psychological distress (Bleiker, Pouwer, van der Ploeg, Leer, & Ader, 2000).

The research literature has documented a number of negative psychological

consequences of a cancer diagnosis, including clinical depression and anxiety (Bleiker et

al., 1995; Payne et al., 1999; Razavi & Steifel, 1999; Spiegel, 1996). Breast cancer

patients also struggle with performing daily physical, occupational and/or social activities

with a considerable number (20-46%) suffering from moderate to severe emotional

morbidity (van der Pompe et al., 1996).

Spiegel (1996) reported even though about 50%

of all cancer patients have a psychiatric disorder (e.g., adjustment disorder with

depression) "comorbidity of psychiatric with medical illness is a common and under-

recognised problem; [emphasizing that effective treatment of depressive symptoms]

results in better patient adjustment, reduced symptoms, reduced costs of care, and may

influence disease course" (p. 109). Antoni et al. (2001), on the other hand, cited several

studies that researched and reported positive consequences of a cancer diagnosis. The

authors contended:

Although diagnosis and treatment for cancer are distressing and disruptive, there
is an increasing awareness in both research and clinical communities that the
cancer experience often has sequelae that patients view as positive or beneficial.
A substantial number of patients report experiences such as improvement in
personal resources and skills, an enhanced sense of purpose, enhanced
spirituality, closer relationships with significant others and changes in life
priorities. (p. 21)

These findings emphasize the diversity of adjustment responses that may be found across

this nonulation.

46

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.

364).

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.,

47

2001; Bloch & Kissane, 2000; Cunningham et al., 1998; Edelman et al., 1999; Kissane et

al., 1997

Watson et al., 1996),

and mixed modalities (including psycho-education, stress

management, guided imagery and/or hypnosis) group therapy (Spiegel & Moore, 1997

Fawzy et al., 1990; Fukui et al., 2001; Hosaka et al., 2000; Richardson et al., 1997

Simpson et al., 2001; Spiegel & Bloom, 1983; Spiegel et al., 1989).

A number of research studies have explored the efficacy of supportive expressive

group therapy on cancer patients'

emotional expression (Giese-Davis et al., 2002),

psychological adjustment (Classen et al. 1996), distress (Classen et al., 2001; Spiegel et

al., 1999), and survival (Goodwin et al., 2001). It should be noted that supportive

expressive group therapy does not usually incorporate art media in its interventions; the

disciplines of expressive arts therapy and creative arts therapy most commonly do

(Malchiodi, 2003).

Supportive expressive group therapy specifically geared toward emotion-focused

coping has been shown to help women with metastasized breast disease to express their

emotions more openly and freely without becoming hostile (Giese-Davis et al., 2002).

Classen et al. (1996) reported emotional expressiveness and adoption of a fighting spirit

approach to coping (Friedman, Nelson, Baer, & Lane, 1990) were associated with better

psychological adjustment. Supportive expressive group therapy that emphasized

provision of support and helping subjects manage the stress caused by the cancer and its

treatment was found useful in reducing psychological distress in women with

metastasized disease (Classen et al., 2001).

Spiesel et al. (1999) also researched breast cancer patients receiving supportive-

48

Goodwin et al. (2001) reported that participation in supportive expressive group therapy

by women with metastasized breast cancer did not prolong survival in the treatment

group; however, it helped to improve mood and perception of pain,

"particularly in

women who [were] initially more distressed" (p. 1719). Finally, a review of the literature

on the overall efficacy of supportive-expressive group psychotherapy, including emotion-

focused interventions, concluded that overall results suggested these support groups

helped enhance psychological, social and physiological well-being of breast cancer

patients (Gore-Felton & Spiegel, 1999).

Research on Creative Art Therapy and Cancer

An increasing number of oncology patients receiving medical treatment for a

wide range of cancers have opted to participate in art therapy experiences to help them

cope with the physical, emotional and mental stressors that such a diagnosis brings (Lane

& Graham-Pole, 1994). According to Malchiodi (2003) "some practitioners see art

therapy as part of a larger discipline referred to as expressive arts therapy (the therapeutic

use of art, music, dance/movement, music, drama and poetry/writing) and intermodal or

multimodal (moving from one art form to another) approaches" (p. 106). Creative arts

therapy and expressive arts therapy may be aimed at enhancing emotional expression,

spiritual connectedness, and psychological well-being of cancer patients.

Research exploring the efficacy creative art therapy on cancer patients has

primarily focused on qualitative methods (D. Aldridge, 1998; Davis, 2000; Dreifuss-

Kattan, 1990; Haegglund, 1976; West, 1995).

engagement in the creative arts can be a healing experience for individuals suffering from

D. Aldridge (1998) explored Life as Jazz, a metaphor for bringing hope and

' meaning to individuals facing life-threatening illness. According to the author, creative

musical improvisation can enhance an individual's ability to tap into inner sources of

strength and resilience. His study focused on'multiple patients dealing with a wide

variety of medical diagnoses, including breast cancer. The author concluded that music

enhanced his client'

lived experience of spirituality and fostered a sense of hope while

facing disease. Music therapy has emerged as a distinct discipline from art therapy;

however, it was included herein to demonstrate the increased use of creative therapies in

cancer patient treatment and research.

Davis (2000) developed a book that offers cancer patients a structured writing

intervention to guide the emotional expression of thoughts and feelings as they come to

terms with and learn to cope with their disease. Dreifuss-Kattan (1990) provided

psychooncological and psychoanalytical overviews of subjects'

experience of cancer and

reported that multimodal creative art therapy helped enhance their emotional and

psychological well-being.

Haegglund (1976) conducted a psychoanalytic study addressing the relationship

between creativity, the death and dying experience, and attitudes of cancer patients. The

author contended that poetry writing may appease and help soothe the pain of loss and

mourning often associated with a cancer diagnosis. Haegglund conducted a literature

review and its findings supported his original hypothesis (that a relationship among these

constructs does exist). The author illustrated his point by presenting five cases studies of

individuals suffering from cancer who used poetry writing as a way to face feelings of

50

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
a*
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,

1995).

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
al
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

itself.

Wyatt-Brown approached Philip's work as an exploration of the themes of

creativity and professional identity. She conceptualized Philip's

writing and self-

disclosure process as a way of coming to terms and wrestling with the experience of

dying. (Philip moved from secrecy the first 3 years after diagnosis to broad self-

disclosure via journal publications the last year of her life).

Wyatt-Brown suggested this

choice to write and express her thoughts and feelings in a public professional forum was

an emotionally healing experience for Philip.

One study explored the roles of spirituality and creative art therapy in mental

health care practice (Greenstein & Breitbart, 2000).

Greenstein and Breitbart proposed a

group intervention to help cancer patients address the challenges that their disease brings.

They developed sessions focusing on aspects of meaning, including a sense of

transcendence, spirituality, responsibility, values, priorities, and personal creativity. The

group intervention incorporated aspects of the creative arts by exposing patients to

instances of meaning, which can be found through the appreciation of beauty in nature or

works of art. According to the authors: "whether pursuing creative goals and experiential

values or reframing one's attitude, [individuals] may attain a sense of meaning in part

through transcendence" (p. 497), a spiritual experience of connectedness with others or

with a universal, larger whole beyond ourselves. In their qualitative explorations of

spirituality and creativity in healing, the authors concluded that creative art therapy

enhanced patients'

ability to ooenlv express painful emotions, including the experience

52

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'

self-reported

psychological

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,

2000).

G. Aldridge (1996) conducted a case study of a 35-year-old female patient

diagnosed with breast cancer. The participant began a music therapy experience after

undergoing radical mastectomy of one breast. The therapy was geared to provide a

vehicle for melodic expression and a forum to reflect upon the emotional experience of

managing her disease. The author defined creative music therapy as "an approach that

actively pulls the client into the process of performing music-the therapeutic

gestalt-[and] exerts an influence on the abilities of the patient to express herself'

(p. 213). G. Aldridge explored the melodic flow of the subject'

improvisations and

interpreted them as therapeutic experiences of emotional expressivity and as reflection of

the subject's

emotional healing process. The author contended that spontaneous musical

improvisation assisted his client to access her creative power, a potential source of

53

creativity and creative strength to cope with their crisis and maintain coherence through

their illness ... within a culturally accepted form"

(p. 221-222).

Cruze (1998) provided a case study of the breast cancer experience by reporting a

subjective, personal account of her struggle with the disease and the healing she

experienced through a collaborative creative process. Cruze, a physician, was diagnosed

with breast cancer in 1991 and underwent a mastectomy and chemotherapy treatments.

Four years prior to her diagnosis she had attended a presentation by sculptor Christiane

Corbat, who helps cancer survivors make plaster sculptures of their torsos after

mastectomies. These artistic pieces, named the Amazon torsos, tour the United States and

serve as symbolic representations of the women's

stories of tragedy and triumph. Cruze

and Corbat met and discussed this artistic process after Cruze had finished her cancer

treatment. The author was surprised to hear Corbat indicate that she had a hard time

finding women who could bring out the positive aspects of their cancer experience. Cruze

reported she also felt unable to see anything positive in her struggle. After this exchange,

Cruze realized that her future happiness and well-being depended upon her ability to

view the experience with breast cancer and surgery in a positive light. Cruze decided to

have Corbat complete a sculpture of her torso. She described her experience thus:

The plaster cast made me think that I was broken and being reset in order to heal.
My plaster exoskeleton became a warm chrysalis and my soft bug bits solidified
as my pupa matured to imago. As I wriggled out of my hard shell I remembered
having watched a monarch butterfly pump its moist crumpled wings out full and
shapely and dry. I mimicked the movement and made as if to take flight. I felt
transformed! (p. 402)

Corbat completed a sculpture of Cruze's plaster torso and named it Night Light.

of happiness and optimism and, ultimately, gaining the ability to reframe her cancer

experience. Cruze concluded that looking at the sculpture makes her feel "triumphant,

victorious over [her] disease for the first time"

(p. 402).

Predeger (1996) conducted qualitative research using the feminist process

method, a feminist esthetic cooperative inquiry, described as purposeful authentic

collaboration and shared meaning that allows the power of collectivity to emerge.

Predeger and her co-researchers named this process Womanspirit: A journey into healing

through art in breast cancer. A convenience sample of 18 women (ages 39 to 70) from

diverse backgrounds and representing various disease stages, participated in this research

for a 6-month period. The women used artistic expression in the form of painting,

photography, collage, and writing. Collaborative reflection among the coresearchers was

central to the feminist esthetic framing the study. The study

method is described as

evolving within a group session format that "followed a deliberate structure of centering,

art experience, reflection, and action"

(p. 51).

The centering part of the group session

began with a check-in, or an opening-up, where participants became present to each

other. A question was then posed to encourage centering and reflection. The women

proceeded to choose a favorite art medium and to utilize the creative process as vehicle

for describing the breast cancer experience. Sharing among group members took the form

of synthesizing and interpreting the observation of images. Analysis of emergent themes

ended each session. In order to secure data, each session was audio taped and transcribed;

transcripts were discussed and analyzed collectively during later sessions. Additional

data sources came from participants'

reflections about their art, researchers' field notes,

process where emergent themes were discussed and would be revisited in subsequent

sessions, thus deepening the coanalysis of the experience. Leadership, group direction,

individual and group insights occurred throughout the research process.

The guiding research questions were (a) what is the meaning of healing through

the expressive arts for women living with breast cancer and (b) what are the processes

and outcomes of women cocreating personal and collective knowing? Predeger (1996)

chose a holistic nursing paradigm to guide the inquiry. This paradigm affirms multiple

ways of knowing and multiple healing perspectives. The author chose a participative

worldview lens whereby the lived experience of the women's

reflections of healing

through art and group work could be viewed. Predeger described her research

methodology as "open, reflective, dialogic and engaging whatever methods best meet the

aims of the study" (p. 50).

The following themes on personal and collective healing emerged:

* Actualizing the need to express
* Losing and gaining control
* Illuminating a changing perspective
* Transcending and becoming braver
* Connecting with sisters
* Creating a safe harbor
* Fueling the creative spark
* Celebrating the feminine
* Womanspirit.

Actualizing the need to express refers to the women's contention that being able

to express their feelings and thoughts through art was viewed as timely and opportune.

The ability to express became more important than the media used or the final product

itself. The sharing deepened as the group sessions progressed.

56

regain control. This paradoxical process of surrender and empowerment also deepened,

and became easier with time.

Illuminating a changing perspective refers to their reframing of the breast

cancer experience. Art is described as a pathway toward healing and meaning making

that transcended prior interpretations of the struggle with the disease. The women were

able to focus on the goodness in their lives rather than the negative aspects of struggling

with cancer.

Transcending and becoming braver refers to the wish to move beyond their

own struggle and reach out to assist others facing the disease. Becoming proactive

emerged as an important aspect of healing for the women; this took the form of political

involvement, expressing thoughts and feelings assertively, or reframing themselves from

victims to survivors.

Connecting with sisters refers to the collective engagement in feminist research

and embracing an ideology that promotes support and encouragement of women. The

experience of sisterhood provided companionship and warmth that reduced feelings of

alienation or loneliness.

Creating a safe harbor refers to the women's

framing their art-making process

as a place of rest and replenishing. The time spent together provided needed relief from

everyday worries.

Fueling the creative spark refers to the power of the collective to inspire the

women to explore their thoughts and feelings through the creative process. Some of the

women reported a reawakening of their creative selves they had long neglected.

Celebrating the feminine refers to the experience of making art within a feminist

Womanspirit underlies the spirit of women reaching out and bravely
transcending their own boundaries in their quest for healing; [it] captures the
process of knowledge cocreated from experience, exploration, expression, and
empowerment of the women realized within the collective methodology....
Women, connected in spirit, are finding their own way. (p. 57)

Predeger (1996) concluded that the voices of personal and collective healing, as

experienced by the women through their artistic creative process, must be heard; health

care practitioners and researchers "would benefit by collaborating with women in a

nonhierarchical participative model where dialogue of experiences and possibilities are

uncovered" (p. 57).

Dibbell-Hope (2000) explored the use of dance/movement therapy in the

psychological adaptation to breast cancer. The study was an attempt to address the lack

of systematic, quantitative, controlled approaches to clinical therapy research. Authentic

Movement was chosen as the clinical intervention and is described as a therapeutic

process based on the Jungian concept of active imagination. The dancer is encouraged to

move at her own pace, in her own time, within her physical limitations and is always in

control of the process. The dancer is also encouraged to attend to her inner experience by

closing her eyes and listening to her body, learning to trust herself, and opening up to

others'

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.

58

The research questions were (a) can an Authentic Movement group help women

with breast cancer increase their level of psychological adaptation to the disease and its

treatment and (b) can that increase be sustained over time? Research hypotheses were

(la) Participation in an Authentic Movement treatment group will improve '
psychological adaptation of women with breast cancer significantly more than
waiting for treatment.

(1 b) Improvement will be sustained over time.

(2) Women who show the most improvement will be older, have had earlier stage (I
or II) cancer diagnosis, less invasive medical treatment, more time elapsed since
the end of treatment, and more past experience with physical activities (i.e., sports
or dance).

Inclusion criteria were as follows:

* Diagnosed with Stage I or Stage II breast cancer.
* Treatment completed 6 to 60 months prior to the study.
* No prior breast cancer diagnosis.
* No active psychiatric symptoms (i.e., hallucinations, delusions, severe psychiatric
morbidity).
* 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

59

image and self esteem scores in the Borscht-Walker-Bohrnstedt Body Image Scale

(BWB).

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

=54.7

Therapy

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

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

60

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

distress

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
4
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

women.

Hypothesis 2 was tested through a step-wise multiple regression procedure to

if the demographic factors selected (age, stage of cancer, type of treatment, time since

treatment, and experience in sports and dance) may predict level of psychological

adaptation. The stage of breast cancer was the most frequent predictor of mood and

distress. Age was the most significant predictor of satisfaction with body image and self-

esteem. Hypothesis

was largely supported.

Qualitative data from the interviews and written evaluation were analyzed within

a phenomenological framework "in order to capture the nature of each woman's

individual experience, to point out any common elements or themes and to summarize

descriptively and succinctly the essence of the experience"

(p. 62). Most women,

according to the author, reported that the Authentic Movement dance therapy experience

was positive and healing, assisting them to resolve issues related to their breast cancer

struggle, especially disturbances in mood, negative feelings about their bodies, and social

isolation. The author acknowledged that subjectively perceived improvement in distress,

mood, self-esteem, and body image after the therapeutic dance experience cannot be

interpreted as a direct causal relationship since she made no attempt to correlate or track

62

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

subjects'

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,

63

Conclusion

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

patients'

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'

emotional

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

findings reported in this literature review appear promising and have shown

psychological benefits associated with engagement in creative arts therapy. Research

studies about the efficacy of art therapy on patients with various types of cancer have

included music therapy (D. Aldridge, 1998

West, 1995),

structured and unstructured

journal writing, including poetry and prose (Davis, 2000; Haegglund, 1976; Philip, 1995;

Smith, 1995; Wyatt-Brown, 1995), art appreciation (Greenstein & Breitbart, 2000), and

multimodal art therapy (Dreifuis-Kattan, 1990). Research studies about the efficacy of art

collaborative sculpting (Cruze, 1998), multimodal art therapy (Predeger, 1996), and

dance therapy (Dibbell-Hope, 2000).

Dibbell-Hope's (2000) study about the efficacy of dance therapy on the

psychological adjustment of breast cancer patients was the only one to use both

quantitative and qualitative measures. No treatment effect was found for post-treatment

or delayed treatment variables measured quantitatively. Subjective assessments, however,

showed post-treatment benefits, as have the other qualitative studies reviewed here

(G. Aldridge, 1996; Cruze, 1998; Predeger, 1996).

A number of studies found, which examined the efficacy of experimentally

induced expressive writing, music therapy or creative art therapy,

reported positive

findings (e.g., enhanced emotional expression and psychological well-being) that were

also described (by the authors and/or the subjects) in spiritual language and overtones

(e.g., D. Aldridge, 1998; Philip, 1995; Predeger, 1996; Stanton & Danoff-Burg, 2002).

Although not directly exploring spiritual or religious factors, these studies suggest that

cancer patients' experiences of psychological and/or emotional healing may be

subjectively appraised as spiritual ones; thus underscoring the value of a holistic

approach to health care practices and research.

Clearly a diagnosis of breast cancer presents great challenges to a woman's

body,

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.

CHAPTER 3
METHODOLOGY

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.,

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

66

relevant variables, instrumentation, and data analysis. Methodological limitations of this

research study are also discussed.

Research Hypotheses

The following research hypotheses were evaluated in this study.

Ho(l): There is a significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on emotional expression,

as measured by the Emotional Approach Coping Scale (EACS) in newly diagnosed,

Stage I and Stage II breast cancer patients.

Ho(2): There is a significant difference between the experimental group's

pre-and

post-session scores on positive and negative emotional expression/states as measured by

the Emotional Assessment Scale (EAS) in newly diagnosed, Stage I and Stage II breast

cancer patients.

Ho(3): There is a significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on spirituality, as

measured by the Expressions of Spirituality Inventory-Revised (ESI-R),

in newly

diagnosed, Stage I and Stage II breast cancer patients.

Ho(4):

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.-

67

Ho(6): There is a significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on the psychological well-

being subscale, Anger-Hostility, as measured by the Profile of Mood States pomsS),

newly diagnosed, Stage I and Stage II breast cancer patients.

Ho(7): There is no significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on the psychological well-

being subscale,

Vigor-Activity, as measured by the Profile of Mood States.(POMS), in

newly diagnosed, Stage I and Stage II breast cancer patients.

Ho(8): There is no significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on the psychological well-

being subscale, Fatigue-Inertia, as measured by the Profile of Mood States pomsS), in

newly diagnosed, Stage I and Stage II breast cancer patients.

Ho(9): There is a significant difference between the experimental group of

creative art therapy and the control group of delayed treatment on the psychological well-

being subscale, Confusion-Bewilderment, as measured by the Profile of Mood States

pomsS), in newly diagnosed, Stage I and Stage II breast cancer patients.

Description of the Population

The population was comprised of newly diagnosed breast cancer patients. The

subjects were diagnosed with Stage I or Stage II breast cancer within 12 months of being

referred to the study. The sample was recruited from women recently diagnosed with

breast cancer who reside in the North Central Florida area and were receiving treatment

+lnw^Birn-l it l-%a d~f nnaryr^ na~r at ilCl. ani le ~n-^' L-Jnot o1--rri +l-in no nnor n- a ntnrf i M at N/^nrtln 171 ^yrlr A a P oa nn 1

The U

Census Bureau (2001) estimates that the North Central Florida area,

which includes Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,

Lafayette, Levy, Madison, Marion, Putnam, Suwanee, Taylor, and Union counties, has

about 936,700 residents with 47% being female. North Central Florida area's population

breakdown by race/ethnicity is 79% Caucasian, 17% African-American, 4% Hispanic,

0.6% Asian, and 0.5% Native American. Alachua County, where this experimental study

took place, has about 218,800 residents with 51% being female. Alachua County's

population breakdown by race/ethnicity is reported as follows: 74% Caucasian, 19%

African-American, 8% Hispanic, 4% Asian, and 0.2% Native American.

According to the American Cancer Society (ACS, 2002) 211,300 new cases of

invasive breast cancer and 55,700 in situ breast cancer cases among women are expected

in the U.S. in 2003; of these cases, 39,800 deaths are expected.

Breast cancer is the

second most common form of cancer, "accounting for nearly one of every three cancers

diagnosed in American women,"

with African-Americans more likely to die from the

disease than Caucasians (ACS, 2002). In the state of Florida, the incidence of female

breast cancer is 18.0 (In situ) and 110.0 (Invasive) with mortality rate of 23.2 per

100,000, age-adjusted to the 1970 U.S. standard population (ACS, 2002).

Data Collection and Attrition

This study was conducted from November of 2003 through July of 2004; all data

was collected throughout that time. In order to advertise the study, research flyers were

posted in parking garages at Shands Hospital at the University of Florida (including the

1~~~ C, i. I Ii 1 I l In .1 ci Ir A ir1I-

ni

radiology, and oncology surgery, and at the local American Cancer Society's

Hope

Lodge and related support groups. Social work, counseling, nursing and oncology care

personnel at Shands Cancer Center and the aforementioned oncology offices were also

given flyers and they referred subjects who qualified and expressed interest to participate

in the study.

Table 1 outlines the referral sources of women who participated in the

study. Most of the subjects were referred by local oncology physicians (41.0%), or by

friends, who knew about the study (30.8%), designated as "Other"

in the demographic

questionnaire. Shands Hospital at UF, specifically Shands Cancer Center personnel

(20.5%) and American Cancer Society support group members (7.7%) referred the rest of

the subjects who participated.

Table 3-1.

Referral sources

Referral sources Treatment group (%) Control group (%) Total (%)
Private physician 10 (50.0%) 6 (31.6%) 16 (41.0%)
Shands Hospital 2 (10.0%) 6 (31.6%) 8 (20.5%)
American Cancer Society 2 (10.0%) 1 (5.3%) 3 (7.7%)
Other 6 (30.0%) 6 (31.6%) 12 (30.8%)
Total 20(100.0%) 19(100.0%) 39(100.0%)

Once contact was made with a potential research subject, the primary investigator

explained details of the study to her. If the woman chose to participate, she was randomly

assigned to the experimental or control group. Experimental and control group subjects

received an appointment to meet with their randomly designated counselor following

completion and receipt of all pretest documents, pretest measure, and informed consent.

Experimental group subjects began individual art therapy treatment at the appointed time.

Control group subjects met with one of the study's

counselors at the end of the four-week

70

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

scores.

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

71

participated in this study was 39. In orderto participate, the woman was diagnosed with

Stage I or Stage II breast cancer within .12 months prior to entering the study. A Release

of Information for the subject's

treating oncology physician was obtained (Appendix A)

to ascertain that the subject met inclusiofi criteria. All women in this research study were

voluntary participants.

The subjects were recruited from Shands Hospital and North Florida Regional

Medical Center's cancer treatment centers, from the Suwanee Valley Cancer Center in

Lake City, and from oncologists'

private practice offices in the Gainesville and Lake City

communities. A research announcement flyer was used to disseminate research

recruitment information to subjects who met the research eligibility criteria

(Appendix B). Some subjects were recruited from the local ACS support network. The

subjects were adult women, 18 years of age and older, who volunteered and signed an

informed consent for participation in the study. Posted notices at Gainesville area

community bookstores and worship centers were also utilized. The subjects called a

designated contact number and left a message expressing interest in the research project.

The primary investigator talked to the callers and screened them according to outlined

criteria with verification occurring after receipt of the subject'

signed Release of

Information form and Informed Consent form (Appendix C). Subjects were informed that

they would be randomly assigned, using the flip of a coin, to a control group (delayed

treatment for 4 weeks) or an experimental group (four individual creative art therapy

interventions over 4 weeks).

Control group subjects were informed that they would

r. _

Descriptive Data Analysis

Table

and Table

outline descriptive and demographic variables of the

women who participated in this research study.

Within the treatment group, 3 women

(15.0%) were African American, 14 (70.0%) were Caucasian, and 3 (15.0%) were

Hispanic. Eight (40%) of the women in the treatment group had a high school education,

none (0%) had an associate degree,

master degree or above.

Three women (15.0%) in the treatment group marked "other,

graphic arts.

Within the control group, one (5.3%) was African American, 16 (84.2%) were

Caucasian, and one (5.3%) was Hispanic. Six (31.6%) of the women in the control group

Bachelor degree, and

(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.

Table

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%)

73

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

Table

cancer.

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.

Table

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 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/ ^

(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,

(e.g., Tamoxifen, Femara) over 2 to 5 years posttreatment(s). An additional four

medication therapy (e.g., Tamoxifen, Femara) over 2 to 5 years posttreatment(s). No

other women in the treatment group indicated they expected to receive medication

therapy posttreatment(s).

Table 3-6. Treatment for breast cancer
Types of treatment Treatment group (%) Control group (%) Total (%)
Lumpectomy 15 (75.0%) 11 (57.9%) 26 (66.7%)
Partial mastectomy 1 (5.0%) 0 (0%) 1 (2.6%)
Mastectomy 4 (20.0%) 8 (42.1%) 12 (30.8%)
Chemotherapy 4 (20.0%) 6 (31.6%) 10 (25.6%)
Radiation 6 (30.0%) 2 (10.5%) 8 (20.5%)
Chemo/radiation 5 (25.0%) 5 (26.3%) 10 (25.6%)
Drug(s) with chemo 2 (10.0%) 2 (10.5%) 4 (10.3%)
Drug(s) without chemo 3 (15.0%) 4 (21.1%) 7(17.9%)

Note.

* Multiple responses

The lapsed time since diagnoses at enrollment into the study is summarized in

Table

Within the treatment group, nine women (45.0%) were diagnosed 1-3 months

women (26.3%) were diagnosed 1 to 3 months prior to enrollment into the study, five

women (26.3%) 4 to 6 months, four women (21.1%) 7 to 9 months, and five women

(26.3%) 10 to 12 months.

Table 3-7

Time since diagnosis at enrollment

Time from diagnosis Treatment group (%) Control Group (%) Total (%)
1-3 months 9 (45.0%) 5 (26.3%) 14 (35.9%)
4-6 months 6 (30.0%) 5 (26.3%) 11 (28.2%)
7-9 months 1(5.0%) 4 (21.1%) 5(12.8%)
10-12 months 4 (20.0%) 5 (26.3%) 9 (23.1%)
Total 20 (100.0%) 19 (100.0%) 39 (100.0%)

Design of the Study

The experimental study involved a pretest/posttest control group design and

included the random assignment of subjects to a treatment group (independent variable of

individual creative art therapy intervention) or a control group (delayed treatment for 4

weeks).

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

inception.

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

was

years of age at the time of the study. The second counselor has a master's

degree

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

76

Once a potential research subject was identified, the primary researcher randomly

assigned the individual to the experimental or control group. The primary investigator

contacted each subject randomly assigned to the experimental group, informed her about

the study, and asked if she still wanted to participate. Each experimental group subject

who agreed to be in the study received (via U.S. mail) an introduction to the study letter

(Appendix D), a release of information form, an informed consent form, a pretest

measure (profile of mood states) and a demographic questionnaire (Appendix E) to be

completed and returned via U.S. mail prior to arrival for the first therapy appointment.

Experimental group subjects received an appointment, to meet with their designated

counselor, following completion and receipt of the release of information, informed

consent, pretest measure, and demographic questionnaire.

The primary investigator contacted each subject randomly assigned to the control

group, informed her about the study, and asked if she still wanted to participate. Each

control group subject who agreed to be in the study received (via U

mail) an

introduction to the study letter (Appendix F), a release of information form, an informed

consent form, a pretest measure (profile of mood states), and a demographic

questionnaire.

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

77

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

minutes.

If an experimental group subject was unable to attend the final, posttest session,

she received a phone call where the counselor instructed her to complete the posttest

measures (Emotional Approach Coping Scale, Expressions of Spirituality Inventory-

Revised, Profile of Mood States) and an exit interview form (Appendix I) that was sent

via U.S.

mail. A cover letter (Appendix J) and written instructions (Appendix K) were

78

Delineation of Relevant Variables

Independent Variable

The independent variable used in this study was an individual creative art therapy

intervention. There were a total of four individual therapy sessions over a 4-week period.

Each session lasted approximately 60 minutes. The last session lasted approximately 90

minutes to allow for completion ofposttest measures. The individual sessions consisted

of guided, semi-structured, creative art therapy exercises. The interventions were adapted

from art therapy manuals and texts (Crockett, 2000; Horovitz-Darby, 1994; Lesser, 1999)

and were specifically designed to facilitate emotional expression, spiritual connectedness,

and psychological well-being (Appendix L).

Although the sessions were semi-structured, the counselors took care to attend to

each woman's

emotional and psychological needs at the time of the interventionss. The

women were encouraged to bring into each session whatever issues) of concern were

salient that particular week. The semi-structured interventions were designed to provide a

framework of emotional and psychological exploration and an opportunity for emotional

expression and support. The guiding theoretical framework was positive psychology; a

humanistic psychology that encourages uncovering and building upon clients' strengths

rather than psychopathology. Each woman brought a set of traits and characteristics that

they drew from in the process of adjusting to and managing their breast cancer diagnosis

or any other emergent concerns. Each woman was encouraged to explore their strengths

and ways to engage these in their healing process, including managing difficult emotional

states. The exploration of these themes was done both verbally and through the creative

79
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

metaphor.

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

80

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

use of active imagination. They were then instructed to write two poems using the words

from a list of answers. The themes were life and death and were meant to assist with the

uncovering of personal meaning and beliefs about each. This session enhanced self-

awareness pertaining to deeply held beliefs about the purpose of life itself and ideas

around death and/or the dying process. All individual sessions were aimed to facilitate

self-awareness, emotional exploration and expression, and the discovery of personal

strengths and potential areas of growth.

Dependent Variables

The dependent variables of this study were emotional expression, including pre-

and possession emotional reactivity for the experimental group subjects, spirituality, and

select aspects of psychological well-being. Emotional expression was assessed by the

Emotional Approach Coping Scale (EACS) (Stanton, Kirk, et al., 2000). Pre- and

postsession emotional reactivity for the experimental group was assessed by the

81

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).

Instrumentation

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

complete.

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

assess

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).

82

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

rotation"

(Stanton, Kirk, et al., 2000, p. 1153) that yielded 9 factors: Emotional

Processing, Emotional Expression, Distress-contaminated Coping, Seeking Social

Support, Problem-focused Coping, Alcohol-drug Disengagement, Avoidance, Humor,

and Turning to Religion. The Emotional Identification and Emotional Processing

domains loaded on a single factor.

Using hieh factor loadings and lack of redundancy as criteria, the authors chose

for emotional processing, r = 0.72 and for emotional expression, r = 0.82. Test-retest

reliabilities were emotional processing = 0.73 and emotional expression

= 0.72. The

correlations between the emotional processing scale and the emotional expression scale

and the EEQ were reported as significant (p

< .005). Stanton, Kirk, et al. (2000) reported

"the correlation between the emotional processing and emotional expression scales was

at Time 1 and .65 at Time

< .0001)" (p. 1153). In order to control for self-report

response bias, the researchers conducted another study where students and family

members assessed each other's coping. The researchers reported internal consistencies

for self-reported coping through Emotional Processing as: a

.88 for students, .90 for

mothers, and .80 for fathers; for Emotional Expression they were reported as: a

.92 for

students, .91 for mothers, and .90 for fathers.

The final EACS consists of 16 items measuring the constructs: emotional

processing (eight items) and emotional expression (eight items). Stanton, Kirk, et al.

(2000) suggested that the scales be interpreted separately whenever emotional approach

coping is not the primary variable of interest. Although the authors embedded the

original EACS into other multi-dimensional coping measures, in this study, only the

Emotional Expression sub-scale was used to measure emotional expression.

Emotional Assessment Scale (EAS)

The EAS was designed by Carlson et al. (1989) to measure emotional reactivity.

This 24-item, self-report instrument is used to capture multiple, complex, simultaneous

emotions min individuals. It examines eight emotional states considered consistent across

cultures: anger (items 4. 12. 20). anxiety (items 6. 14. 22). disgust (items

. .

11. 19). fear

84

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"

emotional

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

emotion.

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

processes

" (p. 315-316). The fact that a metric is used (instead of easily remembered

numbers) also decreases the chances that respondents' posttest ratings will be influenced

by pretest responses.

The EAS was developed on undergraduate psychology students, ages 18 to 34,

62% being female and 38% male. Reported means and standard deviations were as

follows: anger mean

14.6 (SD

= 18.9); anxiety mean

= 32.4 (SD

= 24.5); disgust

mean

= 9.7 (SD

13.3); fear mean

13.0 (SD = 14.5)

guilt mean

12.6 (SD

14.5);

happiness mean

= 38.8 (SD

= 19.1 (SD

= 19.6); and surprise

mean

= 10.7 (SD

10.4) (Fischer & Corcoran, 1994).

Carlson et al. (1989) reported

85

The EAS is reported to have very good concurrent validity, with several of the

subscales correlating with existing measures such as the POMS, the Beck Depression

Inventory, and the State-Trait Anxiety Inventory (State form). The subscales are sensitive

to externally induced stress levels, making if particularly useful to measure emotional

reactivity in newly diagnosed breast cancer patients attempting to adjust to and cope with

a highly stressful situation. It is reported that the EAS'

with inter-item reliability for emotion factors ranging fr<

reliability is "good to excellent"

3m .70 to .91 and split-half

reliability of .94 (Fischer & Corcoran, 1994, p. 203).

Expressions of Spirituality Inventory-Revised (ESI-R)

The Expressions of Spirituality Inventory (ESI), developed by MacDonald

(2001), is a measure of spirituality derived from a two-stage factor analytic study of more

than 70 measures of spirituality with about 1,400 subjects (MacDonald,

Kuentzen, &

Friedman 1999). MacDonald created the ESI "to provide a well-designed and validated

measure of spirituality that incorporates existing psychometric conceptualizations into a

coherent organizational framework on which to understand and research the various

elements of the construct" (p. 157).

Spiritual dimensions resulting from the factor analysis were (a) Cognitive

Orientation Towards Spirituality (COS), (b) Experiential/Phenomenological Dimension

(EPD), (c) Existential Well-being (EWB), (d) Paranormal Beliefs (PAR), and

(e) Religiousness (REL).

The Cognitive Orientation Towards Spirituality (COS) dimension refers to

spiritual beliefs that are not expressed through religious affiliation. These may involve

86

The Experiential/Phenomenological Dimension (EPD) refers to spiritual

experiences that are of a transpersonal and mystical nature.

The Existential Well-being (EWB) dimension involves aspects of spirituality

related to existential facets of human functioning. This dimension appears to include

three main components: meaning and purpose in life, which derives from any number of

sources, a sense if inner strength and perceiving oneself as able to effectively cope with

fundamental aspects of life. The latter includes a relaxed approach to self and to everyday

life challenges.

The Paranormal Beliefs (PAR) dimension involves beliefs in scientifically

unproven phenomena.

The PAR dimension has been associated with higher indices of

pathology, including unusual thought patterns, psychosis, external locus of control, and

suggestibility (MacDonald, LeClair, Holland, Alter, & Friedman, 1995; MacDonald et

al., 1999).

Finally, the Religiousness (REL) dimension involves an intrinsic religious

orientation based on organized religious affiliation and practices. The REL dimension is

comprised of two aspects: (a) nondenominational beliefs about a higher power or being

and (b) religious practices such as prayer, attendance to religious services and meditation.

Extrinsic religious orientation (i.e., religious attendance for social status or gain) is

specifically excluded from the REL dimension.

Respondents of the ESI use a 5-point Likert-type scale (0

= Strongly Disagree,

= Disagree,

= Neutral,

= Agree, 4

= Strongly Agree) to rate agreement or

disagreement with given statements. The long form consists of 98 items (42 reverse

developed test with reasonable reliability and validity that systematically embodies

numerous constructs as tapped by several existing measures of spirituality"

(p. 159).

According to MacDonald (2000a), feedback from research participants and from
(
other investigators indicated that a 98-item version of the ESI presented problems that

made use of the measure difficult. Specifically, elderly populations reported problems

with the length of the instrument, other respondents complained that the items were

repetitive, and some of the reverse or negatively worded items proved difficult to certain

respondents, especially those for whom English was a second language. In order to

address these issues, MacDonald developed a revised version of the ESI. This study

utilized the revised version of the instrument, to minimize strain on subjects.

The ESI-R consists of 32 items. As in the original ESI, two items at the end were

added to provide face and content validity.

MacDonald (2000a) reported that the ESI-R

is different from the longer version of the test in three ways:

(1) The revised ESI consists of 30 items, six for each dimension; (

) Items were

selected from the 98-item version of the ESI based upon both uniqueness of
content as well as evidence of satisfactory psychometric properties. As such, any
appearance of item repetition is virtually eliminated from the instrument. Further,
the psychometric properties and correlates of the revised ESI are highly similar to
those for the longer version (e.g., all revised dimensions have been found to
produce scores with good reliability and satisfactory factorial validity); and (3)
Reverse worded items are kept to a minimum. (p. 18)

The ESI-R'

alpha coefficients range from .85 for Existential Well-Being to .97

for Cognitive Orientation towards spirituality. MacDonald et al. (1999) reported that

"corrected item-dimension total score correlations range from .40 to .80 for all items"

(p. 158). MacDonald (2000a) reported evidence of factorial, discriminant, convergent,

88

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,
Si
depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-

bewilderment. Subjects indicate mood states or reactions for the "past week including

today" or for brief periods such as "right now" (Eichman, 1978). Reliability of the POMS

ranges from .84 to .95 and test-retest correlations range from .65 to

.74. This is reported

as a considerable difference; however, congruent with a measure of mood states that are

deemed transient and changeable. Eichman concluded that the POMS "appears to be

optimally reliable and sensitive to change ... and a valid measure of mood states [that] is

simple and easy to use" (p. 1018). Face validity is reported as good (Eichman, 1978).

The POMS are a frequently used product development tool. Scores that form each

of these scales can be combined to yield a total mood disturbance score. Historically, the

scales have been used in research requiring a sensitive measure of affect following a

program of behavior modification, among others. Because of their documented use with

the population of breast cancer patients (Carver et al., 1993; Classen et al., 1996; Dibbell-

Hope, 2000; Goodwin et al., 2001; Hosaka et al., 2000; Spiegel et al., 1999; Stanton &

Danoff-Burg, 2002; Stanton, Danoff-Burg, et al., 2000) and considerable psychometric

properties (Eichman, 1978), the POMS sub-scales'

scores were used as a measure of

psychological well-being in this study.

Demographic Questionnaire

Demographic variables about each woman with breast cancer were obtained by

of breast cancer, medical treatment received for the breast cancer, and previous

experience with art therapy. The questionnaire also included details about the subject'

(in-home or out-of-home) employment situation. Finally, an open-ended question

explored whether the subject wanted to disclose additional information about her self that

had not been included in the questionnaire. The information included in this demographic

questionnaire was used in the final analysis of data.

Exit Interview

An exit interview form was obtained from each research subject in the control and

experimental groups who completed all four creative art therapy sessions. The exit

interview form explored the subjects' assessment of their participation in the study, their

opinions about the helpfulness of the creative art therapy interventions, whether they

would recommend the experience to other breast cancer patients, and suggestions for

health care providers, including mental health counseling practitioners, in general, and

the researchers of this study, in particular. The information obtained in this form was

used as a measure of clinical significance as it reflected each woman's subjective

appraisal of the individual creative art therapy experience, including perceived emotional

and psychological benefits thereof. This information also helped inform

recommendations for future research and clinical practice.

Finally, the main researcher of this study kept a reflective journal of the research

process min an attempt to document issues or concerns pertaining to research design,

subject recruitment, treatment implementation, results, and any other noteworthy items

that could help inform future research and clinical practice. Relevant entries from this

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THE EFFICACY OF ART THERAPY TO ENHANCE EMOTIONAL EXPRESSION SPIRITUALITY AND PSYCHOLOGICAL WELL BEING OF NEWLY DIAGNOSED ST AGE I AND ST AGE II BREAST CANCER PATIENTS By ANA PUIG 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 UNIVERSITY OF FLORIDA 2004

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"Hope is the thing with feathers That perches in the sou l And sings th e tune Without th e words And never stops at all Emily Dickinson

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This dissertation is dedicated to my mother Miltho Lad y 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 H ector Enrique Pui g Alfonzo the man who always introduced me as his daughter the doctor." I have finally earned the title you bestowed upon me so many years ago. I know your spirit smiles and lays blessings upon me from wherever you are. I miss you Papi And to my beautiful steadfast and faithful partner R ebecca 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.

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ACKNOWLEDGMENTS 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 Miles and Kate Vellis from Dr.Carroll's office and Marsha Weber Ms. Rosetta Williams and Ms Mary Parmerlee from Dr. Shea's office, for patiently helping and IV

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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. Wendy Edmons of the ACORN Clinic and Julia Howell of the Shands Anesthesia Preoperative Clinic also provided referrals and suggestipns. 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 every step of the way. I am indebted to her kind gentle spirit for enduring the whirlwind I can sometimes be. Dr. Anne Seraphine pro v ided invaluable statistical V

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analyses a istance he was affirming of my ability to take on this task and offered useful suggestions throughout the data analysis and evaluation process. She is a superb teacher making what can be a complex and obscure subject easier to grasp and dare I say, enjoyable! A few individuals from various disciplines provided much needed assistance support, and mentorship Tricia Sample kindly shared her art therapy skills and resources as I conceptualized the treatment intervention. Dr. David Miller's timely consultations for vexing statistical questions coupled with his open-door policy saved me mOFe 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 the y were always th e re 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 Departm e nt of Counselor Education. They pro v ided tactical and technical help and se lfles s ly worked to facilitate whatever task I engaged in I could not have accomplished this without their ongoing s upport. My doctoral s tudi es would mean nothin g to me without the love support e ncoura ge m e nt and unconditional lo ve of m y friends and family. Dr. Lyn Goodwin provid e d not only se lfl ess practical research s upport and assistance ; s he was an inspiration to m e. I watched her bla ze the trail before m e and fell to the contagion of her sp irit ed lau g ht er. S h e was my very own cheerleading s qu a d a nd will always be a priced co ll eag u e a nd friend. Dr. Sang Min Lee whom I affect ionat e l y dubbed my Counselor Vl

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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 m y journe y. 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 the y are but also for making my life so much fun to be in. My mother Mil tho Lady Figueroa de Puig was a source of nourishment when I needed it most. She and m y baby sister Maria Puig Jordan provided needed respit e 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 m y process as I considered creative art therap y 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 nephew s (Ga b y, Ton y, Paloma Ana Yi Lucas, and Leia) are bright rays of su nshine in my heart. Finally I thank m y steadfast, patient and lo v ing partner Rebecca Anne Fields who stood by me held me supported and unconditionall y l oved me, sometimes in spite of myself. I lo ve her more than words can say and man y ha ve been uttered her e. Everything good to come of this process belongs to her. Vil

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TABLE OF CONTENTS ACKNOWLEDGMENTS ........................ ....... ............... 1 v ABSTRACT ... .. ... ..... .. . .. ..... . ............ .. ... ... . . . . X CHAPTER 1 INTRODUCTION .. ................. .. ... .. ... .. ........ .. ... . .. 1 Overview .. .. . .. .... ... ... ..... ...... . .. . ..... ... ... : ....... 1 Scope of th e Problem .. .............. .. .......... . ...... ... .. ... ... 5 Theoretica l Fram ewo rk and Rationale .... .. .. .... .................. .... 10 Need for the Study . .. . .... .. ............................. ... ....... 24 Purpose ........................ ............... .. . ............... 25 Research Qu es tion s ................... ........... .... .... .... ...... 25 Definition of Terms ..... . ...... ..... ..... .. ... . . .... .......... 25 Organizat i on of th e Study . .. . ..... .. .. .. . .. . ......... ... .. . .. 27 2 REVIEW OF TH E LITERATURE ... .. .. ... ................. . : ....... 28 Introdu ction ................. .... ... .... .... . ..... . ........ .. 28 R esea rch on Ca nc e r Patients and E motional Expression ........ ... ......... 29 Research on Cancer Patients and Spir itu a li ty .. .... ............. .. .. ...... 38 R esearc h on Ca nc e r Patient s and Psycholo g ic a l We ll-b eing . ........... . .... 44 R esea rch on Creat i ve Art Therapy and Ca nc e r .. .... . .. ............. .. .. 48 R esearc h on C r ea tiv e A rt th era p y and Br east Ca nc er ......... .. .. .... ... .. 52 Co nclusion ......... .. ... .. ..... ... . ... .. .. .... .. .... .. .... . .. 63 3 METHODOLOGY ... .... ..... .. ........ .. ... . ........... .. ...... 65 Statement of Purpo se . .. .. .... .... . . .. ..... .. ...... .... ... .... 65 Research H ypotheses .. . .................. ........... ... ........ .. 66 Description of the Popu l a ti o n ...... .. ......... . ... ... .. ... . .. .... 67 Data Co ll ec tion a nd A ttrition ... ... .. .. ... ........ .. ...... .. ..... ..... 68 Sample and Samp lin g Procedures .......... .. ...................... . ... 7 0 Descriptive Data Ana l ys i s .. .. .... . ... ........ ... .. ...... ........ .. 72 Design of the S tu dy . . ....... ... . ........ ..................... ... 75 De lin ea ti o n of Relevant Variab l es .... ..... . .... .. ....... .. .... .. .... 7 8 Data Ana l ys i s ............. .. .. ........... ........................... 90 Methodologica l L imit at i ons . . .. .. .. ........ .. . .. .... .. ........ . 90 V III

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4 RES UL TS OF THE STUDY ............ .... .......... .. .............. 92 Summary and Chapter Overview ..................................... . 92 Results of Hypotheses Tests ..... ...................................... 92 Clinical Significance .................. ..... .... .... ............... 103 SummaryofFindings ...... ......... ...... .. ...... .... ............... 106 5 DISCUSSION ................................. .. ..... ...... .. 108 Research Sample ......... .. ...... .... ......... .................... 108 Discussion of Results .. .. . ........... .. .............. .. ..... ....... 109 Clinical Significance ....... ... ....... ..... .. .... ............. ..... 123 Limitations of the Study ....... ... . ........ .. ...... ............. .. 123 Implications ................... ... ...... .. ..... .. . ... ........... .. 12 8 Qualitative Journal .. .. ... ....... .................. .. .. .. ...... .. 137 Conclusion ..................... ............... .................. 139 APPENDIX A EXIT INTERVIEW FORM ........................................... 141 B RELEASE OF INFORMATION .... .. ......... .... ..... .. ......... .. 142 C RESEARCH ANNOUNCEMENT FL YER ........... .... ....... .... 143 D INFORMED CO SENT ............ .. ............................... 145 E INTRODUCTION TO STUDY LETTER EXPERIMENT AL GROUP .. ... 152 F DEMOGRAPHIC QUESTIONNAIRE .............. . .... ............ 153 G INTRODUCTION TO STUDY LETTER-CONTROL GRO U 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 REFERENCES ..... .......... ....................................... 163 BIOGRAPHICAL SKETCH .... ........... .. ............... ..... .. .... 181 IX

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A b s tra c t o f Di sse rt a tion Pr ese nt e d t o t h e Gradu a t e School of th e U ni ve r s i ty o f Florid a i n P a rti a l Fulfillment o f the R eq uir e m e n ts fo r th e D eg r ee of D oc t o r of Phil oso ph y T H E EFFICAC Y OF A R T T H E RAP Y T O EN H ANCE E MO T ION AL E XPRESSIO N S PIRI TUA LI TY AN D P SYC H OLOG I CA L WELL -B E IN G OF NE WL Y DIA GN O SE D STAGE I AN D ST A G E II B REAST CANCE R P AT IENTS B y Ana Pui g D e c e mb e r 2 004 C h a ir : P e t e r A D S h e rr a rd Ma j o r D e p art m e nt: Co un se l o r E ducation Br eas t ca n cer i s th e m os t c o mm o n ty p e o f ca n ce r a m o n g w omen in the United S t a t es. T h e p syc h o l og i ca l imp a ct of the di sease m ay includ e a dju s tment disorders d ep r ess i o n a nd a n x i ety a nd m ay ge n era t e fee lin gs o f fea r a n ge r g uil t, a nd e moti o nal r e pr ess i o n E m o ti o n a l r e p ress i o n h as b ee n link e d t o wo m e n w i t h br eas t ca ncer. E m o t io n a l ex pr ess i o n h as bee n link e d t o b e tt e r ps y c h o l og i ca l ad j ust m e nt a nd a hi g h e r q u a li ty of li fe Exis t e nti a l i ss u es ra i se d b y a ca n cer di ag n os i s hi g h l i g ht t h e in tegra ti o n of s piritu a li ty t o ca n cer r esearc h w hi c h h as d oc um e nt e d t h e b e n efic i a l ro l e o f s piri t u al i ty in a ll e v i a tin g ex i s t e nti a l a n x i e ty evo k ed by a canc e r d i a g n o s i s. T h e p u rpose of thi s s tud y wa to d ete rmin e t h e e f fi cac y of a co m p l e m e nt ary a rt th e rapy i n terve nti o n t o e nh ance e m o ti o n a l e xpr ess i o n s p i ri tu a li ty a nd p s y c h o l o g i ca l we ll -be in g in n ew l y di ag n ose d b r e a s t ca n c e r p a t i e nt s X

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Forty-four women with Stage I and Stage II breast cancer agreed to participate in this study. Subjects were randomly ass~gned to an experimental art therapy group or a control group of delayed treatment. Forty-one women completed the study in which they were 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 analyze the results which indicated that the intervention was not effective in enhancing the emotional approach coping style of emotional expression or the level of spirituality of subjects in this sample. However participation in the art therapy intervention helped decrease negative emotional states and enhanced positive ones of experimental group subjects. These shifts in feeling states indicate that the women were able to process and express feelings during session in productive ways a finding that is congruent with anecdotal clinical observations. Additionally the creative art therapy intervention enhanced psychological well-being of women in this sample by decreasing tension-anxiety depression-dejection anger-hostility and confusion-bewilderment ; affective aspects of this construct. Finally as hypothesized the intervention did not effect changes in the physiological aspects of psychological well-being: vigor-activity and fatigue-inertia. XI

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CHAPTER 1 fNTRODUCTION Overview Breast cancer second only to nonmelanoma skin cancers is the most common type of cancer among women in the United States An estimated 211,000 women will be diagnosed with the disease in 2003 (National Cancer Institute [NCI], 2003). A breast cancer diagnosis can have a profound impact on a woman's life and the lives of her significant others. Women struggling with the disease may worry about caring for their families keeping their jobs or continuing daily activities. Concerns about tests, treatments hospital stays and medical bills are also common" (NCI 2003). Researchers have also documented the psychological impact of the dis ease; 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, 200 I a). Spiegel added Avoidance and distraction in the face of [breast cancer] is draining: It isolates one from others, makes it harder to manage the inevitable painful emotions that accompany s eriou disease and arduous treatment and makes it difficult to plan additional means of coping. (p 287 )

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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 ul~imate goals of reducing cancer-related mortality and improving quality of life and psychological well-being (Glanz & Lerman 1992). 2 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 sparked greater attention to the psychosocial effects of breast cancer (Glanz & Lerman

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1 99 2 ) and ha v e al o h e lped breast cancer patient s become the largest single category of cancer sur v i v ors (Jacob s on & Verret 2001 p 307 ). Multiple research studies have explored the benefits of psychologi~al and/or complementary mind-bod y interventions on brea s t cancer patients emotional 3 e x pression ps y cholo g ical 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. 2002 ; Goodwin et al. 2001 ; Gore-Felton & Spiegel 1999 ; Spiegel Bloom & Yalom 1981 ; Spiegel et al. 1999) supportive cognitive behavioral group therapy (Antoni et al. 2001 ; Bloch & Kissane 2000 ; Cunningham et al. 1998; Edelman Lemon Bell & Kidman 1999 ; Kissane et al. 1997; Wats on Fenlon Mc Vey & Fernandez-Marcos 1996) and mixed modalities group therapy, including psycho-education stress management guided imagery and / or hypnosis (Spiegel & Moore 1997; Fawzy et al. 1990 ; Fukui Kuga y a & 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 of ps y cho s ocial interventions on cancer (Andersen 1992 2002 ; Fawz y, Faw z y Arndt & Pasnau 1995 ) and breast cancer patients (Glanz & Lerman 1992 ; Tapper 1999 ; van der Pompe et al. 1996 ) ha v e also been done A small number of qualitati v e s tudi e s have e x plored th e benefits of the complementary mind bod y inter v ention of cr e ati v e art therap y on breast cancer patients (G. Aldridge 1996 ;

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Cruze, 1998; Predeger 1996) and we found one mixed (qualitative and quantitative) study on the subject (Dibbel l-Hope 20~0). 4 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 effective l y treating depression symptoms in cancer patients results in better patient adjustment reduced symptoms and may influence disease course (Sp ie gel 1996 p. 114). The purpose of this study was to determine the efficac y of a complementary mind-body creative art therapy intervention to enhance emotional expression spiritual connectedness and psychological well-being in newly diagnosed Stage I and Stage II breast cancer patients.

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Scope of the Problem O n e of every e i g ht wo m e n i s at ri s k to r ece i ve a br e a s t cancer diagnosis in her li fe tim e (ACS 200 1 ). Br eas t c a n ce r i s th e se c o nd m os t common form of cancer 5 acco untin g fo r n ea rl y o n e of every thr e e canc e r s dia g no se d in American women ," with Afr i ca nAme ri ca n s m o r e lik e l y t o di e from th e di se as e than C aucasians (ACS 2002 ) T h e incid e n ce of br eas t ca n ce r b y rac e and e thni c ity (19962 000 ) per 100 000 persons i s 140 8 Whit e (92. 7 Whit e Hi s p a nic a nd 148. 3 Whit e Non-Hi s panic ); 121.7 Black ; 97 2 As i an/ P ac ifi c I s l a nd e r ; 5 8 A merican India n/ Ala s ka Nati ve; and 89 8 Hispanics of other races M o rtali ty rat es ( 1 996 2 000 ) per 100 000 p e r s ons ar e 2 7. 2 White ( 18 3 White Hi s pani c and 2 7.4 Whit e Non-Hi s panic ); 3 5 9 Black ; 12 5 Asian/Pacific Islander ; 14 9 A m e rican Indi an/A l as k a n Nati ve; and 17 9 Hi s pani cs of other races (NCI 2003) Gre e r and M o rri s ( 1 9 75 ) reported a s tati s ticall y si g nificant association between a b reas t can ce r dia g no s i s a nd unh e alth y r e lea se of e motion s (ex trem e suppression and less c ommonl y ex tr e m e ex pr ess ion ) W a t s on e t al. ( 1991 ) r e p o rt e d an association between e m o ti o nal control a nd a fa t a li s tic attitude a bout br e a s t cancer. The y also found a pr e di c t e d l ow but s i g nifi ca nt ass oci a tion b e t wee n h e lpl ess n ess a nd th e control of anger a nd a n x i ety. G r ee r a nd W at so n (1 9 8 5) a nd W a t so n e t a l. ( 1 99 1 ) h av e de s cribed a T y pe C b e h av i o r p a tt e rn assoc i a t e d w ith ca n ce r p a ti e nt s w h e r e s uppr ess ion of an ge r i s the pr e d o min a n t c h aracte ri s ti c W a t so n e t a l. r e p o rt e d th a t r esea r c h h as s h o wn wom e n with br eas t ca n ce r a r e m o r e li ke l y t o co ntr o l e m o ti o n s th a n tho se w ith b e ni g n br e a s t dis e a se or h ea l t h y co nt ro l s" (p. 5 1 ). T h e Type C p e r so n a li ty i s furth e r d escr ib e d as charact e ri s ti c of indi v idu a l s w h o avo id ex pr ess i o n of n ee d s a nd fee lin gs ( i. e ., b e li eve it i s u se le ss to exp r ess th ese) a nd h ave a t e nd e n cy t o fee l h ope l ess a nd h e lpl ess a bout th e ir s ituation Wa t so n et a l. a l so r e p o rt ed a hi g hl y s i g ni fica n t assoc i a ti o n ( P < 0 0001 ) b e tw ee n a

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6 fatalistic attitude toward the cancer diagnosis and the tendency to control negative emotions (p. 53) (e.g. anger anxiety ~d 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 express i on was generally seen in this patient group (p. 302 ) Fernandez -B allesteros 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 interp~rsonal relationships (p 41 ) Emotional suppression the tendenc y 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 s uch as pain and longer sur v i v al time ( Spiegel 1996 ) Howe v er research result s are inconclusi v e about whether the Type C personality commonly associated with emotional s uppr e s s ion pree x isting emotional and / or ps y chiatric disorders or ps y chological adju s tment increases a woman s risk of developing breast cancer or whether a breast cancer dia g nosis affects emotional e x pression ( i e. leads to suppression of emotions) emotional o r ps y chiatric morbidity and psycholo g ical adjustment. In addition to emotional and ps y chological distr ess and adjustment a brea s t cancer diagnosis puts women face-to-face with existential lif e -and-d e ath i s sue s that m ay

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elicit a need to addre s 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. 7 Mickle y 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 oncology ocial workers echo this suggestion adding that interventions that support and reinforce patients' spirituality

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involve active listenin g and use of self to help patients exp l ore ... questions regarding life and death" (p. 71 ). 8 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 whe~her 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 -b eing, quality oflife 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 emotiona l support to cope with the cancer (91 %), social support (70%) and meaning-making abi lit y (64%) during the experience of dealin g wi th 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 accessing spiritua l re so urces to cope with the disease. The author emp ha size d the importance of context in understandin g the lives of the women s tudied in this case,

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9 Eastern ve r us We tern 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 li fe's gifts) ; Creating Meaning (pertains to opening up to awareness of life s purpose finding ways to reframe the cancer experience and learn from it embracing spiritua li ty/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 forefront. 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 ps yc holo g ical distress Additionally, women who experienced God s presence in their li ves and f e lt a sense of God bein g in contro l of the relationship reported high e r levels of optimism. Cole and Par ga m e nt ( 1999) have de ve loped spiritua l ps y chotherapeutic intervention s for cancer patients gea red toward s pirituall y oriented individuals Preliminary findin gs of a n o utcome s tud y utilizing this int erve ntion appear promising (p. 405) at thi s stage of data collection. Although a limited number of qualitative studies hav e ex plored the efficac y of art therap y on brea s t cancer patients emotiona l expression

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10 (G. Aldridge, 1996; Predeger, 1996) and one mixed method study explored psychological adaptation (Dibbell-Hope 2000), we f~und 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 of perfection and balance that has been lost through illness or injury (1997 p 6) Achterberg (1992) defined healing as 'creativity. passion. and love. a lifelong journe y

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t wa rd w h 1 n s. a recalling of th in g forg tten. an embrac in g of thing feared, an opening of what i s cl sed, a l earning t tru t li fe. a tran ce nd ence t an exp rience of th divine" (p. 31 ). This study and o ur creative art therapy intervention mbra ed a holistic approach t breast cancer patients' exper i e n ce of healing. Greer ( l 999) und er co r ed the imp ortance of ''de lin eat i on, mea urement. and p syc hoph ys i o l ogy of positive sta t es of mind [that] have been orely n eglected [a n d r ep re ent] a promising area fo r future r esearc h (p. 236). This re ea r ch study maintained a positive focus on breast cancer patients' personal strengt h s. As researchers, we attempted t o h elp s ubj ects access these stre n gt h s thro u gh creative art therapy int erve ntion s that ma y facilitate e moti ona l expression, spi r it ualit y and psychological well-being. Thus, guided b y a holi st ic approach to th e tr ea tm ent of brea t cancer patients. th e conceptual backdrop to thi s study was the newl y e m e r g in g field of positi e p syc holo gy. in ge neral and Cs ik sze ntmihal yi 's (1990a, 19906 1 996, 1 997) theor of flow specifica ll y. Conceptual and research literature on the relation s hip of spirituality and h ea lth also informed our lin e of inquiry. Positive Psychology Po s iti ve psycholo gy ha s recently emerged as "a cience of p os iti ve subjective experience, po s itive individual trait s, and positive in titutions [that] promi es to [h lp] improve '' the quality of human live (Se ligman & Cs ik sze ntmibal yi, 2000 p. 5). Positi e p syc h o l ogy emphasizes indi v idual s tren g ths a nd th e belie f in the human potent ial for growt h and change. Th i s relatively new framework under cores the po si t i e meanings inh ere nt in th e e m ot i o nal psychological, a nd s piritu al challenges indi idual face in eve r y day life. In th e o rd s of it s c hi ef proponents, li g m a n a nd Cs ik sze ntm i hal yi (2000 :

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12 The field of positive psychology at the subjective level is about valued subjectiv:e experiences: well -bein g 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 vocat ion courage, interpersonal skill aesthetic sensibility perseverance, forgiveness origina li ty future mindedness spirituality high talent anq wisdom. (p. 5) A breast cancer diagnosis presents an enormous challenge to a woman s sense of her self her mind her emotions and her spiritual life (Co l e & Pargament, 1999). Clinical oncology which focuses on the physiological aspects of cancer diagnosis and treatment has been increasingly collaborative with psycho-oncologists who attend additi0nally, 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 ps y chopathology 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 creati v ity access to personal strengths, emotional expression (e.g. emotion-focused coping) spirituality and psychological well -b eing. 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 Csikszentmihal y i ( 1990a) ; it refers to an autotelic experience that

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Lifts the course of life to a different level. Alienation gives way to involvement enjoyment replace s boredom helplessness turns into a feeling of control, and psychic energy works to reinforce the sense of self, instead of being lost in the service of external goals. (p. 69) 13 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 rele ase 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 'c reative' 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 ps yc hological well-being in clients. Our experimental research study focused on th e latter. Csikszentmihaly (1990b) credited the work of Magyari-Beck a Hun ga rian researcher who developed a mod e l of creativity r esea rch that t akes into account qualitative and quantitative methodological options as distingui hing "three main forms in which the creative process m a nif es t s itself: as a trait a a proce and as a product

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14 (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 personall y transforming aspects of the creative process and the experience of flow Based on his interviews Csikszentmihal y (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; w~ 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 swa y ed by the possibilities you see in this work (as cited in Csikszentmihaly p. 121 ) His words captured the sense of timelessness inherent in the experience of flow. Csikszentmihal y proposed that an optimal experience of flow helps individuals make meaning of their life experiences helps enhance the quality of their li v es and their ps y chological 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 meaning involves achieving purpose ( havin g significant life goals) expressing intentionality (resolving to carry out our life purpose ) and synthesizing purpose and

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15 intentionality into a congruence of thoughts feelings and actions that create a sense of harmony for the individual. Purpose r~solution and harmon y unify life and give it meaning by transforming it into a seam l ess flow experience (p. 2 18 ). This experimental study examined the way the creative art therapy process facilitates the experience of flow and emotional expression. Our functionalist view of emotio nal express ion as a goal oriented (Campos Mumme Kermoian & Campos 1994 ) emotion -focused coping strategy (Stanton Danoff-Burg Cameron, & E llis 1994) is congruent with Csikszentmihaly s conceptualization of th~ experience of flow as described h erein. 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 Sa ndhu and Painter (2000) described sp iritu a lit y as "a pervasive force in contemporary American society [that] i s deeply influ encing severa l helpin g professions such as counse lin g, education medicine nursing psychology [and] social work (p. 204). Assess in g and understanding the role sp irituality plays in clients li ves 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). Griffit h and Griffith (2002) defined spiritua lit y as "a comm itm ent to choose as the primary context for und e r s tanding and acting one s relatednes s with all that is [adding that] with thi s commitment_ one attempts to stay focused on relationships between onese l f and other p eo pl e the physical environment on e's heritage and tradition s, one 's bod y, one 's ancestor s sa ints Hi g her Power or God (p. 15 16). This definition captures th e r e lational e mpha s i s (Flemons 2002 Gergen 1994) that i s central to this study. R e li g ion on th e other hand solidifies [spirituality] into particular forms

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16 rituals sacred scriptures doctrines rules of conduct and other practices" (Anderson & Worthen 1997, p 5 as cited in Rivett & Street 2001 p. 460 ). The terms are used interchangeably in much of the literature. The medical community in research and practice is paying increased attention to spirituality and attempting to understand its relationship to health and healthcare provision (Cook & Hetrick 2001 ; Thoresen 1999) a trend giving greater credence to research endeavors in this area. Thoresen (1999 ) reviewed literature addressing spirituality and health and reported that there is empirical evidence based on over 300 studies that demonstrated in many but not all cases that a positive relationship exists between spiritual or religious factors and health (p. 294). He cautioned that correlation does not imply causality and emphasized that attempts must be made to operationalize these constructs. His review of the literature presented physiological and psychological evidence that offers promise and possibility for further exploration of these relationships Thoresen concluded with a note that something called spiritual and / or religious seems to be often related positively to health status and it is well-worth pursuing (p 298). Cook and Hetrick (2001) explored the relationship between religion spirituality and health by conducting a meta-review of existin g literature Their primary focus was on religiousness as an aspect of spirituality. In keeping with our positive psychology framework only findin g s pertaining to spirituali ty and health ( not ps y chopathology) are highlighted. Cook and Hetrick begin with an anal y sis by Miller and Thorensen ( 1999 ) (who summarized work by Larson Swyers and McCullough 1997 ) and reported the following : when spiritual and religious in v ol v ement has been measured ( even poorl y ) it has with surprising consistency been found to be positiv e l y related to health and inversely related to disorders ( p.11 ). Chamberlain and Hall ( 2000 ) contended it can be

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said with some confidence that religion is positively associated with a sense of well being healthier se lf-esteem and better personal adjustment' (p. 96). George Larson, Koenig and McCullough (2000) noted significant relations between religion and the delayed onset of severa l ph ys ical problems and also noticed that religion tends to be associated with longevity and better recovery from phys\cal illness Attendance to religious activities was often the strongest predictor of positive physical and mental health variables. 17 George et al. (2000) summarized tl-ee mechanisms by which religion might benefit health : (a) Religion l eads to healthy behaviors which in tum leads to better physical and mental health (ac counts for 10 % of variance); (b) participation in religious activities brings potential b e nefits of increased soc ial support (accounts for 5%-10% of variance); and (c) the coherence hypothesis which proposes that religion benefits h ea lth b y providing a se nse of coherence and meaning so that people understand their role in the universe the purpose of life and develop the courage to endure suffering" (p 11 ). Koenig McCullough and Larson (2001) reported that religiousness was beneficiall y r e lat e d to a variety of ph ys ical health conditions (including low e r incidence of cancer) as we ll as mental h ea lth va riabl es (including higher sense of we ll-b eing happiness life sa ti sfac tion hop e and optimism) ; Mc C ullough Hoyt Larson, Koenig and Thoresen (2000) comp l e t e d a m eta -an a l yt ic r ev i ew of data from 4 2 ind e p e ndent s tudie s and r epo rt e d that r e li g iou s inv o lv e m e nt was s i g nificantly associated with l ower mortality (p 2 11 ). A sa li e nt point of thi s lit era tur e r ev i ew i s th e ca ll fo r r esea rch e nd ea ors that u se quantitative d esig n a nd m et hod s so ca u sa l r e l a tion s hip s ca n b e eva luat e d In a r ev i ew of psycho s ocia l r esearc h in co rporatin g r e li g i osi t y a nd s piritu a lity int o the study of phy s i ca l and emot i o n a l illn ess Mytko a nd Knight ( 1999) reported religiou

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and spiritua l beliefs and practices may provide ph ysio logical 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 disease" (p. 447). Creative art therapy interventions may help clients reconnect with themselves holistically and make meaning of their current life 's struggles. In recursive fashion engaging in the creative process may enhance holistic healing facilitate emotional expression improve psychological well-being and nurture personal spirituality and the optimal experience of flow. Our experimentally controlled study sought to explore these relationships. Emotional Expression 18 The processing and expression of emotion as an adaptive function in the face of distressful events have received empirical support (Stanton Kirk Cameron, & DanoffBurg 2000). Stanton and Danoff-Burg (2002) added there is both experimental and corre lation al evidence providing preliminary support for the important role of emotional express i on for individuals who confront a cancer diagnosis (p. 45). The idea of emotionally expressive coping is derived from a functionalist v i ew of emotions (Stanton Parsa & Austenfeld, 2002) and represents a dep a rture from the traditional view of intense emotiona l expression as dy sfu nctional and irrational (Averill, 1990 as cited in Stanton et al. 2002). A functiona li s t v iew of emotions hold s that emotions are relational and contextual (i.e., the y cannot be understood alone or as intra-p syc hic processes ; Campos et al., 1 994) Levenson ( 1 994) pre se nted a functionalist outlook of emotions as short-lived ps y chological -ph ys iolo g ical phenomena that represent efficient modes of adaptation to changing environmental demands Ps y chologically emotions alter attention shift certain behaviors up war d in response hierarchies and activate relevant associative networks in memor y. Ph ys iologicall y, emotions rapidly organize the re s ponse s of different biological systems including facial expression

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19 muscular tonus, voice autonomic nervous system activity and endocrine activity to produce a bodily milieu that is optimal for effective re ponse. Emotions serve to establish our po s ition vis-a-~is 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 reapp~aisal) versus away from (e.g. mental disengagement) a stressful encounter (p. 51 ). 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. emotionfocused) 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 pe1iaining 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 treatment. Research literature on emotional expression and cancer has addressed tw o que s tions: First does emotional expression play a role in the initiation or progression of the disease ? Second does emotional expression facilitate or hinder adjustment in those

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20 who confront a cancer diagnosis?' (Stanton & Danoff-Burg 2002 p. 32). Servaes, Vingerhoets 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 blaming (p. 45). This research study addressed the potential role of emotional expression in enhancing psychological well -b eing not its hypothesized role on initiation or progression of the disease. Some correlational ( l ongitudinal and cross sectional) research studies have reported poorer psychological adjustment (Campas et al., 1999) and emotiona l 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 therap y to encourage and facilitate emotional expression in cancer patients (Giese-Davis et al. 2002; Goodwin et al., 200 I ; 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 e motional expression or emotiona l approach coping on the p syc holo g ical we ll b e in g of br eas t cancer patients. The multi-center s tud y of Spiegel et al. ( 1999) of Stage I and Stage II breast cancer patients receivin g supportive-expressive gro up th erapy y i e lded significant positive re s ult s, includin g a 40 % decrease in total mood disturbance scores of the Profile of Mood States (POMS) and a reduction in total symp tom scores of anxiety and depression of the

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21 Hospital Anxiety and Depre ion cale (HADS). The authors concluded that supportive expressive group psychotherapy resulte d in reduced overall distress. Gore-Felton and piegel ( 1999) conducted a literature review on the effectiveness of supportive-expressive group psychotherapy and concluded there is a grow in g body of evidence suggesting that support groups for women witb 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 emotiona l expression about the disease Stanton et a l. (1994) argued that current research results on the role of emotiona l express ion in cancer adjustment were confounded by the researchers' use of instrumentation that includes psychopathologyor psychological distress-related items. In response to this problem Stanton et al. (2000) developed a new scale to measure emotion-focused coping (the Emotiona l Approach Coping Scale) that is reportedly not confounded with extraneous var iabl es Using the newly developed instrum ent to research the influence of emotion-focused coping on women's adjustment to breast cancer the authors reported positive psychological adjustment in cases in volving 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 comp laint s such as pain than did the l ess expressi e individuals. Finally Stanton et al. (2002) proposed coping through emotional processing and expression is an important area of inquiry for positive psychology (p 150). Within a positive ps y chology theoretical orientation this research study explored whether a creative art therapy intervention could facilitate emotional expres ion

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and enhance psychological well-being in newly diagnosed Stage I and Stage II breast cancer patients. Creative Art Therapy 22 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 client s' unconscious material ( Wadeson 1980) Creative art therapy has evolved into a strategy for healing as well as a strateg y for diagnosis and treatment.

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The creative process that art therapy facilitates has been described as a way to uncover memorie s and reco ver feeli~gs [and] a process of self-expression that allows [one] to act out painful e motions attain a cathartic sense of relea se, and experience a repertoire of varied emotions" (S paniol 1995 p 227) The process of art making has been described as a healin g journey and as more important than the final product ; the proce ss itself is described as a healing experience and often includes a reference to spirituality as a s ignificant contributing factor (Farrelly-Hansen, 2001; Spaniol, 1995 ). 23 Creativity in the form of painting ~rawing 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 ps yc hological counseling and / or medical treatment for life threatening illnesses Stanton and Danoff-Burg (2002) ha ve reported beneficial outcomes in research with breast cancer patient s usin g the standard expressive writing paradigm ( Pennebaker & Beall 1986) for intentional emotional expression and release. Creative art therap y interventions ma y help d ec rease ego defen ses that k eep int e nse emotions suppressed within the individual and allow for th e ir exp r ess ion in non-lin ea r nonve rbal ways ; so m e art th erap ists hav e also emp ha s i ze d th e int egrat i ve and healing properties of the crea ti ve process itself which does not r e quir e ve rbal r eflec tion ( Wade so n 1980 p. 13). C r ea ti ve art therapy int ervent i ons ha ve been show n to en h a n ce emo tion a l ex pr ess ion sp iritual connec t ed n ess, a nd p syc holo g ical well-being of breast cancer patients (G. A ldrid ge 1 996; C ru ze, 1 998 ; Dibbell Hope 2000 ; Predeger 199 6; tanton & Danoff-Bur g, 2 00 2). Creat i ve art t h erapy may fac ilit ate the autote li c exper i ence of flow through the creativ e u se of a spec ific art m ed ium. Breast ca n cer patients e n gaged in the creat i ve act can l ea rn to ope n up to th e nine cond iti o n s of flow Once int erna li ze d

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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 24 Greer ( 1999) underscored the challenge for psycho-oncology and mind-body medicine is to develop effective scientifically based psychotherapeutic methods that will make a significant contribution to patient care and become an integral part of clinical practice (p 242). Review of the literature indicated a relative absence of research studies that utilized experimentally controlled testing of individual creative art therapy as a treatment intervention for breast cancer patients. Counseling interventions should be informed by sound theory and research (Greer 1999) We 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 Creati v e art therap y 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 ; Cru z e, 1998 ; Prede g er 1996) and ps y chological adaptation (Dibbell-Hope 2000 ) has been studi e d it s efficac y on breast cancer patients emotional e xpression spirituality and ps y cholo g ical well-bein g had y et to be collectively examined.

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Qualitati v e s tudie s of breast cancer patients that recei v ed creati e art therap y interventions reported the women describing the experiences as powerful connecting 25 moving (Cruze 1998 ; Prede g er 1996 ; Samuels & Lane 2000 ), deepl y spiritual ( Samuel s & Lane 2000) and beneficial in several ways: facilitated acti v e coping (G. Aldridge 1996) emotional release (Cruze 1998 ; Predeger 1996 ) increased self-control ( Cruze 1998 ; Predeger 1996) and enhanced psychological well-being and adjustment ( Dibbell Hope 2000) The relationships among these constructs had yet to be explored using rigorous experimental design and methodqlogy. Purpose 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 newl y diagnosed Stage I and Stage II breast cancer patients Research Questions The following research questions were addressed in this study : Can creative art therapy help enhance newly diagnosed Stage I and Stage II breast cancer patients emotional expression? Can creative art therapy help enhance newly diagnosed Stage I and Stage II breas t cancer patients self-reported levels of spirituality ? Can creati v e art therap y help enhance newl y diagnos e d Sta g e I and Sta g e II breas t cancer patient s' ps y chological well-being ? Definition of Terms Creative art therapy is a ps y chotherap y modality wherein client s use v arious art media to explore e xpre ss ion of emotional and ps y chic m a terial and help generate meaningful insights about their inner and outer life experience s

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26 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 upon 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 th~t emphasizes individual strengths and the belief in the human potential for growth and change and underscores the positi ve meanings inherent in the emotional, psychological and spiritual challenges individuals face in every da y 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 Profil e of Mood States-Short Form Spirituality for the purposes of this stud y, 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 -S hort Form. Stage I breast cancer for the purpos es of this stud y, is defined as a tumor 0-2 centimeters (c m ) without lymph node in vo l ve ment (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 cm. with positive lymph node involvement and no meta s tasis ; a tumor 2-5 cm with or

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without l y mph nod e in vo l ve ment and without metastasis ; or a tumor larger than 5 cm. without lymph node in vo l ve m e nt and without metastasis (Love, 2000). Organization of the Study 27 Rele v ant literatur e i s r ev iewed in Chapter 2. All aspects of research methodolo gy, includin g a s tat e ment of the purpose of th~ study h y potheses description of the populati o n description of the sample and sampling procedures design of the study delin ea tion of rele va nt va riables instrume~tation data analysis and methodolo g ical limitation s are outlined in ~hapter 3. The results of the statistical analyses of the data are reported in Chapter 4 The results of the analyses, the implications for theory and practice the limitations of the study and suggestions for future research are addressed in Chapter 5

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CHAPTER 2 REVIEW OF THE LITERATURE Introduction 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 genera-;te 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 (Spaniel 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 way s to divert ourselves from problems, to get relaxed and in touch with others [ and] to express feelings (Levick 2001 p 25). Art therapy techniques are numerous and varied (e. g ., see Wadeson 1980 pp 334-336) Research that applied and studied these therapeutic interventions with cancer patients has included the use of 28

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music, dance painting drawing sculpting journal poetry or prose writing (e.g. see D. Aldridge 1998 G. Aldridge 1996 ; Ha~gglund 1976 ; Pennebaker & Beall 1986 Wadeson 1980). 29 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 therap y 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 c ancer patient populations the following databases were searched: CAM on PubMed EBSCOHOST MedLine and Psychlnfo. 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 be e n rai s ed in the literature (Goleman 1995). Goleman contended The problem is when medical personnel ignore how patients are reacting e motionall y, e v e n w hile attending to their phy s ical condition [health care provider s ar e ] n eg l e ctin g a g rowing body of e vidence showin g that p e ople s emotional states can pla y a sometimes si g nificant role in their vulnerability to disea se and th e cour se o f th e ir recovery (p. 165 ) Goleman went on to su gge st that the medical profe s sion as a whole is lackin g in e motional int e lli ge n ce, a nd und e r sc or e d th e importanc e o f mindin g b o th th e b o d y an d th e e motions of individu a l s s tru gg lin g with ph ys ical dis e a se dia g no ses He r e p o rt e d ev id e nc e th a t s u gges t s a r e l a ti o n s hip ex i s t s b e tw ee n ph ys i ca l sy mpt o m s a nd di s tr ess fu l e m o tion s s u c h as c hr o ni c o r ac ut e a n ge r (e.g., ho s tilit y), a nxi e ty (e.g., p a ni c), a nd sa dn ess (e.g., d e pr ess i o n ).

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30 Researchers have demonstrated a positive association between emotional expression and an individual 's health status (Pennebaker 1989 ; Pennebaker & Beall, 1986). Lilja et al. (1998) reported cancer patient studies have demonstrate~ an association between emotional inhibition including suppression and repression of aggression and anger and incidence of cancer diagnoses. They specifically noted several studies have "fo und 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 variab l es for example, psychological adjustment (reporte~ levels of distress and well-being) (C lassen et al. 2001; Classen Koopman Angell, & Spiegel, 1996 ; Cohen 2002; Com pas 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 ef ficac y (Giese-Davis e t al. 2002) quality of lif e (Gore-Felton & Spiegel 1999 ; Helgeson et al. 2001 ) incidence and recurrenc e of diseas e (Spiegel & Kato, 1996), and surv ival and mortality (Deroga ti s, Abeloff & Melisaratos 1979 ; Watson Haviland Greer Davidson & Bliss 1999 ; Weihs Enright Simmens & Rei ss, 2000) The role of these persona li ty factor s on the e tiolo gy and incid e nc e of disease diagnosis represents one of the most controversial aspects of cancer r esearc h (Cox & MacKay 1982).

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31 Emotional Expression and Cancer Incidence The relationship between emotional suppression and incidence of breast cancer diagnosis has been researched and results indicated there is no significant association between a cancer outcome and emotional suppression when the patient's age a highly significant variable is controlled for (O Donnell Fisher Irvine Rickard, & McConaghy 2000). The authors added that although the results suggest that suppression of emotion may not be relevant to the development of breast cancer .. its role in the progression of existing disease requires clarification" (p. 1079). In a retrospective study Fernandez-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 exp l ained 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 v ery 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 s imilar study comparin g healthy women (n = 49) with breast cancer patients (n = 48) yielded slightly different conclusions (Servaes et al. 1999). Re v iew of e x tant literature about the role personalit factors ( including emotional suppression and repre s sion) on cancer etiology concluded that research to date has provided inconclusi ve e vidence regarding the role of emotional suppression or repression

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32 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 adjustmept 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 s coping style and / or tendency to suppress negative emotions play a significant role in her breast cane er diagnosis her response to treatment and / or long-term prognosis (Bleiker & van der Ploeg 1999). Stanton and Danoff-Burg (2002) have clearly cautioned against the potential for victim blaming associated with research about the role of personality factors (i.e. abnormal emotional expression associated with the Type C personality) on a c ancer diagnosis. We reiterate our research study addressed the potential role of emotional expression in enhancing psychological well-being not its h y pothesized role on initiation or progression of the disease Emotional Expression and Psychological Well-Being Research results on the relationship between emotional control adjustment to cancer and depression and anxiety in earl y stage breast cancer patients indicated a highly significant association between subjects tendenc y to control emotional reactions and a fatalistic attitude about the disease ( Watson et al. 1991 ) Additionally the authors discovered (with rather low but significant coe f ficients ) a predicted association between control of anger and helplessness [and] between control of anxiety and helplessness (p. 55) Watson et al. concluded that their research confirmed a relationship exists

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between the Type C personality trait of emot ional control and a fatalistic attitude about cancer and, to a lesser extent, fee lin gs o.f helplessness ; adding that these variables were related to increased fee l ings of depression and anxiety thus negatively affecting breast cancer patients psychological morbidity. 33 Psychological distress may take the form of a psychiatric diagnosis in up to 50 % of cancer patients (Spiegel, 1996) Spiege l has researched the incidence of clinical depression in cancer patients and suggested that treatment options include among others, interventions to faci litat e emotiona l expression: Cancer e li cits strong affects, including fear anxiety sadness, depression and anger. Such feelings become l ess overwhelming a nd more manageable when dealt with directly in therapy. Many seriously ill individuals feel i solated with their fear and sadness, unable to discuss it with health professionals fami l y 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 effective l y. (p. 111) Sp i ege l emp ha sized that a growing body of ev id e nc e indicates psychiatric therapy for the physically ill is an essentia l and important aspect of health care delivery Servaes et al. ( 1 999) 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 se l f-effacing and represses aggression and impulsivene ss (p. 27). The ambiva l e nc e to ex pre ss e motion s the authors contended, re s ult e d from their conscious atte mpt to appear s tron g and avoid bein g burdensome to others. According to the r esea rch e r s th e breast cancer pati e nt s chose to control their e motions suggesting a conscio u s and deliberate act rather th a n a psychologica l defense mechanism beyond their contro l. Even thou g h the ca nc er patients were more anx iou s th an the h ea lth y controls there were no differences on depression se lf -es t eem and we ll -being ; a s urpri sing find

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34 given the stressfulness of a cancer diagnosis. The authors h y pothesized this may be part of the breast cancer patients attempt to appear in control of their situation and not show their real feelings to o thers Servaes e t al. concluded that the brea st cancer patients displa y of "ca ncer-prone characteristics are a consequence of confronting a life threatening disease rather than reflecting premorbid personality features" (p. 27). Emotion-Focused Coping Emotion-focused coping in vo l ves the active processing and expressing of emotions and is considered a significant coping stra t egy in br eas t cancer patients approach to dia g no s i s a nd treatment of the di sease (S tanton e t a l. 2 00 2) Stanton Kirk et al. (200 0 ) research e d the effects of emotion-focused coping w hich involved purposeful emotional proc ess in g a nd ex pr ess i on, o n psychological a dju stment to cancer and reported that "wo men who expressed e moti o n s s urroundin g cance r at st ud y entry had fewer medical appointments fo r cancer-related morbiditi es (e.g. pain), e nhanced self-perceived physical h ea lth and v i gor, a nd d ecreased distress during the subse qu e nt 3 months relative to le ss ex pr ess i ve wo m e n (Sta nton & Danoff-Bur g 2002, p 3 4 ). One s tud y on a h o m oge n eo u s sa mpl e of I srae li ( J ewis h ) wome n reported that e m ot ionfocused cop in g had a deleterious effect on emot i ona l we ll-b ei n g and predicted hi g h e r l eve l s of d ep r essio n in patients w ith breast ca n ce r recurrence ( m e t as tati c m a li g n a n cy o r loc a l recurrence) (Co h en 2002). His t o ri ca ll y, gro ups of patients enro ll e d in ra nd o mi ze d co nt ro ll ed trial s tend t o be r e l at i ve l y h omoge n eous in d e mo gra phic composition (Ric h a rd so n et a l. 1 998). Sta nt on a nd Danoff-Bur g (2002) cautioned r esea r c h e r s to co n s id e r w hether reported outcome s diff e r among ca n cer patient s as a function of gender race a nd / or ethnicity.

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35 Stanton and Danoff-Burg (2002) have also addressed the benefits of explicit experimental emotional expression through expressive writing on cancer patients. They conducted a randomized experimental expressive writing intervention on 60 women (mean age = 50 years ; mean time since diagnosis duration = 28 weeks) diagnosed with Stage I and Stage II breast cancer (Stanton et al. 2002) Their goals were to (a) test the effects of expressive writing on psychological and physical health-related outcomes and (b) assess the effects of encouraging subjects to write about the positive aspects of their cancer diagnosis and experience. Subjects were randomly assigned to one of three writing conditions and completed four, 20-minute writing sessions within a 3-week period. Trained research assistants read instructions from prepared scripts. Writing 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 expenence. 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 symptoms and number of medical appointments for cancer-related morbidities) The researchers also sought to explore whether the effect of the given writing conditions

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36 would vary' as a function of participants' self-reported avoidance of cancer-related thoughts and feelings, reasoning that women low o n avoidance might benefit more ~om emotional disclo s ur e than would high-avoidant wo men for whom induced emotional disclosure might be difficult (S tanton & Danoff-Burg 2002 p. 40). The experimentally induced expressive di s closure 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 th e expressive writing literature Although described by the st.ibje~ts as a painful and difficult proce ss most r e ported that ultimatel y th e exerc ise was insightful and helpful. The po s iti ve re s ults of this experience did not hold for any group at I-month and 3-month follow-up assessments. The authors reported that wo men who self-reported as lo w -a vo id a nc e experienced l ess di st r ess than wo men in the hi g h-avoidance category The latter group ben efite d mo s t from the benefit-findin g writing condition. An important findin g of thi s s tud y i s that women do not have to write about painful thou g ht s and feelings in order t o b enefi t from ex pr essive writing. Subjects in the experimentally induc e d ex pr ess i ve di sc lo s ur e gro up a nd th e benefit-finding group had fewer medical appo intm ents in the subseq u ent 3 months than did control gro up subjects T h e ex p e rim e ntall y indu ced ex pr essive disclosure gro up experie nc ed the g r eates t de g ree of b e n efi t regarding overa ll physical h ea lth-r e l a t ed o ut co m es (less ca nc e r r e lat e d medical a pp o intm e nt s a nd l ess overa ll cancerr e l ated physical symp t oms) R egar din g lon g -l as tin g positive effec t s, se l f-pe r ce i ved e nh a nc ed und e r s t a ndin g of their exper i e n ce, and va lu e of the study s ubj ects in th e benefit-finding group r eported a s li gh tl y grea t er b e n efi t than those in the exper im enta ll y indu ced express i ve disclosure gro up did. The researchers co nclud e d that a lth o u g h prompting g r ea t e r imm ed i ate distress exp r ess in g th e full range

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37 of thoughts and emotions surround in g cancer appeared to yie l d 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) conc lud ed "bo th correlational and experimenta l evidence [reported thus far] provides preliminary support for the important role of emotional express ion for individuals who confront a cancer diagnosis (p. 45) Stanton, Danoff-Burg et a l. (2000) have exp lor ed whether emotionally expressive cop in g 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 (SD = 10 .33; age range 28 to 76 years). The subjects completed several measures: a coping measure with the emotional-approach coping sca l es (emotional -pro cessing and emotiona l -express i on) embedded; a hope sca l e, a socia l receptivity scale; a psycholo g ical I adjustment sca l e, the Profile of Mood States (POMS); a health status questionnaire and written documentation of medical visits over time These instruments were given to subjects 20 weeks after medical treatment was comp l eted and again 3 months l ater. 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 throu gh emotional processing. E motionall y expressive coping was "associa ted with decreased di s tress increased vigor improv e d se lf -perce i ved health s tatu s, and fewer medical appointments for morbidities related to cancer and its treatment (p. 84-85). Emotio nall y expressive coping impro ved th e quality of lif e in women who fe lt their socia l support network was hi gh l y receptive to their expressiveness about the strugg l e with cancer. In contrast women who utili ze d

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38 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 proacti v e measure b y 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 li v es 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 r e search ( 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). A number of research studies have focused on the lived experience of spirituality (Chiu 2000) and the role of spiritual well-being on the qualit y of life and psychological

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39 adjustment of breast cancer patients (Brady et al. 1999 Cole & Pargament i 999; Cotton et al. 1999 ; Feher & Mal y, 1999 Gall&, Cornblat 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 patients experiences of religiosity (Feher & Maly, 1999) meaning making (Mickley et al. 1992) and hope (Mickley et al. 1992; Moadel et al. 1999). These studies involved the use of questionnaires interviews and self-report measures. All researchers reported findings indicating that spirituality played an instrumental role in the experience of coping with a cancer diagnosis. Moadel et al. cautioned that as many as 33% of cancer patients reported spiritual or existential needs were unmet in the course of conventional medical treatment. Mickley et al. (1992) examined the roles of spiritual well-being religiousness and hope in spiritual health and indicated that physical health status is independent of spiritual health. This supports the notion that cancer patients may experience spiritual well-being even when facing a poor prognosis. Existential well-being an aspect of spiritual well-being was shown to contribute to patients experience of hope as did maintaining a social support network and the presence of religious beliefs in the subjects spiritual life. Feher and Maly (1999) conducted research on the role of religious faith in elderly cancer patients experiences of coping and found similar results pertaining to the roles of religious beliefs and social support network.

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40 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 t ime. 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 anxiety. Brady et al. ( 1999) administered questionnaires to a large sample of multi-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 oflife. The researchers found that both spirituality and ph ys ical well-being were equally c:!Ssociated 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: R e Creating Your Life : During and Aft e r Cancer The authors made a case for integration of spirituality in psychotherapy programs aimed at addressing existential dilemmas raised b y a cancer diagnosis. The program addressed four existential concerns belie ve d to affect cancer patients: control identity relationships and meaning The group int erve ntion was developed within a holi st ic healin g framework to assist cancer patients cope with th e ir disease They utili ze d an emotion-focused coping approach, believed to be more helpful than problem-focused coping for this pati ent group (Strentz

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41 & Auerbach, 1988 as cited in ole & Pargament 1999 ). The authors concluded "a program that explicitly integrates spirit\lal resources into the psychotherapy process may hold considerable promise for this population [and] the benefits of such a program may even exceed those offered by traditional psychotherapy (p. 405). The role of spiritual factors on long-term adjustment to breast cancer has also been explored (Gall & Comblat 2002). The researchers asked a sample of 39 women long-tern 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 s trength 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 goo dnes s a nd greater purpose in life. This tru st gro und ed these women providing th e m with a so lid se n se of purpose an d place [informing] most spiritual aspects of their adjustment such as their meaning-making aro und the cancer experience. (p 533) The aut hor s acknow l edged the limitation s of a retrospective study based on one question answered by a relatively sma ll sample and s u ggested that a lon g itudin a l qualitative exp loration be g un at diagnosis would better capture the role of spiritual and r e li g ious factors in cancer patients lon g -term adjustment to the disease.

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42 The role of religion on breast cancer survival has also received attention (Roud, 1989 ; Van Ness Jones & Kasi 2001). Roud explored the spiritual dimensions of extraordinary survival of terminal cancer patients He conducted in depth ipterviews (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 resporisib1lity 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 exP.ression 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 reli g ious va riables and their impact on survival: religiou s denomination attendance to religious serv ices religious social network religion as a source of comfort and subjective religious identity Denominational preference was the only variable that y ielded statistically significant results with the Pentecostal denomination showing a possible protective effect when compared with the Protestant reference group. The authors concluded that nonreligious subjects were at increased risk and traditional faith-healing groups showed the greatest protective effect.

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43 Thomas and Ret s as ( 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 aH 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 faith in self others, God and/or another Higher Being" (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 oflife 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 connectedness 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 overlooked or ignored in the process of health care service delivery Literature reviews pertaining to religiosity and spirituality and their relationship to cancer patients mental

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emotional and physical health and quality of life have been conducted (Mytko & Knight 1992 ; Sherman & Simonton 2001) 44 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 Simonton' s findings concurred; in summary General religious orientation and cancer-related religious coping have both been modestly associated with var ious 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 gathe red 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 Ps yc hological adj ustment to cancer is indicated by levels of psychological ( mental and emotional) distress and we ll-being that patients experience as they face disease diagno s i s and treatment choices (Stanton et al. 1998). A diagnosis of cancer has been described as a "jarr in g life-alterin g experience for most patients and their families [with] taxing treatments, disrupted functioning and uncertainty about survival among the burdens the y face" (S herman & Simonton 200 1. p. 167 ). Approximately 20% to 30% of breast cancer patients repo11 experiencing severe psychological distress a year after initial diagnosis ( Ir vine Brown Crooks Roberts & Browne. 1991 ) Cancer patients needs psychological distress and l eve l s of adjustment fluctuate over the course of the disease (An dersen 1992). Levels of di st ress are greatest at the initial diagnosis and treatment

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decision-making period and almost half of early stage cancer patients (including those with relatively good prognosis) have be~n found at risk for moderate to severe psychological distress ( Bleiker Pouwer van der Ploeg, Leer & Ader 2000). 45 The research literature has documented a number of negative psychological consequences of a cancer diagnosis including clinical depression and anxiety (Bleiker et al. 1995 ; Payne et al. 1999 ; Razavi & Steifel 1999; Spiegel 1996). Breast cancer patients also struggle with performing daily physical occupational and/or social activities with a considerable number (20-46%) suffering from moderate to severe emotional morbidity (van der Pompe et al. 1996). Spiegel (1996) reported even though about 50% of all cancer patients have a psychiatric disorder ( e.g. adjustment disorder with depression) comorbidity of psychiatric with medical illness is a common and under recognised problem; [emphasizing that effective treatment of depressive symptoms] results in better patient adjustment reduced symptoms reduced costs of care, and may influence disease course (p. 109). Antoni et al. (2001) on the other hand, cited several studies that researched and reported positive consequences of a cancer diagnosis. The authors contended: Although diagnosis and treatment for cancer are distressing and disruptive there is an increasing awareness in both research and clinical communities that the cancer experience often has sequelae that patients view as positive or beneficial. A substantial number of patients report experiences such as improvement in personal resources and skills an enhanced sense of purpose enhanced spirituality closer relationships with significant others and changes in life priorities. (p. 21) These findings emphasize the diversity of adjustment responses that may be found across this population. The types of concerns affecting breast cancer patients also vary with disease stage diagnosis ; early stage patient worry about recurrence post-operative distress and / or

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46 chemotherapy, which ma y affect bod y 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 b y 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 ps yc hological interventions (p. 364). Extensive critical reviews of the literature have been conducted about psychological inter ve ntion s on cancer patients in general (Anderse n 1992 2002) and breast cancer patients specifically (G lanz & Lerman 1992 ; Tapper, 1999). Problems of conceptualization and confounding ha ve been addressed in psycho-oncology research (Stanton et al. 1994 ). A common admonishment underscored the need for careful scrutiny and interpr etation of the highly hetero geneous sets of extant data from research done on multiple types of cancer cancer stages demographic va riables and psychological interventions (Andersen, 2002 ; Tapper 1999) Our review of the lit erature yie lded multiple studies pertaining to outcomes of psychological interventions on breast cancer patients emotional express ion and psychological adjustment including psychological distress and well-being; recall these st udies ha ve utilized inter vent ions as follows: individual therapy (Lev & Owen 2000; Maccormack et al. 2001 ), s upporti ve psycho-educational group therapy (E dmonds et al. 1999 Fukui et al. 2001 ; Greenstein & Breitbart 2000 ; Helgeson et al. 1999 200 I ; Montazeri et al. 2000) supportive cognitive-behavioral group therapy (An toni et al.

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47 2001 Bloch & Kissane 2000 ; Cunningham et al. 1998 ; Edelman et al. 1999 ; Kissane et al. 1997 ; Watson et al. 1996) and mixed modalities (including psycho-education stress management guided imagery and / or hypnosis) group therapy (Spiegel & Moore 1997 ; Fawzy et al. 1990 ; Fukui et al. 2001 ; Hosaka et al. 2000 ; Richardson et al. 1997 Simpson et al. 2001 ; Spiegel & Bloom 1983; Spiegel e~ al. 1 989). A number of research studies have exp lored the efficacy of supportive expressive group therapy on cancer patients emotional expression (Giese-Davis et aL 2002) psychological adjustment (Classen et al. 1996) distress (Classen et al. 2001; Spiegel et al. 1999) and survival (Goodwin et al. 2001 ). It should be noted that supportive expressive group therapy does not usually incorporate art media in its interventions ; the disciplines of expressive arts therapy and creative arts therapy most commonly do (Malchiodi 2003) Supportive expressive group therapy specifically geared toward emotion focused coping has been shown to help women with metastasized breast disease to express their emotions more openly and freely without becoming hostile (Giese-Davis et al. 2002). Classen et al. (1996) reported emotional expressiveness and adoption of a fighting spirit approach to coping (Friedman Nelson Baer & Lane 1 990) 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 wa s found us e ful in reducing psychological distress in women with metastasized disease (C l assen et al. 2001 ) Spiegel et a l. ( 1999 ) also researched breast cancer patient s recei v ing supporti v e x pre ss ive group th e rap y and r e ported a significant decrease in mood disturbance, a d e crease in anxiet y and depres ion and reduced overall distress in the treatment group

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48 Goodwin et al. (2001) reported that participation in supportive expressive group therapy by women with metastasized breast cancer did not prolong survival in the treatment group ; however it helped to improve mood and perception of pain, particularly ih 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 expressi v e 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 various challenging and life-threatening illnesses including cancer.

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49 D. Aldridge (1998 ) e x plored Life as Ja z z a metaphor for bringing hope and meaning to individuals facing life-thre atening 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. T~e author concluded that music enhanced his client s 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 dem ons~rate the increased use of creative therapies in cancer patient treatment and research. Davis (2000) developed a book that offers cancer patients a structured writing intervention to guide the emotional expression of thoughts and feelings as they come to terms with and learn to cope with their disease. Dreifuss-Kattan (1990) provided psychooncological and psychoanalytical overviews of subjects experience of cancer and reported that multimodal creative art therapy helped enhance their emotional and psychological well-being. Haegglund (1976) conducted a psychoanalytic study addressing the relationship between creativity the death and dying experience and attitudes of cancer patients. The author contended that poetry writing may appease and help soothe the pain of loss and mourning often associated with a cancer diagnosis Haegglund conducted a literature review and its findings supported his original hypothesis (that a relationship among these constructs does exist). The author illustrated his point by presenting five cases studies of indi v iduals s ufferin g from cancer who used poetry writing as a way to face feelings of fear sadnes s g uilt an x iety and pain The therapist s role as a helper in the patients

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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. 50 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, 1995). 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 writings from two divergent perspectives Smith hypothesized that Philip s poetry was another form of revealing thoughts and feelings that may not be clear to the therapist in session but manifest openly on the page. She saw Philip s poetry as a process of coming to terms

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with the loss of identity the loss of loved ones, and the meaning of death and dying itself. 51 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 ai:i.d feelings in a public professional forum was an emotionally healing experience for Philip. One study explored the roles of spirituality and creative art therapy in mental health care practice (Greenstein & Breitbart 2000). Greenstein and Breitbart proposed a group intervention to help cancer patients address the challenges that their disease brings. They developed sessions focusing on aspects of meaning including a sense of transcendence spirituality responsibility values priorities and personal creativity. The group intervention incorporated aspects of the creative arts by exposing patients to instances of meaning, which can be found through the appreciation of beauty in nature or works of art According to the authors: "whether pursuing creative goals and experiential values or reframing one s attitude [individuals] may attain a sense of meaning in part through transcendence (p. 497) a spiritual experience of connectedness with others or with a universal larger whole beyond ourselves. In their qualitative explorations of spirituality and creativity in healing the authors concluded that creative art therapy enhanced patients ability to openly express painful emotions, including the experience of grief and to explore the existential spiritual dilemmas of meaning and connectedness raised by facing death through their life-threatening illness

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52 Our review of the literature uncovered no experimental studies that explored the efficacy of creative art therapy interventions on breast cancer patients' self-reported levels of spirituality or the role of spirituality on breast cancer patients psychological 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, 2000). 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 s improvisations and interpreted them as therapeutic experiences of emotional expressivity and as reflection of the subject s emotional healing process. The author contended that spontaneous musical improvisation assisted his client to access her creati v e power a potential source of strength hope coherence and meaning she could draw from. He concluded active, creative music therapy is an intervention that offers a chance for patients to use their own

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creativity and creative s tren g th to cope with their crisis and maintain coherence through their illness .. within a culturally accepted form (p. 221-222). 53 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 m y 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 sc ulpture of Cruze's plaster torso and named it N ight Li g ht The piece tra ve ls from time to time to conferences and gallerie Cruze reported that the changes s he ex perienced after completing the sculpture amazed her: an increased sense

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of happiness and optimism and ultimately gaining the ability to reframe her cancer experience. Cruze concluded that looking at the sculpture makes her feel triumphant victorious over [her] disease for the first time (p. 402) Predeger (1996) conducted qualitative research using the feminist process 54 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 s method is described as evolving within a group session format that followed a deliberate structure of centering, art experience, reflection and action (p. 51 ). The centering part of the group session began with a check-in or an opening-up where participants became present to each other. A question was then posed to encourage centering and reflection. The women proceeded to choose a favorite art medium and to utilize the creative process as vehicle for describing the breast cancer experience. Sharing among group members took the form of synthesizing and interpreting the observation of images Analysis of emergent themes ended each session. In order to secure data each session was audio taped and transcribed ; transcripts were discussed and analyzed collecti v ely during later sessions. Additional data sources came from participants reflections about their art researchers field notes and surrounding conversations among the women. According to Predeger the generation of themes became a recursive process Meaning making was described as a dialectic

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process where emergent th mes were discussed and would be revisited in subsequent sessions thus deepenin g th e coanalysi s of the experience. Leadership group direction individual and group insi g hts occurred throughout the research process 55 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 world view lens whereby the Ii ved 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 sister s Creating a safe harbor Fueling the creative s park Cel e bratin g th e feminine Womanspirit. Actualizing the need to express ref e rs to the wom e n 's cont e ntion that bein g a bl e to ex pres s th e ir f ee lin gs a nd thou g hts throu g h art wa s v ie we d as tim e l y and opportune Th e ability to ex pr ess b e cam e mor e important than th e media u se d or the final product it se lf. Th e s h a rin g d ee p e n e d as th e g roup sess ion s pro g r esse d Losing and gaining control e m e r ge d a s th e women s s tru gg l e to allow th e m se lv es t o o p e n up a nd full y ex pr ess difficult e motion s (lo se control ) in ord e r t o

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r ega in control. This paradoxical process of s urr e nd e r and empowerme n t also deepened and became easier w ith time. 56 Illuminating a changing perspective refers to their reframing of the breast cancer experience. Art i s described as a p at h way toward healin g and meaning making that transcended prior int erp retation s of th e s tru gg l e w ith the disease. The wo men were able to focus o n th e goo dne ss in their li ves rather than the negative aspects of struggling with cancer. Transcending and becoming braver refers to the w i s h to move be yo nd their own struggle and re ac h o ut to assist others faci n g the d isease B ecomi ng proac t i ve e m erged as an imp o rt a nt aspec t of healing fo r the wome n ; this took the form of political in vo l veme nt expressing thoughts and feelings assert i vely, or reframing themselves from v ictim s to su r vivors Connecting with sisters refers to the collective engagement in fem inist research and em bracin g a n ideology that promotes support and encouragement of wo men. The ex p erience of sisterhood provided companionship and warmth that reduced feeli ngs of a li e n a tion o r l one lin ess. Creating a safe harbor refers to the women s framing their art -makin g proce ss as a place of rest and replenishing. The time spent together provided needed relief from every da y wo rri es. Fueling the creative spark refe r s to the power of the collective to inspire the wome n to explore th eir thoughts and fee lin gs through the creative process. Some of the wome n reported a reawakening of their c r eative selves the y had l ong neglected. Celebrating the feminine refers to the experience of making art within a feminist framework as affirmi n g of the creative power and the feminine wit hin each participant. F in a ll y th e concept of Womanspirit e m e r ged as a particularl y powerful theme:

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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 b y 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). 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 others 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 b y encouraging active participation in the healing process which can lead to a better medical prognosis and impro v ed quality of life (p. 53 ). The ultimate goal of this approach i s to help the dancing client develop awareness of give form to (through improvis e d dancing) and inte g rate conscious and unconscious material her feelings about her bod y and her s e lf.

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58 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 (1 a) Participation in an Authentic Movement treatment group will improve psychological adaptation of women with breast cancer significantly more than waiting for treatment. ( 1 b) Improvement will be sustained over time (2) Women who show the most improvement will be older, have had earlier stage (I or II) cancer diagnosis less invasive medical treatment more time elapsed since the end of treatment and more past experience with physical activities (i.e., sports or dance) Inclusion criteria were as follows: Diagnosed with Stage I or Stage II breast cancer. Treatment completed 6 to 60 months prior to the study. No prior breast cancer diagnosis. No active ps yc hiatric symptoms (i.e. hallucinations delusions severe psychiatric morbidity). No history of inpatient psychiatric treatment. The treatment consisted of 3 hours of Authentic Dance sess ions 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 s ubject widely. Participants were recruited via letters with assistance from the San Francisco Bay Area's Alameda County American Ca nc e r Society. Int erested respondents were contacted by phone after inclusion criteria were ve rified a face-to-face was interview scheduled. Durin g the first in-p erson interview pretreatment qualitative data was ga thered regardin g the subject s personal experiences with cancer dia g nosis and tr ea tment including how it affected h e r feelings abo ut h e r body or h e r se lf. A paper-and-pencil packet of questionnaires was admi ni stered to measure pretreatment l eve l s of psychological adaptation as ev id enced b y mood scores in the Profile of Mood States (POMS) psychological di s tr ess scores in the Symptom C h eck List 90-Revised (SCL-90R) bod y

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59 image and elf esteem scores in the Borscht-Walker-Bohrnstedt Body Image Scale (BWB). 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 = 54 7 Therapy 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 psycholo g ical adaptation were made between control and treatment groups at pretreatment po s t tr e atment and delayed post-treatment. After dela y ed post-treatment members of the treatment g roup completed a written evaluation to rate ( on a Likert-type s cal e) de g r ee of chan g e e xp e ri e nc e d and stren g ths and weaknesse of th e dance th e rap y ex p e rience The y al s o g av e s u gg estions for future improvement s.

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60 Dibbell-Hope reported that only the control group subjects from the Northern S~ 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 la 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 difference~ appeared i n 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 le ve ls of Fatigue and Total Mood Disorder in the POMS (p < .05) than did the Southern treatment group The Northern group also had higher distress levels on th e SCL-90R (p < .001) and greater dissatisfaction with body image in the BWB (p < .05) than did the Southern treatm e nt group. The Northern control group also showed higher overall mood disturbance di stress, and dissatisfaction with body image. The Southern treatment gro up reported statistically hi g her levels of body image (p < .05) than did the Southern control group. Statisti-cal testing of interaction of treatment b y region was done and no significant interaction effect was found Dibbell-Hope concluded that Hypothesis 1 a was generally unsupported ANOV A was calculated at post-treatment and dela ye d treatment times to assess whether treatment effects were sustained over time. Between-groups analysis indicated that the significant

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61 improvement in Fatigue Vigor and Somatization was not sustained over time. Hypothesis 1 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 th~t the areas where small impro veme nt was reported related to the ph ys ical body (Fatig ue Vigor and Somatization) and hypothesi zed that Authentic Movement might have contributed to a sense of physical well-being in the women. Hypothesis 2 was tested through a step-wise multiple regression procedure to see 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 ps yc hological adaptation. The stage of breast cancer was the most frequent predictor of mood and distress. Age was the most s ignificant predictor of satisfaction with body image and self esteem. Hypothesis 2 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 descriptivel y 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 h ea lin g assisting them to resolve is s u es related to their breast cancer strugg le especially disturbances in mood n ega tiv e feelings about their bodies and soc i a l i so lation The author acknow l edged that subjectively perceived improv ement in distress mood se lfesteem and body im age after the therapeutic dance experience cannot be interpreted as a direct causa l relationship since s h e made no attempt to correlate or track individu a l c h anges from entry to exit int erviews or to corre l ate subjective and objective

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62 data. She concluded that further qualitative (phenomenological) and quantitative resear~h 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 discrepanc y 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 noteworth y qualitative finding came through the subjects' 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 g reater 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 therap y 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 s truggle with the disease and by facing their own mortality and enhance overall psychological well-being. Controlled randomized quantitative s tudies examining these constructs h ave been called for and are clearly needed

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63 Conclusion 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 suppoD 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 patients self-report helped decrease their feelings of fear sadness distress and isolation and provided an increased sense of personal control. The multi modal 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' emotional 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 mu s ic therapy (D Aldridge 1998 ; We s t 1995 ), structured and unstructur ed journal writing includin g poetry and prose (Davis 2000; Haegglund, 1976 ; Philip 1995 ; Smith 1995 ; Wyatt-Brown 1995) art appreciation (Green tein & Breitbart 2000), an d multi modal art therapy (Dre ifu s-Katta n 1990). R esearc h tudi es abou t the efficacy of art therapy on breast c ancer patients hav e includ ed music therapy (G. Aldrid ge 1996),

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collaborative sculpting (Cruze 1998) multimodal art therapy (Predeger, 1996), and dance therapy (Dibbel l-Hop e, 2000). 64 Dibbell-Hope s (2000) study about the efficacy of dance therapy on the psychological adjustment of breast cancer patients was the only one to use both quantitative and qualitative measures. No treatment effect was found for post-treatment or delayed treatment variables measured quantitatively. Subjective assessments, however showed post-treatment benefits as have the other qualitative studies reviewed here (G. Aldridge 1996 ; Cruze 1998 ; Predeger 1996). A number of studies found which examined the efficacy of experimentally induced expressive writing music therapy or creative art therapy reported positive findings (e.g enhanced emotional expression and psychological well-being) that were ' also described (by the authors and / or the subjects) in spiritual language and overtones (e.g. D. Aldridge 1998 ; Philip 1995 ; Predeger 1996 ; Stanton & Danoff-Burg 2002). Although not directl y 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 pres e nt s great chall e nges to a woman s bod y, mind emotions and spirit. Creative art therap y ma y pro v e a v iable and beneficial intervention to assist women in facing this life-threatening challenge. The pretest / posttest control group design experiment described herein e xamined the efficacy of the complementary mind-body intervention of creati v e art therap y on breast cancer patients emotional expression self-reported levels of spiritualit y, and p sy chological well-being

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CH~TER3 METHODOLOGY Statement of Purpose The psycho-oncology literature contains a number of qualitative studies focused on the efficacy of creative art therapy interventions on emotional expressiqn (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 pot e ntially eff e ctive psychotherapeutic methods that will make a significant contribution to [cancer] pati e nt care and b e come an integral part of clinical practice remain challen g in g a nd s carce (Greer 1999 p. 2 42). The purpose of thi s s tudy wa s to determine th e efficac y of a creativ e art therapy intervention to enhanc e emotional e x pression s piritual c o nn e ct e dn ess and se l e ct asp e ct s of psycholo g ical w e ll b e in g in newl y dia g no s ed Sta ge I a nd S t age II br e a s t canc e r patient s. Thi s c h a pt e r d esc rib es th e r ese arch h y poth es e s, p o pulation data coll ec tion ( includin g attrition ) sa mpl e a nd sa mplin g proc e dure s, d es i g n o f th e s tud y includin g 6 5

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66 relevant variables, instrumentation and data analysis. Methodological limitations of this research study are also discussed. Research Hypotheses The following research h y potheses were evaluated in this study. Ho(l ): There is a significant difference bet wee n the experimental group of creative art therap y and the control group of dela yed tr ea tment on emotional expression, as measured by the E motional Approach Co pin g Scale (EACS) in newly diagnosed Stage I a nd Sta ge II breast cancer patients. Ho (2) : There is a s i g nificant differenc e bet wee n the experimental group 's pre-and po s t-s essio n scores on po s iti ve and negati ve e motional expression/states as measured by the E motional Assessment Scale (EAS) in ne w l y diagnosed Stage I and Stage II breast cancer patients. Ho(3): T her e i s a s i g nificant differ e nc e b e t ween th e ex p eri mental group of creative art th erapy a nd th e control gro up of delayed treatment on sp irituality as me as ured b y th e Ex pr ess ion s of Sp irituali ty In ve nto ry -R ev i sed (ESI -R ), in newly di ag n ose d Stage I and Stage II breast cancer patients. H o( 4): There i s a s i gn ifi ca nt diff ere n ce between the experimenta l gro up of c r ea ti ve a rt th era p y a nd the contro l gro up of d e l ayed tr ea tm e nt on th e psychological we ll b e in g s ub sca l e, Tens i on Anx i ety as measured b y the Profile of Mood States (POMS), in newly diagnosed Stage I and Stage II breast cancer patients. Ho(5): T h e r e i s a s i g ni fica nt difference b e tween th e experime nt a l group of crea ti ve art therapy a n d th e contro l gro up of d e l ayed tr ea tm e nt on the psychological well bein g s ub sca l e D e pr ess i on -D ejec ti on, as mea s ur e d by th e Profil e of Mood States (POMS) in n ew l y dia g no se d S t age I a nd Stage II br eas t ca n cer patients.

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67 Ho(6) : There i s a significant difference between the experimental group of creative art therapy and the control grotJp of delayed treatment on the psychological well being subscale, Anger-Hostility, as measured b y the Profile of Mood States (POMS) in 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 we ll being subscale Vigor-Activity, as measured by the Profile of Mood States ( POMS) in newly diagnosed Stage I and Stage II breast cancer patients. Ho(8): There is no significant difference between the experimental group of creative art therapy and the control group of delayed treatment on the psychological well being subscale, Fatigue-Inertia, as measured by the Profile of Mood States (POMS), 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 (POMS), 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 sub j ects were diagnosed with Stage I or Stage II breast cancer within 1 2 months of being referred to the study. T h e sample was recruited from women recently diagnosed with breast cancer who reside in the North Cen tral F lorida area and were receiving treatment through the cancer center at Shands Hospital the cancer center at North F l orida Regional Medical Center the Suwanee Valley Cancer Center in Lake City F lorid a and/or through onco l ogy specia li sts in the Gainesv ill e and Lake C ity communities.

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68 The U.S. 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. orth 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 exper~mental 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 nearl y 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 of23.2 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 fl y ers were posted in parking garages at Shands Hospital at the University of Florida (including the Shands Cancer Center ), on bulletin boards at the Shands Cancer C enter and Shands at AGH and at local places of worship and bookstores. Flyers were also displayed at physicians private offices in Gainesville and Lake City specializing in oncology

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69 radiology and oncology surgery and at the local American Cancer Society s Hope Lodge and related support groups. Soci~I work counseling nursing and oncology care personnel at hands Cancer Center and the aforementioned oncology offices were also given flyers and they referred subjects who qualified and expressed interest to participate in the study. Table 1 outlines the referral sources of women who participated in the study. Most of the subjects were referred by local oncology physicians ( 41.0%), or by friends who knew about the study (30.8%), designated as "Other in the demographic questionnaire. Shands Hospital at UF, specifically Shands Cancer Center personnel (20.5%) and American Cancer Society support group members (7.7%) referred the rest of the subjects who participated. Table 3-1 Referral sources Referral sources Private physician Shands Hospital American Cancer Society Other Total Treatment group(%) 10 (50.0%) 2 (10.0%) 2(10.0%) 6 (30.0%) 20 (100.0%) Control group (%) 6 (31.6%) 6 (31.6%) 1 (5 3%) 6 (31.6%) 19 (100.0%) Total(%) 16 (41.0%) 8 (20.5%) 3 (7.7%) 12 (30.8%) 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 counselor s at the end of the four-week delayed treatment period to complete the posttest measures. Individual art therapy treatment for control group subjects began upon completion of all posttest measures.

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70 Forty-four women volunteered to participate and 41 completed the study. Two bf the women who initially wanted to participate changed their minds and never comp leted the informed consent form or other pre-test documents Of the twenty women in the control group, seven did not complete the dela yed 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 b y 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 disco ve red two outliers, one in the contro l group and another in the experimental group. The control group subject encountered a crisis about two weeks into the dela ye d treatment wait period. She phoned her designated counselor and a discussion ensued that la s ted approximately 15 minutes. Subsequently this subject exhibited enhanced psychological well-being on post-test scores. We hypothesized that this brief contact may have influenced her post-test scores. The experimenta l group subject reported an accidental death by drowning in her immediate family between sessions two and three a nd her psychological well-being post test scores appear to reflect the emotional repercussions of thi s lo ss. Data collected from these outliers was eliminated du e to the aforementioned circ umstances and probable effects on post-test scores. Sample and Sampling Procedures Approval b y the Institutional Review Board ( IRB) at the U niversity of Florida was obtained before co ll ecting data for this stud y The total sa mple of women who

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71 participated in this stud y was 39. In order to 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 inclusion criteria All women in this research study were voluntary participants. The subjects were recruited from Shands Hospital and North Florida Regional Medical Center s cancer treatment centers, from the Suwanee Valley Cancer Center in Lake City and from oncologists private practice offices in the Gainesville and Lake City communities. A research announcement flyer was used to disseminate research recruitment information to subjects who met the research eligibility criteria (Appendix B). Some subjects were recruited from the local ACS support network. The subjects were adult women 18 years of age and older who volunteered and signed an informed consent for participation in the study. Posted notices at Gainesville area community bookstores and worship centers were also utilized. The subjects called a designated contact number and left a message expressing interest in the research project. The primary investigator talked to the callers and screened them according to outlined criteria with verification occurring after receipt of the subject s 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 complete prete s t mea ure s and begin the treatment protocol 4 weeks later after posttest measures were obtained

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73 Data pertainin g to age by groups is presented in Table 3-4 The mean age for the creative art therap y group wa s 51 8 ye ars 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 Mean St. D Treatment group (n = 20) 51.8 13 0 Control group (n = l 9) 50.9 10 7 Total (n = 39) 51.4 11.88 Table 3-5 and Table 3-6 delineate ~escriptive data regarding participants breast cancer. 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. Table 3-5 Stage of breast cancer Stage of breast cancer Treatment group(%) Stage I 14 (70.0%) Stage II 6 (30.0%) Total 20 (100.0%) Control group (%) 6 (31.6%) 13 (68.4%) 19 (100.0%) Total(%) 20 (51.3%) 19 (48.7%) 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 chemotherapy and expecting to also receive medication therapy ( e.g. Tamoxifen Femara ) over 2 to 5 years posttreatment(s). Additionally three women (15.0%) who

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women (26 3 %) w e re diagnosed 1 to 3 months prior to enrollment into the study fi e women (26.3%) 4 to 6 months four w?men (21.1 %) 7 to 9 months and five women (26.3%) 10 to 12 months. Table 3-7. Time since diagnosis at enrollment Time from diagnosis Treatment group(%) 1-3 months 9 (45 0%) 4-6 months 6 (30 0%) 7-9 months I (5.0%) 10-12 months 4 (20.0%) Total 20 (100.0%) Control Group(%) 5 (26.3%) 5 (26.3%) 4 (21.1 %) 5 (26.3 % ) 19 (100.0%) Design of the Study Total(%) 14 (35.9%) 11 (28.2%) 5 (12.8%) 9(23 1%) 39 (100.0%) 75 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 weeks). Women recently diagnosed with Stage I or Stage II breast cancer were included in the study Two mental hea l th counselors conducted the study. They were doctoral candidates in counselor education at the University of Florida at the study s inception. 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 I icensed mental health counselor in the state of Florida and was 52 years of age at the time of the study. The second counselor has a master s degree in counselor education She is a licensed mental health counselor in the state of Florida and was 41 y ears of age at the time of the study. The counselors have over 30 years of collective experienc e in mental h e alth counseling. Two counselor were used in order to decrease experimenter effect.

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76 Once a potential research subject was identified the primary researcher random,ly 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 comp l eted and returned via U.S. r:nail 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 s ubject randomly assigned to the control group, informed her about the study and asked if she st ill wanted to participate Each control group subject who agreed to be in the study received (v ia U.S. mail) an introduction to the st ud y letter (Appendix F) a relea se of information form, an informed consent form a pretest measure (profile of mood sta te s) and a demographic questionnaire. At the end of th e 4 weeks each contro l gro up s ubject met with one of the study s counselors to complete the posttest measures (Emot i ona l Approac h Cop ing Scale Ex pr ess ion s of Spirituality In ventoryR ev i sed Profile of Mood States) and to set up the first posttest treatment sess ion If a control group subject was unable to attend the posttest sess i on she received a phone call where the counse l or instructed her to complete the questionnaire packa ge that was se nt v ia U.S mail. A cover letter (Ap pendi x G) and written instructions (Appendix H) were in c lud ed in the package. A se lf-addr essed

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77 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 po s tt es t 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 experimenta l 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 approximate l y 60 minutes. 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 po ttest measures (Emotional Approach Co ping Scale Expression of pirituality Inventory R ev i se d Profile of Mood States) and an exit interview form (A pp e ndix I) that was e nt v ia U .S. mail. A cover l ette r (A pp e ndix J ) and written instruction s (A ppendix K ) were included in the packa ge. A se lf-addre sse d stamped envelope was provided o the expe rim e ntal g roup s ubj ec t could r e turn the completed questionnaires to the researcher.

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78 Delineation of Relevant Variables Independent Variable The independent var iable used in this study was an individual creative art therapy intervention There were a total of four individual therap y sessions over a 4-week period Each session lasted approximately 60 minutes The last session lasted approximately 90 minutes to allow for completion of posttest measures. The individual sessions consisted of guided, semi-structured creative art therapy exercises. The interventions were adapted from art therap y manuals and texts (Crockett, 2000 ; Horovit z -Darby 1 994 ; Lesser, 1999) and were specifically designed to facilitate emotional expression spiritual connectedness and ps yc hological well-being (Appendix L). Although the sessions were semi-structured the counselors took care to attend to each woman's emotional and psychological needs at the time of the intervention(s). The women were encouraged to bring into each session whatever issue(s) of concern were salient that particular week. The semi-structured int e r vent ion s were designed to provide a framework of emotional and p syc hological exploration and an opportunity for emotional expression and s upport. The g uiding theoretical framework was positive psychology ; a humani s tic psychology that e ncoura ges unc overing and building upon clients strengths rather than ps yc hopatholo gy. Eac h woman brou g ht a se t of traits and characteristics that th ey dr ew from in th e process of adjusting to and managing their breast cancer diagnosis or any other emergent concerns. Eac h woman was encouraged to ex plore their strengths and ways to engage these in their h ea lin g process includin g m a n ag in g difficult emotional s tate s. The exp loration of these themes was done both verba ll y and throu g h the creative art therapy exe rci ses outlined herein.

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79 Each individual counse lin g session invol ve d the counselor engaging the subject in se mi-structured creative art therapy experiences using pencil s pa ste ls and / or acrylic painting supplies. The subject completed the creative art experience in available multi purpose drawing / paintin g tablets. The counselor focused the creative experience on subjective symbols and metaphor s of emotional expression spirituality, and the use of color to represent sal ient 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 therap y 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 ex ploration of spiritual themes including the role that a belief in a higher being ( i .e. G-d Jesus Allah Krishna Buddha) pla ys in the experience of coping with life problem s ; including the br eas t cancer. The last session included a creative poetry writing exercise gea red toward th e ex pl ora tion of life and death issues throu g h words ima gery and metaphor. The qu est ion s g uidin g sess ion one were m ea nt to e licit meaning makin g of the breast cancer exper i e nc e. As previously s tat e d a breast cancer di agnos i s can raise ex i s t e ntial dilemmas th at put wo m e n face-to-face with i ss u es of lif e purpose m eaning and d ea th (Sp i ege l 1 999). ess i o n two und e r sco r ed th e importance of a holi s ti c approach to h ea lth a nd h ea lin g. It provided a g uided exp l orat ion of body-emotion awarene sand connec tion whereby eac h woman could exper i e nc e se n sa tion s fee lin gs d egrees of comfort and discomfort present w ithin their bodies The experience was geared toward a

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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 sp iritu al development over the l~fespan 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 visua ll y represent their idea of a higher power and delineate the ways that this force has influenced their li ves if at all. Finally the last session was conducted in a spirit of playfulness and through the use of creative written and verba l expression Each woman was asked to answer a se rie s of questions about themselves that encouraged the use of active imagination. They were then instructed to write two poems using the words from a li st 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 se lf-a wareness emotiona l exploration and expression and the discovery of personal s tren gt hs and potential areas of growth Dependent Variables The dependent variables of this stud y were emotional expression including pre and postsession emotional reactivity for the experimental group subjects spir ituali ty and select aspects of psychological well-being Emotional expression was assessed by the Emotional Approach Coping Scale (EACS ) ( Stanton Kirk, et al. 2000). Preand postsession emotional reacti ity for the experimental group was assessed by the Emotiona l Assessment Sca l e (EAS) (Carlson et aL 1989 ). Attempts were made for the EAS to be admi ni stered preand postsession by a counselor other than the subject's

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81 designated one. This practice an effort to take care of the experimenter effect was not always possible or practical. Spiritualit;Y was assessed by the Expressions of Spirituality Inventory Revi ed (ESI-R) (MacDonald, 2000a). Psychological well-being was assessed by the Profile of Moods States (POMS) (McNair, Lorr, & Droppleman 1971 ). Instrumentation The Emotional Approach Coping Scale (EACS) the Emotional Assessment Scale (EAS), the Expressions of Spirituality Inventory-Revised (ESI-R) the Profile of Mood States (POMS) 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 preand postsession tests of emotional reactivity (EAS) for the experimental group took about one minute each to complete. 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 assess 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 ( tanton & Danoff-Burg 2002 ; Stanton Danoff-Burg et al., 2000). Research that explored the conceptual and confounding problems in extant measures of emotion-focu ed coping led to the development of the EACS (Stanton et al.

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82 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 "s ubmitted to a maximum likelihood factor analysis with promax rotation (Stanton Kirk et al. 2000, p. 1153 ) that yie lded 9 factors: Emotional Processing Emotional Expression Distress-contaminated Coping Seeking Social Support Problem-focused Coping Alcohol-drug Disen gage ment Avoidance Humor and Turning to Religion The Emotional Identification and Emotional Processing domains loaded on a single factor. Using high factor loadings and lack of redundancy as criteria the authors chose four items each to represent the constructs of emotional processing and emotional expression. Internal consistencies are reported as follows: Cronbach's coefficient alpha

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83 for emotional pr oce in g r = 0.72 and for emotional expression, r = 0.82. Test-retest r e liabilities were emotional proc ess ing = 0 73 and emotional ex pr ession= 0 .72. The correlations bet wee n the emotional processing scale and the emo tional expression scale and the EEQ were reported as s i g nificant (p < 005). Stanton Kirk, et al. (2000) rep orte d the correlation bet wee n the emotional processing and e motional expression scales was .52 at Time 1 and .65 at Time 2 (p < 0001) (p. 1153) In order to control for self-report response bias the researcher s conducted another study where s tudents and family members assessed each other's coping. Th~ 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 the y were reported as: a= .92 for s tudents .91 for mothers and .9 0 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-dim e nsional coping measures in this s tudy only the E motional Expression s ubsca le was u se d to measure emotional ex pression Emotional Assessment Scale (EAS) The EAS was designed b y Ca rl so n e t al. ( 1989 ) to m eas ur e emotio nal r eact i v i ty This 24it e m se lf-r epo rt in s trum e nt i s u se d to capture multipl e co mpl ex s imult aneo u s emo tion s in indi v idu a l s. It exam in es e i g ht e moti ona l states considered consistent across c ultur es: anger (ite m s 4 1 2, 2 0) a n x i ety ( it ems 6 1 4 22) disgust (i t e m s 3 11 19) fear ( it ems 2 9 1 7) gu ilt (i t ems 5 1 3 1 5) h app in ess ( it ems 8 1 6 24) sadness (items 7 2 1

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84 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 emo tional 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 a I 00mm line. Three items comprising each emotion are summed up for a score for that emotion 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 ongoin g emotional processes of persons engaged in therapy or involved in psychological inter v entions designed to influence emotional processes (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 ps y cholog y students, ages 18 to 34 62% being female and 38% male. Reported means and standard deviations were as follows: anger mean = 14 6 (SD = 18 9 ) anxiety mean = 32.4 ( SD = 24.5) ; disgust mean = 9 7 (SD = 13.3) fear mean = 13.0 (SD = 14 5) ; guilt mean= 12.6 (SD = 14.5) ; happiness mean = 38.8 (SD = 23.8) ; sadness mean = 19 1 ( SD = 19 6) ; and surprise mean = 10.7 (SD = 10.4 ) (Fischer & Corcoran 1994 ). Carlson et al. ( 1989) reported reliability coefficients of: anger = .90 ; anxiety = 91; disgust = .71 ; fear = 89 ; guilt = 74 ; happiness = 90 ; sadnes s= .82 ; and surprise = .70.

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85 The EA i s reported to have very good concurrent val idity with several of the subscales correlating with exi ting 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 it 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's reliability is "goo d to excellent" with inter-item reliability for emotion factors ranging from 70 to .91 and split -h a l f reliability of .94 (Fischer & Corcoran, 199 4 p. 203) Expressions of Spirituality Inventory-Revised (ESI-R) The Expressions of Spirituality Inventory (ESI), developed by MacDonald (2001 ), is a measure of spiritua li ty derived from a two-stage factor ana l ytic study of mor e than 70 measures of spirituality with about 1 400 subjects (MacDonald, Kuentzen & Friedman 1999). MacDonald created the ESI to provide a well-designed and validated measure of spirituality that incorporates existing psychometric conceptualizations into a coherent organizational framework on which to understand and research the various elements of the construct" (p. 157). Spiritual dimensions r es ultin g from the factor analysis were (a) Cogn itive Orientation Towards Spirituality (COS) (b) Experiential / Phenomenological Dimension (EPD) (c) Ex i stent ial Well-being (EWB) (d) Paranormal Beliefs (PA R ) and (e) Religiousness (REL) The Cog nitiv e Orientation Towards Spirituality (COS) dimension refers to sp iritual beliefs that are not expressed through religious affi li ation. These may involve beliefs perceptions and a ttitud es about the importanc e of sp irituality in everyday lif e.

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The Experiential/Phenomenological Dimension (EPD) refers to spiritual experiences that are of a transpersonal and mystical nature 86 The Existential Well-being (EWB) dimension involves aspects of spirituality related to existential facets of human functioning. This dimension appears to include three main components: meaning and purpose in life which derives from any number of sources a sense if inner strength and perceiving oneself as able to effectively cope with fundamental aspects of life. The latter includes a relaxed approach to self and to everyday life challenges. The Paranormal Beliefs (PAR) dimension involves beliefs in scientifi9ally unproven phenomena. The PAR dimension has been associated with higher indices of pathology including unusual thought patterns psychosis external locus of control, and suggestibility (MacDonald LeClair Holland Alter & Friedman 1995; MacDonald et al. 1999). Finally the Religiousness (REL) dimension involves an intrinsic religious orientation based on organized religious affiliation and practices. The REL dimension is comprised of two aspects: (a) nondenominational beliefs about a higher power or being and (b) religious practices such as prayer attendance to religious services and meditation. Extrinsic religious orientation (i e. religious attendance for social status or gain) is specifically excluded from the REL dimension. Respondents of the ESI use a 5-point Likert-type scale (0 = Strongly Disagree 1 = Disagree 2 = Neutral 3 = Agree, 4 = Strongly Agree ) to rate agreement or disagreement with given statements. The long form consists of 98 items ( 42 reverse worded to counteract response bias). Two items at the end were added to provide face and content validity. MacDonald et al. (1999 ) concluded that the ESI is a soundly

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developed test with rea enable reliability and validity that systematically embodies numerous constructs as tapped by seve~al existing measures of spirituality" (p. 159). 87 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 ESL 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; (2) Items were selected from the 98-item version of the ESI based upon both uniqueness of content as well as evidence of satisfactory psychometric properties. As such, any appearance of item repetition is virtually eliminated from the instrument. Further the psychometric properties and correlates of the revised ESI are highly similar to those for the longer version (e.g., all revised dimensions have been found to produce scores with good reliability and satisfactory factorial validity) ; and (3) Reverse worded items are kept to a minimum. (p. 18) The ESI-R s 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, and criterion validit y in the ESI-R.

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88 Profile of Mood States (P OMS ) The POMS de ve loped by McNair et al. ( 1971 ), i s a 65-item 5 -p oint Likert-type sca l e of adjective ratings that are factored in to six mood scores: tension-anxiety depression-dejection anger-hostility vigo r-acti v i ty fatigue inertia and confus ion bewilderment. Subjects indicate mood states or reactions for the "past week including toda y" or for brief periods such as "right now" (E ichman 1978 ). Reliability of the POMS ranges from .84 to .95 and test-retest correlations range from .65 to .74. This is reported as a considerab l e difference ; howe ve r congruent with a measure of mood states that are deemed transient and changeab l e. Eichman concluded that the POMS "a ppears to be optima ll y reliable and se nsiti ve to change ... and a alid mea s ure of mood states [that] is simple and easy to use (p. 1018 ). Face va lidity i s reported as good (Eichman, 1978). The POMS are a frequently used product development tool. Sco r es that form each of these scales can b e combined to y ield a total mood disturbance score. Historically, the sca le s ha ve b ee n used in research requiring a sens iti e mea sure of affect fo ll owing a program of behavior modification among others. Because of their documented u se with the popu l ation of brea s t cancer patients (Carver et a l. 1993 ; Classen et a l. 1996 ; Dibbell Hope 2000 ; Goodwin et al.. 2001 Hosaka e t a l. 2000 ; Spiegel et a l. 1999 ; Stanton & Danoff-Burg 2002 ; Stanton Danoff-Bur g. et al. 2000) and considerable ps yc hometric properties (Eic hman 1 978) the POMS s ubsca l es scores we r e u se d as a mea s ur e of psychological we ll-b ein g in this study. Demo g raphic Que s tionnair e Demographic ariab l e s abo ut eac h woman with breast cancer were obtained b y u s in g the Demographic Questionnaire. T h e measure includ ed information about th e woman s e thnicity age county of residence r eferra l so ur ce to the st ud y, type and stage

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89 of breast cancer, medical treatment received for the breast cancer and previous experience with art therapy. The questi onnaire also included details about the subject's (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 inform~tion included in this demographic questionnaire was used in the final analysis of data. Exit Interview An exit interview form was obtain~d 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 in 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 re s earch and clinical practice. Relevant entries from this narrative process will be reviewed and addressed in the discus ion ection.

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90 Data Analysis To examine the effects of an individual creative art therapy intervention on emotional expression spiritual connectedness and psychological well -being while controlling the covariates (i.e. relevant POMS pretest sub-scales scores), a series of ANCOVA were used to analyze the data. The omnibus hypotheses was tested at a.= .05. To exam in e the effects of an individual creative art therapy intervention on emotiona l reactivity and expression of the experimental group subjects, preand post session using the EAS scores a series of paired t-tests were used to analyze the data. Methodological Limitations Some of the symptoms frequently reported by cancer patients are fatigue, sleep disturbance nausea diminished concentration and pain ; these are due, in part, to the physically taxing treatment regimens of radiation and / or chemotherapy (Jacobson & Verret 2001 ). As a result some women were unable to complete certain aspects of the experimental protocol and sessions required rescheduling to accommodate for treatment related problems ( e.g. side effects). Additionally this experimental study involved a pretest / posttest control group design and included the random assignment of subjects to a treatment group or a control group While the experimental condition required attendance to four sessions over a 4-week period the control condition did not. This differential in attendance over time (pretest treatment, and posttest) produced some mortality ,' which [introduced] subt l e sample biases into the study (Campbell & Stanley 1963 p. 15). The interaction of selection and the individual creative art therapy treatment presented a threat to external genera li zation. Richardson et al. (1998 ) have studied the recruitment of subjects to complementary / alternative therapies including mind-body

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91 int erve ntions. Es timat es of ca nc e r patients who use complementary / alternative and mind-body therapie s range from 50% t~ 80% (Boon, Brown Gavin, Kennard & Stewart 1999 ; Richardson e t al. 1998 ). A review of extant literature b y Richardson et al. indicated that women w ho see k complementary / alternati ve, and mind-bod y therapie s tend to be between 30 and 50 years of age, better educat~d wealthier, Caucasian, and living in the We s t e rn or Northeastern regions of the United States. These facts may ha ve limited the ability to generalize results of this study to the population of ne wly diagnosed breast cancer patients The use of preand posttest scores allowed for the examination of individual performance in specific research subjects (Heppner, Kivlighan & Wampold 1999 ). Heppner et al. ha ve re commen d e d g i vi ng a pretest because "p rete st scores can be used to reduce variability in the dependent variable, thereb y creating a more powerful statistical t es t [plus] a pret es t can b e used to eliminate post hoc threats to int erna l va lidi ty" (p. 1 23). However the interaction of the pretest and the indi v idual creative art therap y tr eat m en t may ha ve presented a thr ea t to the ge nerali za bility of results to the popul at ion ; we are logicall y un a bl e to ge n era li ze to th e lar ge r unpr etes t e d uni verse" of newly di agnosed breast cancer patients (Ca mpb e ll & Stanley 19 63 p. 1 7). T h e u se of a pretest in t hi s s tud y ma y ha ve se n s iti ze d th e sa mpl e and s ub se qu e ntl y affecte d the treatment effec t F in a ll y another limit at i o n of t hi s st ud y i s that control group s ubj ec t s may have shown posttest improv e m e nt du e to th e Hawthorne effec t ( i. e. th ey knew th ey were includ ed in a research st ud y an ti c ip ate d receiving the treatment protocol after 4 weeks and h ad aware n ess of this fact)

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CHAPTER4 RES UL TS OF THE STUDY Summary and Chapter Overview The purpose of this study was to examine through experimental research, the efficacy of a semi-structured individual art therapy intervention to enhance the emotional expression, spirituality and select aspects of psychological well-being of newly diagnosed Stage I and Stage II breast cancer patients. Descriptive and demographic data were obtained about the subjects in this study. An exit interview questionnaire was given in order to examine clinical significance based on subjects opinions and perceptions about beneficial outcomes from participating in this process. Analyses of covariance (ANCOV A) and paired t-test statistical analyses were used to evaluate data pe rtaining to the nine research hypotheses of this study. While the research hypotheses population data collection (including attrition), sample and sampling procedures design of the study, including relevant variables, instrumentation data analysis and methodological limitations of this research study were reported in Chapter 3 this chapter will discuss results of hypotheses testing results of clinical significance and a summary of findings Results of Hypotheses Tests The analyses of data for this study were accomplished through the use of the Statistical Program for Social Sciences (SPSS) version 12.0 ANCOV A were used to determine if there were statistically significant differences between the experimental and 92

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control groups for the dependent variables of emotional expression as measured by the Emotional Approach oping Scale (EACS) -emotional expression subscale, spirituality, 93 as measured by the Expressions of Spirituality Inventory-Revised (ESI-R), tension anxiety as measured by the Profile of Mood states (POMS) tension-anxiety subscale depression-dejection as measured by the POMS depres~ion-dejection subscale, anger hostility as measured by the POMS anger-hostility subscale vigor-activity as measured by the POMS vigor-activity subscale, fatigue-inertia as measured by the POMS fatigue inertia subscale, and confusion-bewilderment as measured by the POMS confusion bewilderment subscale. For purposes of interpreting POMS subscale scores, note that low scores for the following subscales tension-anxiety depression-dejection anger hostility fatigue-inertia and confusion-bewilderment-represent higher psychological well-being. However for the vigor-inertia subscale lower scores represent lower psychological well-being; thus the latter is negatively correlated to all other POMS subscales. Paired t-tests were used to determine if there were statistically significant differences b e tween preand postsession scores on emotional expression/states as measured by th e E motional Assessment Scale (EAS) for the experimental grou p. A ll stat istical tests were conducted at a = .05 The missin g values were r ep lac ed by series means usin g SPSS. Research Hypothesis One The first research h ypot h es i s s tated that th e r e is a significa nt difference between the experimental gro up of creative art therapy and th e control group of d e la ye d tr eatment on emot ional express ion as measured by the Emot ional Approach Coping Scale (EAC )

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94 when controlling for the covariate pretest POMS total mood sco re in newly diagnosed Stage I and Stage II breast cancer patients. Us in g ANCOVA with the pretest POMS total mood s core as the covariate, the first research h ypot hesis was tested. The ~eans standard de v iation s, and F sco re are pr ese nted in Table 4-1. Table 4-1 Mean standard deviation and F score for E motional Approach Coping Scale Treatment group ( n =2 0) Co ntrol group ( n = 19 ) a Partial E ta Squared b Computed using alpha= .05 Mean SD F p (sig) 11 ? a Observed power b 23.15 6 15 1. 33 0 26 0 0.2 21.37 5.15 The result of the analysis indicate s that there i s no s tati s ticall y significant differ e nce between treatment and control gro up s on emotiona l expressio n when co ntrolling for th e covariate pretest POMS total mood score. However since the observed po we r was lo w a t 20, it i s inc o nclu s i ve w h et her a s i g nificant difference exists be twee n tr ea tment and control gro up s on e m o ti o n a l exp r ess i o n as measured b y the EACS. Effec t s i ze i s critical in assess in g th e outcomes of tr ea tment interventions when a sma ll sa mpl e size s u c h as thi s s tud y's (N = 39) s hrink s th e power of s tatistical tests (Co h e n 1988 ). Effec t s i ze (pa rti a l eta sq u ared [17 ]2) was .04. T h at is the independent va ri ab l e ( i .e creat i ve art th erapy int erve nti on) acco unt s for o nl y 4 % of the var i a bility ih the EACS sco r es Research Hypothesis Two The seco nd r esearc h h y poth es i s s t a t e d th a t th e r e i s a s ignificant differ e nc e b etween th e ex p er im e nt a l group s preand po s ts ess i on scores on positive and negative e m o ti ona l ex pres s i on/s t ates as m eas ur e d b y po s itiv e e motion s (i.e. h app in ess and s urpri se) a nd n ega tiv e e motion s ( i. e. anger anx i ety, di sg u st, fear g uilt and sadness) s ub sca l es of the Emo ti ona l Assess m e nt Scal e (EAS) in n ew l y dia g no se d Stage I and

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Stage II brea st cancer p a ti en t s. Us in g paired t-tests this re sea rch h y pothe s is was tested. The means standard de via tion s and t sco res are present e d in Table 4-2 for negati ve emotions and Table 4-3 for p os iti ve emotions. Table 4-2 Mean standard de v iation an d t score for negati ve emotional assess ment scale Presession ( n = 80 ) Postsession ( n = 80 ) Mean 4.11 2 .71 SD 3.99 3.29 t p (sig) 4.77 0 The result of the analysis indicates that there is a statistically significant difference between pr esess ion and postsession on ne g ative e motional expression/states. Us ing Lips ey's (1990 ) e quation effect size score was calculated. Effect size was .46 considered a moderate value (C ohen 1988). 95 Table 4-3 Mean s tandard deviation and t score for po s itive e motional assessment sca l e Presession (n = 80 ) Postsession (n = 80) Mean SD t p (s i g) 7 16 4 .46 7. 3 8 0 11.78 7.00 The result of th e analysis indicates that there is a statistically s ignificant difference b e tween presession a nd postsession on po s iti ve emotional expression/states. Lipsey s (1990) e quation effec t size score was calculated. Effec t s i ze was .64 co n s id e r e d a m odera t e t o hi g h va lu e (Cohen 1988) Research Hypothesis Three T h e third r esea r c h h ypo th es i s sta t e d that th e r e i s a s i g nifi can t difference between th e ex p e rim e nt a l group of creat i ve art therapy and th e control g roup of d elaye d tr eatmen t on sp iritu a lity as me a sured by the Express i ons of Sp iritu a li ty In ventory -R evised (ES I -R) w h en con trollin g for the cova ri ate pretest POMS t ota l mood sco r e in newl y dia g nosed Sta g e I and Sta g e II breast cancer patients U s in g ANCOV A wit h t h e pretest

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POMS total mood score as the covariate the third research hypothesis was tested. The means standard deviations and F score are presented in Table 4-4. Table 4-4. Mean standard deviation and f score for expressions of spirituality inventory-revised 96 Mean SD F p (sig) Observed power b Treatment group (n=20) Control group (n=l 9) a Partial eta squared b Computed using alpha= .05 20.85 20.03 2.49 4.00 0.39 0.53 0 0.09 The result of the analysis indicates that there is no statistically significant difference between treatment and control groups on spirituality when controlling for the covariate, pretest POMS total mood score. However since the observed power was low at .09 it is inconclusive whether a significant difference exists between treatment and control groups on spirituality as measured b y the ESI-R. Effect size (partial eta squared [ri p ] 2 ) was 01. That is the independent variable (i.e. creative art therapy intervention) accounts for only I % of the var iability in the ESI-R scores. Research Hypothesis Four The fourth r esearc h h ypot h es is sta ted that there is a s i g nificant difference between the exper imental gro up of creative art therapy and the control gro up of delayed treatment on the p syc holo g ical well-being su b sca le t ens ion-an x i ety as measured by the POMS ten s ion-an x i ety s ub sca l e when controlling for the covar i ate pretest POMS ten s ion anxiety s ub sca l e sco r e in n ew l y diagnosed S t age I and Stage II breast cancer patient s. Us in g ANCOV A with the pretest tension-anxiety score as the covariate the fourth research h ypo th es i s was t es ted The means s tand ard deviations and F score are pr esented in Table 4-5.

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97 Table 4-5. Mean standa rd deviation and F score for t e n sion -an x i ety Mean SD F p (s ig ) ri? a Obser ve d power b Treatment gro up ( n =2 0) Co ntrol group (n= l 9) a Partial eta s quar ed b Computed u sing a lpha = .05 17.31 5.01 5.41 0.03 0.13 0.62 20.32 6.78 The r es ult of th e a nal ys is indicates that there is a statistically significant difference between treatment and control groups on tensiona nxiety when controllin g for the covariate pretest POMS tension-anxiety subscale scores The observed power was moderately hi g h at .62. Effect size (partial ~ta squared [ ll p ] 2 ) was .13. That is the ind e pendent va riable ( i .e creative art therapy intervention ) accounts for 1 3% of the va riability in the POMS tension-anxiety subscale scores. As previousl y m e ntioned (C hapter 3), the total final sample (N= 39) excl ud e d two outlier subjects. In order to illu s trate the effects of thes e two outliers upon thi s dataset the r es ults of a nal ys i s for the preliminary sample (N=4 l ) are presented in Table 4-6. Table 4-6 Mean s tandard deviation and F score for tension-anxiety for prelimin ary sa m l e Treatment gro up (n = 2 1 ) Co ntrol group (n = 20) a Partial eta squared b Co mput e d u s in g alpha = .05 Mean 17 97 20 .10 SD 5.72 6.67 F p (s i g) 2.07 0.16 Observed power b 0. 1 0.29 The r es ult s of a n a l ys i s fo r the preliminary sa mpl e indicate th a t th ere i s no s tatistically sign ifi cant difference between treatment and contro l gro ups on tension anx i ety w h e n contro llin g for the covaria t e pretest POMS tension-anxiety subsca l e score. The observed power wa low at .29. Effect s i ze (partial e ta squared [ri p ] 2 ) was .05. That i s the independent var i ab l e ( i e. creative art therapy int erven ti o n ) acco unt s fo r 5% of the

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variability in the POMS tension-anxiety subscale scores These results stand in contrast to those of the total final sample (N = 3 9). Research Hypothesis Five 98 The fifth research hypothesis stated that 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, depression-dejection as measured by the POMS depression-dejection subscale when controlling for the covariate, pretest POMS depression-dejection subscale score in newly diagnosed Stage I and Stage II breast cancer patients. Using ANCOVA with the pretest POMS depression-dejection score as the covariate the fifth research hypothesis was tested The means standard deviations and F score are presented in Table 4-7. Table 4-7. Mean standard deviation and F score for depression-dejection Treatment group (n = 20) Control group (n = l 9) a Partial eta squared b Computed using alpha = .05 Mean SD F p ( sig) 11? a Observed power b 20.66 4.74 9.23 0.01 0.2 0.84 26.34 13.48 The result of the analysis indicates that there is a statistically significant difference between treatment and control groups on depression-dejection when controlling for the covariate pretest POMS depre ss ion-dejection subscale scores The observed power was high at .84. Effect size (partial eta squared [ll p ] 2 ) was 20. That is the independent variable (i.e. creative art therapy intervention ) accounts for 20 % of the variability in the POMS depression-dejection subscale scores. In order to illustrate the effects of the two outlier s upon this dataset the results of analysis for the preliminary sample (N = 41) are presented in Table 4-8.

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99 Table 4-8. Mean standard deviation and F Score for depression-dejection for preliminary sample Treatment group ( n = 21) Control group (n = 20) a Partial eta squared b Computed using alpha = 05 Mean SD 22.0 I 7.72 25.98 13.22 F 2.79 p (sig) Observed power b 0.1 0 1 0.37 The results of analysis for the preliminary sampl~ indicate that there is no statistically significant difference between treatment and control groups on depression dejection when controlling for the covariate, pretest POMS Depression-Dejection subscale score. The observed power was lo w at .37 Effect size (partial eta squared [17p] 2 ) was .0 7. That is, the independent variable (i.e., creative art therapy intervention) accounts for 7% of the variability in the POMS depression-dejection subscale scores. These results stand in contrast to those of the total final sample (N=39) Research Hypothesis Six The sixth research hypothesis stated that 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 POMS anger-hostility subscale when controlling for the covariate pretest POMS anger-hostility subscale score in newly diagnosed Stage I and Stage II breast cancer patients Using ANCOV A with the pretest POMS anger-hostility score as the covariate the sixth research hypothesis was te ste d The means standard deviations and F score are pre se nted in Table 4-9. Table 4-9. Mean standard deviation and F score for anger-hostility Treatment group ( n = 20) Co ntrol group (n = l 9) a Partial eta squared b Co mputed u s ing alpha = .05 Mean SD F p (sig) 11 ? a 15 79 3.74 7.31 0.01 0.17 19.10 8.11 Observed power b 0.75

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10,0 The result of the analysis indicates that there is a statistically significant difference between treatment and control groups on anger-hostility when controlling for the covariate, pretest POMS anger-hostility subscale scores. The observed power was moderately high at .75. Effect size (partial eta squared [17 p ] 2 ) was .17 That is, the independent var iable (i .e ., creative art therapy intervention) accounts for 17% of the variability in the POMS anger-hostility subscale scores In order to illustrate the effects of th e two outliers upon this dataset ,' the results of analysis for preliminary sample (N=4 l) are presented in Table 4-10. Table 4-10. Mean standard deviation and F score for anger-hostility for preliminary sample Treatment group (n=21) Control gro up (n=20) a Partial eta squared b Computed using alpha = .05 Mean 16.94 18.90 SD 6.42 7.95 F p (sig) Observed power b 1.67 0.2 0 0.24 The results of analysis for the preliminary sample indicate that there is no statistically significant difference between treatment and control groups on anger hostility when controlling for the covariate pretest POMS anger-hostility subscale score. The observed power was low at .24 Effect size (partial eta squared [17p] 2 ) was .04 . That is the independent v ariable (i.e., creative art therap y intervention) accounts for 4% of the variability in the POMS anger-hosti li ty subscale scores. These results stand in contrast to those of the total final samp l e (N = 39) Research Hypothesis Seven The seventh research hypothesis stated that there is no significant difference between the experimental group of creative art therapy and the contro l group of delayed treatment on the psychological well -bein g subscale v igor-activity as measured by the POMS vigor-activity subscale when controlling for the covariate, pretest POMS vigor

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101 activity subscale score in newly diagnosed Stage I and Stage II breast cancer patients. Using ANCOY A with the pre-test POMS vigor-activity mood score as the covariate, the seventh research hypothesis was tested. The means standard deviations and F score are presented in Table 4-11. Table 4-11 Mean standard deviation, and F score for vigor-activity Treatment group (n = 20) Control group (n=l 9) a Partial eta squared b Computed using alpha = .05 Mean SD F p (sig) 1l p a 22.16 5.92 0.73 0.4 0 22.75 5.24 Observed power b 0 13 The result of the analysis indicates that there is no statistically significant difference between treatment and control groups on vigor-activity when controlling for the covariate pretest POMS vigor-activity subscale scores. However since the observed power was low at .13 it is inconclusive whether a significant difference exists between treatment and control groups on vigor-activity as measured by the POMS vigor-activity subscale scores. Effect size (partial eta squared [ 1lp] 2 ) was .02. That is the independent variable (i.e. creative art therapy intervention) accounts for only 2% of the variability in the POMS vigor-activity subscale scores. Research Hypothesis Eight The eighth research hypothesis stated that there is no significant difference between the experimental group of creative art therapy and the control group of delayed treatment on the psycholo g ical well-being subscale fatigue-inertia, as measured b y the POMS fatigue-inertia subscale when controlling for the covariate pretest POMS fatigue inertia subscale score in newly diagnosed Stage I and Stage II breast cancer patients. Usi ng ANCOV A with the pretest POMS fatigue-inertia mood score as the covariate, the eighth hypothe s i s was tested. The m eans standard deviations and F score are presented in Table 4-12.

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102 Table 4-12. Mean standard deviation and F score for fatigue-inertia Mean SD F p (sig) n? a Observed power b Treatment group (n=20) Control group (n=l 9) a Partial eta squared b Computed using alpha = .05 15 .5 8 5.22 0.47 0.49 0 0.1 17.80 8.74 The result of the analysis indicates that there is no statistically significant difference between treatment and control groups on Fatigue-Inertia when controlling for the covariate pretest POMS fatigue-inertia subscale scores. However sine~ the observed power was low at 10 it is inconclusive whether a significant difference exists between treatment and control groups on the fatigue-inertia as measured b y the POMS fatigue inertia subscale scores. Effect size (partial eta squared [ 1l p ] 2 ) was .01. That is the independent variable (i.e creative art therap y intervention) accounts for only 1 % of the variability in the POMS fatigue-inertia subscale scores. Research Hypothesis Nine The ninth research hypothesi s stated that there is a sig nificant difference between the experimental group of creative art therapy and the control group of delayed treatment on the ps yc hological well-being subscale confusion-bewilderment as measured by the POMS confusion-bewilderment subscale when controlling for the covariate, pretest POMS confusion-bewilderment subscale scores in newl y diagnosed Stage I and Stage II breast cancer patients. Us ing ANCOVA w ith the pretest POMS confusion-bewilderment mood score as the covariate the ninth research h y pothesis was tested The means standard deviations and F sco re are presented in Table 4-13. Table 4-13 Mean standard de via tion and F score for confusion-bewilderment Treatment group ( n =20) Control group (n = l 9) a Partial eta squared b Computed usin g alpha = .05 Mean SD F p ( sig) 17 2 a Observed power b 14. 25 3.34 6.42 0.02 0.15 0.69 16.47 4.74

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103 The result of the analysis indicates that there is a statistically significant difference between treatment and control groups on confusion-bewilderment when controlling for the covariate pretest POMS confusion-bewilderment subscale scores. The observed power was moderately high at .~9. Effect size (partial eta squared [llp] 2 ) was .15. That is the independent variable (i.e. creative art therapy intervention) accounts for 15% of the variability in the POMS confusion-bewilderment subscale scores. In order to illustrate the effects of the two outliers upon this dataset the results of analysis for preliminary sample (N=41) are presented in Table 4-13. Table 4-13 Mean standard deviation and F score for confusion-bewilderment for preliminary sample Treatment group (n=21) Control group (n = 20) a Partial eta squared b Computed using alpha = .05 Mean 14.66 16.20 SD 3.77 4.77 F p (sig) Observed power b 1.74 0 2 0 0.25 The results of analysis for the preliminary sample indicate that there is no statistically significant difference between treatment and control groups on confusion bewilderment when controlling for the covariate, pretest POMS confusion-bewilderment subscale score. The observed power was low at .25. Effect size (partial eta squared [ llp] 2 ) was .04. That is the independent variable (i.e. creative art therapy intervention) accounts for 4% of the variability in the POMS confusion-bewilderment subscale scores These results stand in contrast to those of the total final sample (N=39). Clinical Significance Information obtained in the exit interview questionnaire was used as a means to determine clinical significance since targeted answers reflected each woman s subjective evaluation of the individual creative art therapy experience including perceived

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104 emotional and psychological benefits resulting thereof. Clinical significance was evaluated by reviewing responses from all subjects who received the creative art therapy intervention (including control group of delayed treatment) to a set of three questions in the exit interview questionnaires: Did you think it was helpful to participate in creative art therapy? Would you recommend this process to someone else with a health problem? What was the most important thing that happened to you as a result of participating in the creative art therapy exercises? A summary of clinical significance outcomes is outlined in Table 4-14. A total of 41 women participated in this study; 21 (51 %) were randomly assigned to the experimental group of creative art therapy and 20 ( 49%) to the control group of delayed treatment. Only data provided by the final total sample (N=39) is included herein. Within the treatment group 20 (100%) completed the Exit Interview questionnaires after receiving the creative art therapy intervention with 20 women (100%) stating they thought it was helpful to participate in creative art therapy and none (0%) indicating that it was not helpful. Twenty (100%) of the women also indicated they would recommend the creative art therapy process to someone else with a health problem while none (0%) indicated otherwise. Finally women in the treatment group who completed exit interview questionnaires offered multiple answers when asked to describe the most important thing that happened to them as a result of participating in the creative art therapy exercises. Within the control group 13 (68.4%) of the women completed exit interview questionnaires after receiving the creative art therapy intervention with 13 women (100%) stating they thought it was helpful to participate in creative art therapy and none (0%) indicating that it was not helpful. Thirteen (100%) of the women also indicated they

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Table 4-14. Clinical significance: ummary of outcomes Exit interview que s tions Was creative art therapy helpful ? Yes No Would recommend creative art therapy? Yes No Most important thing happening* Increased awareness of self/behaviors Helped connect with/express feelings Discovered old issues that need attention Most important thing happening* Allowed time for self care reflection and quiet Relaxed to communicate feelings through art Feel less hopeless / happier Identified coping and stress management options Realized importance of individual counseling Creative art therapy powerful and healing Saw importance of living in present moment Feelings validated Realized need to Express inner feelings Helped proces s and mana ge feelings during chemotherapy Experienced relief / relaxation Expressed inner thoughts Increased creativity Reali ze d process more important than product Most important thin g happ e nin g* Changed perspective on breast cancer With faith and good will All things are possible Reali ze d that go d is a m a jor part of my li fe Refram ed ways of thinkin g Note Multiple responses Treatment group Control group (o/o) (o/o) 20 (100%) 0 (0%) 20(100%) 0 (0%) 5 3 5 5 5 2 3 3 2 13 (100%) 0 (0%) 13 (100%) 0 (0%) 2 3 1 2 1 1 Total (%) 105 33 (100%) 0 (0%) 33 ( 100 %) 0 (0%) 7 6 6 5 5 4 3 3 2

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lOp would recommend the creative art therapy process to someone else with a health problem and none (0%) indicated they would not. Finally women in the control group who completed exit interview questionnaires also offered multiple answers when asked to describe the most important thing that happened to them as a result of participating in the creative art therapy exercises. Since 6 of the women (31.6%) in the control group did not complete the delayed creative art therapy treatment offered in this study exit interview questionnaires were not obtained from them. Summary of Findings The purpose of this study was to examine through experimental research if a semistructured individual art therapy intervention could enhance the emotional expression spirituality and psychological well-being of newly diagnosed Stage I and Stage II breast cancer patients. Research subjects were assigned to two groups: an experimental group of creative art therapy and a control group of delayed treatment. The two groups were compared using a series of ANCOVA analyses. Paired t-tests were conducted for preand postsession changes on emotional expression/states. Power analyses were conducted for research hypotheses found to have no statistical significance to assist with interpretation of results. ANCOV A analyses indicated that there were no significant differences between groups on emotional expression or spirituality. Paired t-tests indicated that there were significant differences on postsession emotional expression/states for women who received the creative art therapy intervention ( including control group of delayed treatment subjects). Furthem1ore ANCOVA anal y ses also indicated there were significant differences between the experimental and control groups on the psychological well-being subscales: depression-dejection anger-hostility tension-anxiety and

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107 confusion-bewilderment. Finally there were no statistical differences between g roups on the psychological well-being subscales of vigor-activity and fatigue-inertia. Results of clinical significance indicated that all women who received the creative art therapy experience found it helpful ~d would recommend it to others with a health problem. The women also reported that the most important happenings as a result of participating in the creative art therapy intervention were increased self-awareness connected with feelings disco ve red old issues that need attention allowed time for se lf care, reflection and quiet emotional expression (both verbally and through the use of art) feel less hopeless happier and identified coping and stress management options among others.

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CHAPTERS DISCUSSION This study examined the efficacy of a creati v e art therap y intervention to enhance emotional expression spirituality and psycholo g ical well being of newly diagnosed Stage I and Stage II breast cancer patients. The e x periment consisted of two groups: (a) an experimental group that received an individual creative art therapy intervention designed to enhance emotional expression spirituality and ps y chological well-being and (b) a control group of dela y ed treatment. Research participants received four individual creative art therap y sessions o v er a four-week period Descripti v e statistics paired t-tests and a series of ANCOV A were used to anal y ze the data. This chapter will present a brief description of the re s earch sample discussion of re s earch results limitations of the study implications for theory practice and future research ( including insights from a qualitative journal kept by the researcher throughout this process ), and conclusion. Research Sample A total of 41 women newly diagnosed with Stage I or Stage II breast cancer participated in this stud y The total final sample consisted of 39 women. In the study sample the treatment group consisted of 14 Caucasian women ( 70 0 %), 3 Hispanic women ( 15 0 %), and 3 African American women (15.0 %) Within the treatment group 14 women (70.0 % ) were diagnosed with Stage I breast cancer and 6 women ( 30 0 %) with Stage II. Also within the treatment group 9 women ( 45.0 %) had been diagnosed 1 to 3 months prior to enrollment into the stud y, 6 women ( 30.0 %) 4 to 6 months one woman (5.0 % ) 7 to 9 months and 4 women (20.0 %) 10 to 12 months. 108

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109 In the study sample the control group consisted of 16 (84.2%) Caucasian women one (5.3%) Hispanic woman and one (5.3%) African American woman. Within the control group 6 women (31 6%) were diagnosed with Stage I breast cancer and 13 women (68.4%) with Stage II. Also within the control group 5 women (26.3%) had been diagnosed 1 to 3 months prior to enrollment into the stupy 5 women (26.3%) 4 to 6 months 4 women (21.1%) 7 to 9 months and 5 women (26 3%) 10 to 12 months. Discussion of Results Efficacy of Creative Art therapy to Enh;mce Emotional Expression The first research hypothesis stated that there would be 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. Results of the ANCOV A tests indicated that there was no significant difference between the two groups; that is both groups were equal on emotional expression. Since observed power was low and effect size small our conclusions are tentative ; that is it would not be reasonable to conclude that there is no significant difference between treatment and control groups on emotional expression Recall the effects of the creative art therapy intervention accounted for only 4% of the variability in the EACS scores. This caveat aside the fact that both groups were equal on emotional expression raises the issue of the Type C personality profile associated with a breast cancer diagnosis. It is possible that the women in this sample already possess a particular type of emotional approach-coping style as measured by the EACS emotional expression subscale that may represent a personality trait rather than an emotional state; that is the scale measures a tendency to manage emotions in certain ways it does not measure

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110 changes in emotional expression over time. Our sample size (N=39) may also account f,or the lack of differences between the groups in this study. Two other plausible explanations for thi s lack of differences may be the small sample size in our study and/or the short duration (i.e., limited number of sessions) of our treatment intervention. We surmise that a larger sample may more accurately reflect changes in emotional expression or a treatment of longer duration wou ld be more effective in enhancing emotiona l expression than our brief four-session intervention was. Critical reviews of psychosocial interventions with cancer patients reported average sample sizes of 30 to 60 subjects for educational studies 16 to 123 for behavioral training studies 32 to 308 for individual psychotherapy studies (Fawzy et al. 1995) As previously reported the volatility of our sample became apparent during data analysis, when we discovered two outliers who drastically affected significance levels for some of the variables in this study Therefore our sample size may account for the lack of significant differences between groups for the construct of emotional expression. Future research in this area should consider inclusion of a larger sample of breast cancer patients and a greater number of treatment sessions. Anecdotally one of the salient pieces of feedback we received in the exit int erv i ew is that some women wished the number of sessions would be greater than it was perhaps reflecting their perception that continued work ma y have yielded different outcomes. An investigation of cancer patients receiving psychotherapy also documented participants stating: six to eight sessions of psychotherapy had been very helpful a lth ough some expressed a need for further sessions ( Maccormack et al. 2001 p 57 ). Significant changes in emotional expression ma y require longer-term clinical interventions than we were able to provide the sample in this stud y

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111 Research s tudie s which examine the relationship between breast cancer patient s' personality and ps yc hological well-being have constructed a profile of women who ex perience conflicting emotions about self-expression and exhibit a tendenc y to be reserved, feel anxious repress hostile or impulsive tendencies and undervalue themselves (Servaes et al. 1999) This profile described both the experimental and control group s ubjects in our study sample. Many of the women who participated in this study reported feeling afraid of being a burden to their loved ones; they struggled to meet their responsibilities in the face of low energy levels fatigue, pain and emotional turmoil. These statements are similar to descriptions reported by other researchers that the women wish to appear strong and avoid being burdensome to others (Servaes et al. 1999 ; Watson et al. 1991 ) What is of s pecial interest i s that this wish by the women in this sample of breast cancer pati e nts leads them to exercise control over their emotions. This exercise constitutes a conscious and deliberate act rather than a psychological defense mechanism beyond their control. (Servaes et al., 1999). Although man y of the women wanted to appear strong a nd self-reliant they clearly tr eas ur ed th e suppo rt the y r ece i ve d and ex pressed grat itud e and s urpri se at the a mount of care and concern gra nt ed b y family, friends and eve n coworkers. Some women r eported th e breast ca nc er expe ri e nc e h e lp e d them to r edefi n e th e ir r e l atio n s hip s a nd ga in tru s t in ot h e r s. Some of the artwork produced during sess i ons r eflected this newfound connection wit h s i g nific a nt others. The second research h ypo th es i s s t a t e d that there would be a sign ifi cant difference between the exper im enta l gro up 's preand postsession scores on negative and positive emot i o n a l express i on/states a measured b y the E m o tional Assess m e nt Scale (EAS) in

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112 newly diagnosed Stage I and Stage II breast cancer patients. Results of paired t-tests indicated that there was a significant difference between the experimental group's pre and postsession scores; that is posttest scores showed significant changes in negative and positive emotional expression/states for experimental group subjects tested. Results of Research Hypothesis 2 stand counter to those of Research Hypothesis 1 Participation in the creative art therapy intervention appears to have helped decrease negative emotiona l states and enhanced positive ones ; that is the women in this sample were able to process negative emotions during the sessions and reported a decrease in these negative emotional states. Additionally as evidenced by EAS postsession scores the women who received the creative art therap y intervention reported enhanced positive emotional states These shifts in feeling states appear to indicate that they were able to process fee lin gs and express themselves during session in productive ways. Again the clinicians who conducted these sessions observed and reported open, if at time s reluctant emotional expression in many of the women. These findings were also supported through the exit interview questionnaires our measure of clinical significance where man y of the subjects stated the most important thing that happened as a result of participation in creative art therapy related to the enhancement of emotional expression: Helped me realize the need to express my feelings Helped to validate my feelings Helped me connect with and express feelings Helped me relax to communicate my feelings through art Helped me process and manage m y feelings during chemotherapy Helped me experience relief and relaxation We reiterate the plausible explanation that choice of instrum e ntation ma y ha ve influenced the outcomes of these research hypotheses where the EACS subscale of emotional expression is a measure of emotional approach coping style and by definition

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113 a personality trait whi l e the EA represents a measure of shifts in emotional states better a bl e to reflect the women s process of emotional expression during session. These conclusions are made cautiously since we are mindful of the fact that the EAS was a pre and postsession self-report instrument and as such vulnerable to the pretest treatment interaction and social desirability bias. Sample size and ~reatment duration as previously stated may account for the lack of significant differences in emot i onal exp r ession in the two groups as measured by the EACS scores. Our findings for Research Hypothe ses 2 concur qualitatively with a few studies similar to the present one that utilized creative art therapy as a treatment intervention for cancer patients in genera l and breast cancer patients in particular. Dreifuss-Kattan (1990) reported that a multimodal creative art therapy intervention helped enhance cancer patients emotional well-being a construct associated with emot i ona l expression (Stanton & Danoff-Burg 2002). The women in the present study reported having benefitted from the creative art therapy intervention in part by being able to explore and express themselves during sessions both verba ll y and through their artwork. One woman found the experience of poetry writing so useful that she reported having purchased a journal where she now writes poetry as a way of processing her feel in gs Another subject reported going back to scu lptin g c l ay a soothing activity she had abandoned sometime before her cancer diagnosis. Simi l ar to Predeger s (1996) research of group art therap y with breast cancer patients our creative art therapy intervention helped the women express their feelin g s and thou g hts throu g h art and th e ir abi li ty to express appeared mor e important than the media u s ed or the final product itself. Some of the subjects a l s o reported relief at havin g

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114 allowed themselves to open up and fully express difficult emotions (in Predeger's study., this is reported as the paradoxical sense of losing control in order to regain control). Also in line with Predeger s (1996) findings some of the women in this study reported the creative art therapy intervention helped them to reframe their view and interpretation of the breast cancer experience. It is noteworthy that most of the women chose to interpret the breast cancer experience as an opportunity for growth and transformation qualifying it as a wake-up call that changed the course of their lives. Finally many of the subjects in this study expressed a desire to help others also struggling with breast cancer. Like the participants in Predeger s study, many of the women who participated in this research wanted to reach out to assist others facing the disease. One subject a medical social worker stated she is now committed to educate others in prevention and early detection. She is actively sharing her story with other women so they may empower themselves to detect symptoms as early as possible or avoid a breast cancer diagnosis altogether. Another woman has joined forces with a fellow breast cancer survivor and a local oncologist to explore ways of enhancing the support services network of breast cancer patients after they complete oncology treatment. These commitments have become part of these women s healing journey. Although focused on music therapy rather than art therapy G. Aldridge s (1996) reported findings are also similar to this study s results. Participation in the creative art therapy intervention according to exit interviews was a therapeutic experience of emotional expression and became part of the subjects healing process. Many of the women expressed surprise about their ability to access their creative power and the emotional release experienced after each session Again through exit interview questionnaires the women reported increased awareness of self and own behaviors,

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increased ability to identify cop ing and stress managem e nt options and found the creative art therap y exper i ence powerful and healing. Re s ul ts of H ypo thesis 2 testing although unclear and tentatively made appear promising. Future research utilizing a stronger desi gn including a larger sample size and additional treatment sessions, may help clarify the effects of this intervention on breast can~er patients' emotional express10n. Efficacy of Creative Art Therapy to Enhance Spirituality 115 Research Hypothesis 3 stated there would be a significant difference between the experimental group of creative art therapy and the control group of delayed treatment on spirituality, as measured b y the Ex pressions of Spirituality Inv e ntory-Re v ised (ESI-R), in newly diagnosed Stage I and Stage II breast cancer patients. Results of the AN COVA tests indicated that there was no significant difference between the two groups; that is both groups were equal on spirituality. Since observed pow e r was low and effect size small our conclusions are tentative ; that is it would not be rea so nable to conclude that there is no significant difference between treatment and control g roups on spirituality. R eca ll th e effects of th e creative art therapy intervention accounted for only 1 % of the variability in the ESI-R scores. This findin g indicat e d that the creative art therap y inter ve ntion did not enhance the le ve l of spir itualit y of this samp le of breast cancer patients it appears many of the wo m e n who chose to participate in this study already considered themselves to be fairly spir itual and some appea r ed to be hi g hl y religious. Th i s aware n ess l ed us to wonder if individuals w h o cons id er themselves to be more spir itu a l are drawn t o the u se of co mpl e m e nt ary th erap i es more so than non spir itu al p eop l e are. Predisposing factors in the adoption of comp l ementary therapies warrant further st ud y and clarification. Again

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116 we reiterate that sample size and treatment duration may have influenced this outcome. Additionally self-selection may be a key factor playing a role in this study's results Many women in both the experimental and control groups reported that spirituality had played a role in their coping with the breast cancer experience. Session three of this art therapy intervention provided an opportunity to explore the women's spiritual beliefs and meaning making regarding the breast cancer experience. This exploration yielded important data about many of the women s sense of connection to a higher being and to a community of like-minded people. Some women reported being prayed for" by multiple concerned others. They reported feeling held, nurtur~d, and blessed by significant others and loved ones and described this experience as a spiritual one. This is in line with research that has documented cancer patients' experience of spiritual connections in part through significant relationships in their lives (Chiu, 2000). Anecdotally the women in this sample of breast cancer patients tended to feel more empowered through their relationships to God family and friends, more optimistic and hopeful about their future and less anxious or preoccupied about the possibility of cancer recurrence. Specific religious and / or spiritual practices including prayer meditation worship witnessing and reading sacred texts became part of their treatment and healing process. Several subjects described themselves as being nonreligious or nonspiritual. One woman a lesbian described a childhood experience of religious wounding which "occurs when religious structures directly hurt or restrict people s authentic selves (Fukuyama & Sevig 1999 p. 92) that led her to renounce her faith. Through the creative art therapy explorations she uncovered that she is a spiritual person that chooses not to affiliate with

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117 any religious denomination ; instead she seeks connection through nature and the animal world. Another woman who described herself as an atheist drew her idea of God as a community of di ve r se people the world over : Although disconnected from an y particular spiritual or religious tradition she r e ported having discqvered that she was more lo ve d and appreciated than s he previously thought ; she believes her spirituality happens through relationships She qualified her breast cancer experience as a gift '. because of the lessons it taught her. There is research ~vidence suggesting that this type of benefit finding and meaning-making attitude results in greater optimism for this population (Antoni et al. 2001). The creative art therap y intervention in this study did not help enhance subjects sense of spiritual connectedness ; however many subjects reported that the breast cancer experience had awakened their desire to reconnect with and / or enhance their spiritual lives. It should be noted that similar to the findings of Greenstein and Breitbart (2000) w ho conducted qualitati ve explorations of spirituality and creativity in healing the creative art therapy intervention in this study enhanced the subjects ability to openly ex press ne ga tive and positive emotions and to explore the existential spiritual dilemmas of meaning and connectedness raised by their breast cancer diagnoses. Efficacy of Creative Art therapy to Enhance Psychological Well-being R eca ll the Profil e of Mood States ( POMS ) sca le used to m eas ure the construct of psychological well-being in this s tud y i s comprised of six subscales: tension-anxiety depression-dejection an ge r-h o tility vigo r-acti v ity fatigue-inertia and confusion bewilderment. O ur research so u g ht to exa mine a creative art therap y inter ve ntion 's e fficacy to e nh a nc e ps y chological we ll-b e ing as measured b y the POMS subscales

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118 concerned with the affective component of this construct. We hypothesized that the POMS subscale scores concerned with the physiological aspects of psychological well being would not show statistical significance. Review of existing literature yie lded multiple psycho-oncology research intervention studies that have used the POMS as an outcome measure of psychological well -b eing. In order to present a comprehensive picture of our results vis a-vis extant relevant research the results of hypotheses testing for this variab l e will be reported first and detailed discussion w ill follow. Tension-Anxiety Research Hypothesis 4 stated that there would be a significant difference between the experimenta l group of creative art therapy and the contro l group of delayed treatment on the psychological well-being subscale tension-anxiety as measured by the Profile of Mood States (POMS) subsca le tension-anxiety in newly diagnosed, Stage I and Stage II breast cancer patients Results of the ANCOV A tests indicated that there was a significant difference between the two groups on tension-anxiety. This study's results indicated that the individual creative art therapy intervention was beneficial by decreasing le vels of tension-anxiety in this sample of breast cancer patients. Depression-Dejection Research Hypothesis 5 stated that there would be a significant difference between the experimental group of creative art therapy and the control group of delayed treatment on the psychological we ll-b eing subscale depression-dejection as measured by the POMS s ub sca l e Depression-Dejection in newly diagnosed Stage I and Stage II breast cancer patients Results of the ANCOV A tests indicated that there was a significant difference between the two groups on depression-dejection This study s results indicated

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119 that the individual creat i ve a rt th era p y intervention was beneficial b y r ed ucin g l eve l s of depr ess ion-dejection in thi s sa mple of breast cancer pati e nt s. Findin gs of Res ea rch H y pothesis 5 indicating that the indi v idual creati ve art therapy intervention was b e neficial b y reducing levels of depre ss ion-dej ec tion are si milar to tho se reported b y C ru ze ( 1998 ), a physician and bre as t cancer survivor, w ho experienced a decrea se in hop e le ss ness and helplessnes s known aspects of depression and an increased sense of happine ss and optimism. Cruze al s o ga ined the ability to reframe her cancer experience after compl~ting a creative art (s culpture ) experience. Several women in our study reported feeling surprised at their ability to enhance their sense of well-being and to reframe the breast cancer experience and see it as an opportunity for personal transformation and growth; these findin gs also underscore th e va luable effect of benefit finding (A ntoni et al. 2001 ). Anger-Hostility Re sea rch H y pothe s i s 6 s tat e d that there would b e a sig nificant difference betwe e n the ex perim e ntal gro up of creative art therap y and the control gro up of dela ye d tre a tm e nt on the ps yc hological well-being subscale, anger-hostility as mea s ured b y th e POMS s ub sca l e anger-hostility in n ew l y dia g nos e d Stage I and Stage II bre as t cancer p a ti e n ts. Results of th e AN COVA tests indi ca t e d that there was a s i g nifi can t diff e r e n ce between th e two gro up s on a n gerh ost ili ty. T hi s s tud y s r es ult s indicated t h at th e indi vid u a l crea tive a rt th erapy int erve n t i o n was b e n efic i a l b y reducing le el of anger -h ost ilit y in thi s sa mpl e of br eas t cancer p a ti e nt s Vigor-Activity Research Hypothesi 7 stated that t h ere wo uld not be a si g nifi cant difference between th e experi m enta l g ro up of c r ea ti ve art th erapy a nd th e contro l gro up of delayed

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120 treatment on the psychological well-being subscale, vigor-activity as measured by the POMS subscale vigor-activity, in newly diagnosed Stage I and Stage II breast cancer patients. Results of the ANCOV A tests indicated that there was no signifi~ant difference between the two groups on vigor-activity, thus confirming this research hypothesis. Review of the research literature on cancer patients indicated that symptoms frequently reported b y this population are fatigue sleep disturbance nausea, diminished concentration and pain; due in part to the physically taxing treatment regimens of radiation and / or chemotherapy (Jacobson & Verret 2001). We hypothesized that many of the women in our sample of breast cancer patients would be experiencing these symptoms as a result of their treatment regimens and unlike psychosocial interventions de ve loped to potentiall y help increase the psychological well-being aspect of vigor activity (e.g. guided imagery and relaxation therapy; Zahourek 1988 ) the creative art therap y intervention used in this study, an affective and cognitive exercise, would not influence the subjects' scores on this construct. Fatigue-Inertia Research H y pothesis 8 sta ted that there wou ld not be a significant difference between the experimental grou p of creative art therapy and the control group of delayed treatment on the p sycho logical well-being subsca le fatigue-inertia as measured b y the POMS subscale fatigue-inertia in ne w l y diagnosed Stage I and Stage II breast cancer patients. Results of th e A COY A tests indic ated that there was no significa nt difference bet wee n the two groups on fatigue-inertia thu s confirming this re searc h hypothesis. Similar to Research Hypothesis 7 here we a l so hypothesized that some women in our sample of breast cancer patients would be experiencing side effects from their oncology regimens and the creative art therapy int ervention used in this study would not

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121 help decrease subjects scores of the fatigue-inertia subscale of psychological well -b eing We found one research study that utili'zed an art therapy int ervention: the dance therapy intervention named Authentic Movement and documented increased scores on the vigor act ivi ty subsca l e of psychological we ll-bein g and decreased scores on the fatigue-inertia subsca l e after treatment (Dibbe ll-Hop e 2000). T h e auth or n oted that the areas where improvement was reported related to the physical body (vigor -acti v i ty and fatigue inertia) and h ypothes i zed that A uth e ntic Movement might have cont ribut ed to a sense of physical we ll-b eing in the women. Her sta~ i stical findings stood in contrast to her qualitative findings According to the aut hor although no statistical sign ific ance was found in any of the other POMS subsca l es the women reported sma ll improvements in overa ll psychological we ll-b eing The contrasting quantitative and qualitative findings in her s tud y und erscore the difficulty in reconciling s ubje ctive a nd objective data accurate l y interpreting results and genera li zing to the population at hand. We found no other studies utilizing art therapy interventions that specifically exp l ored effect of interventions upon these physiological aspec t s of psychological we ll-b eing. Co nfusion-Bewilderment Research Hypothesis 9 stated that there wo uld be a sign i ficant d i fference between the experimental group of creative art therapy and the contro l group of delayed treatment on the psycholo g ical well-bein g subscale Confusion-bewi ld e rment as m e asur e d b y th e POMS sub s cal e confu s ion-bewild e nnent in newl y dia g no s ed Stage I and Sta g e II br e ast cancer pat i ents. Re s ult s of th e ANCOV A tests indi cated that there was a si g nificant difference betw ee n the two g roup s on confu s ion-bewilderm e nt. This stud y s r es ult s indicated that th e individual cr e ati v e art therap y interv e ntion was b e n e ficial b y reducin g l e v e l s of confu s ion b e wilderm e nt in thi s s amp l e of brea s t canc e r pati e nt s

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122 The observed power for statistical analyses of posttest affective subscales of ps yc hological well-being ranged from moderate (te n s ion-anxiety = 62; confusion bewilderment = .69 anger-hostility= .75 ) to high (dep ression-dejection= 84), thus allowing us to conclude that the creative art therap y intervention enhanced psychological well-being of Stage I and Stage II breast cancer patients in this sample. Our research results concur with those that utilized group ps yc hotherapy interventions (including supportive expressive group therap y) on Stage I and Stage II breast cancer patients and reported decreases in tension-anxiety depression-dejection and anger-hostility scores posttreatment (Antoni et al., 2001 ; Fawzy et al., 1990 ; Hosaka et al. 2000; Montazeri et al. 2000; Spiegel et al. 1999 ) Fawzy et al. ( 1990) also reported decreased levels of confusion-bewilderment and improved vigor-activity. The latter study's group intervention included a rel axat ion therapy and stress management component that ma y account for the impro ve ments on v igor-acti v ity. Mixed results have been reported for women w ith metastatic disease where some studies indicate psychosocial gro up int erve ntions were s uccessful in reducing psychological distress (i.e., enhancing ps yc holo g ical well-being; Goodwin et al., 200 1 ; Spiegel et al., 1989 ; Spiegel et al. 1981 ) while others were not (Edmo nd s et a l. 1999 ). This research st udy so u g ht t o address in part the potential role of a creative art therapy inter ve nti on to enhance p sycholog ic a l we ll -be in g by decreasing ne ga ti ve l y correlated s ubscal es for this construct (i.e. t e n s i o n-an xiety depression-dejection, anger ho stility and confusion-bewilderment). Results of these hypotheses testing indicated low er l eve l s of t ens ion -a n x i ety depression-dejection. an g er-host ili ty and confusion bewilderment after receipt of th e indi vidua l creative art therapy intervention when co ntrollin g for pr e t es t scores on eac h s ub sca l e. Results seem to indicat e that the creative

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123 art therapy intervention was beneficial to this sample of breast cancer patients in this regard Finally it appears that women who were able to express their feelings openly had less psychological distress (i e. increased psychological well-being after treatment ended) These findings concur with previous research exploring this association in breast cancer patients (Goodwin et al. 2001 ). Clinical Significance Results of clinical significance provided anecdotal evidence of the perceived benefits from participating in this experien~e. As previously stated all women who received the individual creative art therapy found it useful and would recommend it to others with health problems. Reported benefits were congruent with some of our statistical findings in that the therapy was perceived to enhance emotional expression/states and reduce negative affective aspects of psychological well being. Critical review of psychosocial interventions in oncology care indicated that "individual psychotherapy is a long-established method used to ease the distress and disruption that accompany the diagnosis of cancer [adding that] support compassion and empathy form the cornerstone of successful individual psychotherapy (Fawzy et al. 1995 p. 104). We acknowledge that the perceived beneficial aspects of our creative art therapy intervention may have resulted from the therapeutic stance inherent in individual psychotherap y practices rather than from particular theoretical and applied techniques utilized in this study Limitations of the Study There w e r e a numb e r of limitations in this stud y that compromised our abilit y to ge nerali ze it s findin gs to th e population of Sta g e I and Stage II breast cancer patients

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124 These included the research design, reacti ve arrangements subject self-selection, novelty effect, conceptualization of variables and instrum e ntation. They are discussed herein Research Design This experimental study had a pretest / posttest control group design with random assignment. The utilization of a pretest a control group and random assignment helped to control for known sources of internal validity (Gay, 1996) ; however~ exposure to the POMS at pretest may represent a possible interaction between the pretest and the treatment which ma y make the results generalizable only to other pretested groups (p. 366). This interaction i s especially likel y with experimental s tudies of short duration such as the present one (i.e. 4 weeks). Of particular concern and perhaps the greatest limitation of the present study was its small sample size. Small effect sizes and low po we r may have seriously compromised our ability to detect changes between groups and / or generalize documented outcomes to the population of Stage I and Stage II breast cancer patients. We are optimistic that our results show promise and a stronger design (including larger sample and longer treatment duration ) in future research would help improve this limitation. Although a pretest / posttest control group design w ith random assignment helps to control for the maturation threat it is noteworth y that several of the women reported critical events durin g the art therapy proce ss that may ha ve influenced treatment outcomes ; including two significant outliers that were eliminated from the dataset. These events included among others financial problems homelessness a breast cancer diagnosis of one subjects mother and another subject 's dau g hter hospitalization due to severe side effects of chemotherapy une x pected deaths in the family and marital discord.

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125 Reactive Arrangements The women who participated in this study (both experimental and control group subjects) had awareness of this fact which may have produced a Hawthorne effect. Therefore caution should be used when interpreting results to mean that the individual creative art therapy intervention was solely responsible for documented improvements in emotional expression states or psychological well-being and its relevant sub-scales. Subject Self-selection The women who participated in thi.s study were volunteers who self-selected to become involved in a creative art therapy intervention. As previously stated researchers have estimated 50% to 80% of all cancer patients choose to receive complementary therapies; within this group women who choose to participate in mind-body interventions such as the present study provided tend to be between 30 and 50 years of age, better educated wealthier and Caucasian (Boon et al., 1999; Richardson et al., 1998). Although our sample of Stage I and Stage II breast cancer patients appears relatively diverse and representative of the area where the study was conducted there may be other psychological or emotional characteristics that may account for their self selection participation completion and ultimately for the documented outcomes of the study. Since the women self-selected for participation we cannot know what the characteristics of women who chose not to participate are. Future research should make a concerted effort to reach out to these reluctant participants so that we may understand what keeps some women from choosing to participate in potentiall y beneficial studies Novelty Effect A total of 41 women participated in this study 39 were included in the final total s ample with only four of them having had any prior experience with creative art therapy

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126 interventions. The fact that this type of treatment represented a new theretofore unknown experience may have posed a threat to external validity through the novelty effect which refers to increased interest motivation or participation on the part of subjects simply because they are doing something different. In other words (the] treatment may [have been] effective because it [ was something] different ," not because it was psychologically valuable (Gay 1996 p. 357). Conceptualization of Variables and Instrumentation The main variable of this st ud y was emotional expression. This construct was conceptualized through a functional theory of emotions which holds that emqtions are relational and contextual and cannot be understood alone or as intra-psychic processes (Campos et al. 1994) To this end the creative art therapy inter ve ntion was designed to facilitate emotional expression related to the breast cancer e x perience and assist breast cancer patients manage it however subjectively conceptua li zed and understood. The Emotiona l Approach Coping Scale (EACS), Emotiona l Expression Sub-Scale used in this research has been extensively emp l oyed with samples of breast cancer patients (Stanton & Danoff-Burg 2002 ; Stanton Danoff-Burg et al., 2000). In this study it appears that both groups were equal in emotional expression thus disproving research hypoth esis one. However the Emotional Assessment Scale (EA S) used to document shifts in emotiona l expression preand postsession captured changes in the women's positive and negative emotional states. These differences lead one to question what each sca l e is truly measuring: Is the EACS measuring inher e nt or l earned characteristics ( i .e traits ) and / or coping styles related to management of emotions in ge neral while the EAS captures shifts in emotional states? For purposes of this research in retrospect it appears that the EAS may have been more accurate in capturing changes in emotional states,

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127 indirectl y depictin g facilitation or enhancement of emotional ex pression occurring during individual creative art th era p y sess ions . Spirituality as conceptualized in this study, represents a co ntextual and relational construct of an experience that g uides human interactions and helps enhance their sense of relatedness to all that is including the idea of God or a higher being ( Griffith & Griffith 2002) The complexity inherent in the ideas of spirituality and religion has been broadly explored in the literature (Cook & Hetrick 200 I ; Thoresen, 1999) and became evident in this research study. Many of the women self-described as highly spiritual or deeply religious while a few did not. Explorations into their spiritual lives led to some discoveries about the m ea nin g of spirituality and religion and the differences between them Our choice of instruments to measure spirituality came from MacDonald (200 1 ) who develop e d a sca le based on factor analysis of mor e than 70 other measures attempting t o capture thi s construct. Our conceptuali za tion of sp irituality as a contextual and relational experience may not have been adequately captured b y the ESI-R. This also led us to h y poth es i ze that sp irituality is also a trait rather than a state that ma y b e influen ce d throu g h p syc holo gica l intervention s The creative art th era p y intervention in thi s study did not e nhance l eve l s of s pirituality in the women ; most already con s id e r ed themselves to b e hi g hl y sp iritu a l or r e li g ious. Are sp iritual or religious individuals drawn to ex plor e comp l eme nt ary therapies mor e so than th ei r n o n-r e li g i o u s counterparts ? This i s a n int e r es tin g a r ea of inquiry that m ay warrant furth er sc rutin y. A ll in s trum e nt s u sed in this s tud y were se lf-r eport. Re searc h r esults may have been influenced b y the socia l de s i rab ili ty bi as inh e r e nt in th e use of se l fr epo r t measures (Co n e & Fos t er 1 993) T h e wo m e n ma y h ave made unc o n sc i o u s or consc i o u s efforts to

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128 appear doing and feeling better than they actually were at preand post-session testing for all who received the treatment and/or at post-test after four weeks of treatment or wait (delayed treatment) time. Implications Theory A premise of this study was that creative art therapy interventions could help clients in part reconnect with themselves holistically (in mind, body emotions and spirit) and make meaning of their struggle with the breast cancer experience . In recursive fashion engaging in the creative process could 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. Subscribing to a positive psychology framework we deliberately focused on the women's personal strengths and available resources for growth and transformation. Mindful of our theoretical framework we contend characteristics of the T y pe C personality profile was anecdotally exemplified in the sample of breast cancer patients in this study. The absence of differences in emotional expression between control and treatment group subjects also led us to speculate about our study subjects' possible preexisting tendenc y to suppress difficult emotions This controversial theory has received some support (Fe rnandez-Ballestero s et al. 1 998; Greer & Watson 1985 ; Lilja et al. 1998 ; Watson 1991) and been cautiously minimized (Bleike r & van der Ploeg 1999) b y researchers in the field of ps yc ho-oncolo gy. While victi m blaming remains a potential problem in considering this theory ongoing exploration i s clearl y warranted especially in light of th e potential deleterious effects of emotional suppression and repression on psychological well-being.

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129 The creative art therapy intervention in this study attempted to provide an opportunity for focused exploration of the breast cancer experience emphasizing meaning-making increased body awareness through a guided meditation experience enhanced spiritual awareness through a spirituality beliefs inventory and spontaneous creativity through a structured poetry-writing exercise. These interventions aimed to present opportunity for creative engagement in autotelic flow experiences (Csikszentmihalyi 1990a) Many of the women reported looking forward ~o the sessions as a way to carve out personal time and allpw for self-exploration and expression. According to self-report, the creative art therapy intervention facilitated these feelings in the women. These findings are congruent with the very few studies we found that reported similar beneficial effects of various forms of creative art therapy with breast cancer patients (G. Aldridge 1996 ; Cruze, 1998; Dibbell-Hope 2000; Predeger 1996). On the other hand it should also be noted that for some of the subjects participating in the art exercises was a difficult task. They required encouragement and prompting to become engaged in the creative process. Two of the research subjects commented that the creative art therapy experience goes beyond the creation of art and this should be emphasized to potential participants. These women felt that the tem1 "a rt therapy may represent a deterrent for some women who do not feel artistic or creative and are not familiar with the therapy process itself. The art therapy experience may make them self-consciou and nervous thus rendering the process frustrating and ineffectual. This reality challenges our concept of flow as delineated herein We discovered it is important to acknowledge that flow experiences appear to be ubjecti e representations of individual interests and talent Therefore facilitating an autotelic flow experience

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may not be realistic, possible or even relevant for breast cancer patients who prefer verbal expression alone or creative expression that does not involve art media. 130 Results of this research offer a mixed picture regarding the construct of emotional expression. As stated previously it is unclear whether instrumentation became a factor in our ability to measure emotional expression/states and determine whether the creative art therapy intervention enhanced the women's ability to emote and helped improve overall psychological well-being. Results of Research Hypothesis 2 indicated that for this sample of breast cancer patients the creative art therapy process facilitated expression of negative and positive emotions. Based on our findings we believe the constructs of emotional expression and spirituality including conceptualizations and correlations among them, warrant further scrutiny and clarification. Practice This study and its creative art therapy intervention were designed to help women with breast cancer enhance their emotional expression spirituality and psychological well-being. Although the individual creative art therapy sessions were semi-structured in nature many of the women who participated uncovered personal issues during ses sions that would appear not to be directly related to the breast cancer experience. Some women felt that their development of breast cancer may be related to these unresolved psychological and emotional issues (i.e. childhood history of sexual or physical abuse, neglect, abandonment by one or both parents) and ensuing emotional distress sometimes unexplored or expressed for years thence per subjects self-report. As salient unresolved concerns they received some attention during sessions and women who expressed a desire to receive ongoing assistance with these unresolved conflicts were referred to appropriate treatment providers in their communities.

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131 These women tated they planned to seek ongoing ps ychothera py after the creative art therapy inter ve ntion was completed As pre vio u sly s tated some of them spo ntaneousl y spec ulated if the cancer diagnosis could b e relat e d to these unre so l ve d emotional issues. The lit e r a ture has reported mixed findings regarding the relationship between emotional repression and breast cancer etiology with some studies concluding none existed (O Donnell Fisher Irvine Rickard & McConagh y, 2000), others supporti n g some connect i on (Fe rnandez-Ballesteros et al. 1 998) and some stating data are inconclusive to date (B l eiker et al. 1995) Further study on the relationships among e motional expression emotional repression and breast cancer incidence is clearl y warranted. A salient th e me of this study was the women s sense of uncertainty abo ut life after treatment. Of the 3 9 women in the total final samp l e, 14 were diagnosed 6 to 12 months prior to beginning the creative art therap y intervention. One of the main concerns r evo l ved around th e l ack of dir ec tion and support the y felt is ava ilable to women once the oncology treatment regimen e nds. T he prospect of cancer r ec urr e nce insurance and financia l concerns tran sfo rmed interpersonal relationships changes in emp l oyment s tatu s and a s udd e n thrust into menopaus e as a s id e effect of tr ea tment were nam ed as ripple effects re s ultin g from th e intens e period after di scovery of the lump dia g no s i s s ur gery and tr eatme nt s Many of these women fe lt that th e world ex p ected th e m to pick up where they l eft off a nd resume their norma l li ves th ey were not ready. Accordin g t o so me of th e m s upporti ve se r vices fo r th e po s ttr eatme nt period a nd b eyo nd are n ee d ed and l ack in g. Most of th e women w h o participated in this s tud y atte nd ed treatment a nd doctor 's appo intm e nt s accompan i ed by s i g nifi cant others. In th e co ur se of meetin g th e s ub jects

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132 who chose to participate, their husbands and partners had occasion to speak to the study '. s researchers. Their stories warrant mention here. Today a woman diagnosed with breast cancer has a plethora of resources both in the professionals who treat them, and in print and electronic media that she can draw from to uncover facts and information about the breast cancer diagnosis repercussions treatment and prognosis; information to assist their significant others is not as prevalent. At least three husbands or partners of research subjects asked this researcher not to conclude the study without speaking to them. They felt a need to underscore the importance of providing information and assistance to those supporting the breast cancer patients in their process. These individuals wished to be (and were) a steadfast source of encouragement and comfort to their wives and partners ; however they felt their own psychological and emotional struggles and the issues arising from the breast cancer diagnosis of their loved ones were a burden they alone carried. These people urged us to include an admonition for the health care community including mental health and social work practitioners to develop supportive programs for caregivers family, and friends of breast cancer patients. They wish to be heard as well. Many of the women who participated in this study expressed concern for their loved ones well-being. They felt that husbands partners family and friends lacked the degree and depth of support to process their experience of walking alongside the breast cancer patient in her journe y. Throughout the sessio ns and in the exit interview questionnaires several issues emerged regardin g health care providers service delivery. A fair number of the women who participated in this st udy shared the same oncology team of practitioners. Many commented on the p e rceived competent comprehensive compassionate and caring tr eat m e nt provided while th ey were not only in acute physical and emotiona l distress but

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confused and uncertain about their choices and options They reported feeling satisfied with the quality of care received and expressed appreciation for their physicians approach to healthcare practices. Some of the women offered some suggestions for all health care providers to consider. They include things they would have liked to s~e and receive during the treatment process and beyond. Predominant comments are listed herein: 133 Take a more holistic approach to treatment: Physicians need to recognize the power of the mind and its connection to health; offer advice on nutrition, exercise counseling and complementary therapies. Encourage women to participate in complementary therapy studies. Provide more information about breast cancer treatment options and prognosis. Encourage more posttreatment care of self. Increase communication with the patient and among treatment providers to minimize confusion. Allow time for the patient to talk about her feelings ; be more sensitive to her emotional state during visits Take care to make the post-surgical space warmer and more healing Recognize the sense of grief that accompanies a mastectomy (loss of a breast) and provide assistance as warranted. Include a mental health professional in the treatment team of health care providers. Predeger (1996) who conducted a creative art therapy intervention for a group of women based on systemic holistic feminist principles concluded that the voices of personal and collective healing as experienced by the women through their artistic creative process must be heard and that health care practitioners and researchers would benefit b y collaboratin g with women in a nonhierarchical participative model where dialogue of e x periences and possibilities are uncovered (p. 57). Many of the women in

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134 this study echoed this admonition. Through the exit interview questionnaires the women voiced their frustration with some oncology health care practitioners dismissal or minimization of emotional and psychological issues resulting from the breast cancer diagnosis and ensuing treatment process. After having experienced the individual creative art therapy intervention many of the women expressed a desire to see this type of treatment offered as part of the oncology regimen for breast cancer patients. Particularly noteworthy is the fact that even women who had completed all their oncology treatment prior to joining the study (usually, those 6 to 12 months since diagnosis ) expressed a desire to receive ongoing support posttreatment in order to deal with the psychological issues arising from fears of recurrence and other repercussions of the cancer expe rience. One of our research subjects s ummarized it best when she posed these questions during session: "Wh at am I supposed to do after treatment i s over? Forget that I had cancer and it may come back? Pick up the piece s and get on with my life ? When treatment ends that's when all these thoughts and feelings come up ... And where do I go to deal wit h these ? These questions deserve answers and as clinicians we are in a position to help un cover them. Future Research The process of psychotherapy i s cli e nt-focu sed As sc holar practitioners, we aim to conduct, in part ri goro u s l y contro ll ed outcome stud i e s that could help enhance our knowledge a nd und e r standing of specific treatment strategies upon relevant psychological variables. Holding a dual role within the process of professional e n gage ment a co nflict of identities may emerge ; counse l or or r esearc her ? As a therapist attention to th e clients' ne e ds i s paramount. As r esearc h er one seeks adherence to protocol s and procedures in order to maintain th e int egr i ty of the r esearc h process to

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135 keep it intact and valid. Jn session, while therapeutically engaged, we attend to whatever emerges. The circumstances proved no different when dealing with the breast cancer patients in this sample. One eager subject, for example signed up for the study in order to explore not her dual breast cancer diagnosis and treatment (each bre~st had a lump discovered within a 3-month period) but th e unresolved feelings surrounding the unexpected death of her 29 year old son the month between diagnoses Much of the sessions' time revolved around her profound sense of loss and grief. That she also endured a double mastectomy chemotherapy, and radiation treatments during that time paled in comparison to the sudden death of her only child. Another control group subject (one of the outliers dropped from the study's preliminary sample) encountered a crisis about 2 weeks into the dela ye d treatment wait period. She phoned her designated counselor and tearfully disclosed she had had an upsetting argument with h e r husband and bemoaned his lack of s upport and attention during this difficult time in her life The counselor listened to her and encouraged her to see k supportive s i g nificant others to help her in this tim e of need. She was assured that in 2 -weeks time we co uld del ve into whatever issues of concern she had At postt est she sco red significantly hi g her on p syc hological well-being, showing impro ve ment from pre test sco re s. We h ypo th esized that thi s bri ef interv e ntion over th e phone may ha ve e licit ed e nou g h of a r espo n se for h er to r epo rt improvem e nt in mood and well-being. This incident raises et hical concerns regarding attention to clients n eeds vers u s adherence to research protocols T hi c h a ll e n g in g area warrants ongoing di course among scho l ar practitioners in co un se lor ed uc a tion

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136' Many of the subjects who participated in this study reported ascribing to a holisti,c view of self and healing. They felt responsible for attending to all aspects of their lives and this, in part motivated their participation in this study. It appears that this sample of breast cancer patients, as part of their attempts to manage the cancer diagnosis, opted to engage in complementary therapies as adjunctive to the oncology treatment regimen (e.g. changes in nutrition herbal supplements acupuncture). Predisposing factors that lead a woman to choose (or not) complementary therapies warrant further study especially as research evidence grows supporting the beneficial outcomes of such interventions. Along this line a potential confound for this study s results is the women's use of other complementary therapies. Some of the women reported taking a very proactive approach to their treatment and opting to receive alternative and complementary therapies as adjunctive to the oncology regimen. It is plausible that exposure to these treatments may account for some of the enhancements in emotional expression and improvements in the psychological well-being subscales in this sample of breast cancer patients. Future research should take care to control for these factors in order to minimize this confound. The present study utili z ed the Emotional Approach Coping Scale s (EACS) subscale of emotional expression Our findings indicated that women who allow them selves to express emotions openly reported higher levels of ps y chological well-being and lower levels of tension-anxiety, depression-dejection anger-hostility and confusion bewilderrnent. These results are similar to the findings of Stanton Danoff-Burg et al. (2000) who explored the relationship between emotionally expressive coping and psychological adjustment to cancer and found it was associated with decreased [levels

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137 of overall] distress (p. 84) among other variables. In contrast, the researchers reported that women who utilized emotiona l pro cessing experienced increased distress. Our study did not include the emotional processing subscale of the EAC Future research should consider the utilization of both subscales ofthe EACS in order to obtain a clearer picture of this construct and its manifestation in this population The present study would have been greatly improved through the administration of additional delayed post-tests given sometime after treatment concluded. This is an ideal follow-up to help assess sustained gains over time and to minimize the interaction of time of measurement and treatment effect(s), a threat to external validity (Gay 1996) Finally, it shou ld be noted that a common suggestion made by the women during the exit interview questionnaire was that they wish the intervention had offered more sessions over time and that they included patients with all types of cancers. Some women wished their significant others could be included in this process so they too cou ld receive support. Qualitative Journal Keeping a narrative journal was an attempt to document insights gained through this research process. The writings included significant events and milestones as well as difficulties encountered. It was a challenge to separate li fe and work; sometimes m y musings took m e plac es that had nothing to do with this study. I found it impossible to compartmentalize pieces of my life ; to m e, this speaks volumes about the holistic nature of human bein gs and th e overlapping circles we inhabit. R ecruiting sub j ec t s for a research s tud y can be a challenging task recruiting breast cancer patients proved to be a dauntin g exercise in humilit y and patience. Many of th e women who contemplated participating in the research proce ss were facing

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138overwhelming unfamiliar and frightening treatments while attempting to come to term~ with an uncertain future. To have the opportunity to provide a modicum of support in this p rocess was truly humb l ing. Completing this study has given me a new appreciation for my chosen profession my health and my life's blessings. The challenges facing breast cancer patients are multifaceted and can become overpowering even when the diagnosis is early stage and prognosis appears good. Conducting research with this population requires flexibility and understanding to accommodate for the unexpected or lingering side effects scheduled surgeries, radiation or infusion therapies and changes in medical appointments or treatment protoc;:ols Research literature supports this need based on the complexities of a cancer diagnosis, treatment, and ramifications on a woman's life (Jacobson & Verret 2001). I have learned that research asks for parsimony and objectivity, and reiterated that clinical work requires focused engagement and creativity. One of the most difficult tasks faced was to receive phone calls from sad anxious eager women who wanted to be a part of the study but did not meet the necessary criteria ; they were diagnosed Stage III or IV, had been diagnosed over 12 months ago or Ii ved too far away to commute into the designated treatment offices Listening to their stories albeit briefly gave me a glimpse of the resilient spirit dwelling within them. It was disheartening to tell them they could not participate. All I could do was refer to the American Cancer Society s network of support groups and encourage them to seek ps y chological assistance if deemed necessary. I made referrals to specialized practitioners a couple of instances for women who appeared depressed or were facing overwhelming multiple stressors. In retrospect I would probably separate my researcher and clinician roles in this process. Holding true to each was my greatest challenge.

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139 Research can be a demanding and lonely endeavor; having the professional and personal support of loved ones and fell?w scholar practitioners made this process an exciting fruitful and ultimately fulfilling journey. Were it not for the steadfast generosity and support of my friends family ; and colleagues this scholarly endeavor Sisyphean at times would not have been as rewarding. Conclusion This chapter presented a discussion of research results and implications for theory practice and future research deriv~d from an experimental study of the efficacy of a creative art therapy intervention to enhance emotional expression spirituality and psychological well-being of newly diagnosed Stage I and Stage II breast cancer patients. Through this study, we were able to determine that a brief semi-structured creative art therapy intervention was not effective in enhancing the emotional approach coping style of emotional expression or level of spirituality of newly diagnosed Stage I and Stage II breast cancer patients in this sample. However we were able to determine that participation in the creative art therapy intervention appears to have helped decrease negative emotional states and enhanced positive ones of experimental group subjects in this sample. These shifts in feeling states appear to indicate that the women were able to process feelings and express themselves during session in productive ways a finding that is congruent with the s tudy s clinicians' anecdotal observations. Additionally the creative art therapy intervention appears to have enhanced psychological well-being of women in this sample by decr eas in g tension-anxiety depression-dejection a n ge r-ho s tilit y, and confusion-bewilderment ; affective aspects of this construct. Finall y, as h ypo th es i ze d the intervention did not effect changes in the physiolo g ical aspects of psychological well-being : vigor-activity and fatigue-inertia

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140 This stud pro ided support for th e Type C personality theory that suggests women diagnosed with breast cancer tend to suppress negative emotions, feel protective of family members and are afraid to become a burden to them. We were also able to confirm that enhancement of emotional expression appears to improve affective aspects of psychological well-being b reducing negative emotions. Furthermore e v idence of clinical significance underscored some of the quantitati e findings in this study, suggesting that the creative art therapy intervention was beneficial by helping the women enhance emotional expression (helped connect with/express feelings; relaxed to communicate feelings through art ; realized need to express inner feelings; helped me process and manage feelings) and ps chological well -b eing (feel less hopeless/happier; experienced relie f/ relaxation ). Clinical significance results a l so supported extant re sea rch that concluded benefit finding in the cancer experience helps women feel more optimistic and hopeful about their future (Antoni et al. 200 I) A noteworth y c l inical finding is that some of the women felt the benefitted from the experience because the y carved time out for self care reflection and quiet; saw the importance of Ii ing in the moment; and discovered that with faith and good wi ll all things are possible. Interestingly, these represent aspects of mindfulness a well-established and increasin g l y popular spiritual practice (Lesser 199 9). Final l y some of the women were able to uncover issues that needed attention and expressed a desire to continue treatment while others increased awareness of self and own beha iors and were able to identi fy coping and stress management options. Although not relevant ariables in our study these a re decidedl y beneficial outcomes of an therapeutic intervention

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APPENDIX A EXIT INTERVIEW FORM Date: Subject# : ____ _ --------Did you think it was helpful to participate in creative art therapy? No Yes What was the most important thing that happened to you as a result of participating in the creative art therapy exercises? Would you recommend this process to someone else with a health problem? D No D Yes What would you like your health care providers to do for you that they have not done ? Given what you have learned about yourself over the last four weeks what would you like to see health care providers asking or doing for women with breast cancer? Is there anything that you would like the investigators of this study to know that we have not asked? Do you have any s u ggest ion s that would make the creative art therapy experience yo u had b e tter for someo n e else? T hank yo u for participating in our st ud y. 141

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APPENDIX B RELEASE OF INFORMATION CONSENT FOR EXCHANGE AND I OR RELEASE OF INFORMATION D By signing below I _________________ give my permission for Ana Puig M.A. to receive information from my primary oncology physician: Name: Address: Telephone: _______ ___________ For the following purposes: To verify the cancer diagnosis for use in the study assessing the effects of the complementary mind-body intervention of art therapy To verify type of treatment for women with Stage I and Stage II breast cancer Name By signing below I ___ ___________ _ give my permission for to exchange and / or release information with / to: Ana Puig MA LMHC MH # 6992 Phone : 352-514-0306 (352) 392-0731, ext. 228 Email: anapuig @ ufl .e du The und ers i g ned i s aware that this consent can be withdrawn at any time Date Ana Puig MA, LMHC Date Lic e n se d M e ntal Health Co unselor (MH 6992) 142

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APPENDIX C RE EARCH ANNOUNCEMENT FL YER

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Complementary MindBody Therapy And Breast Cancer A Research Study At the University of Florida Have you been diagnosed with Stage I or Stage II Breast Cancer in the last 12 months? We invite you to become involved i n a research study about the benefits of the complementary mind-body intervention of art therapy for women with breast cancer. Complementary therapies are used alongside tradit i onal medical treatment in order to help the healing process Participants in this study wi l l receive complementary m i nd-body art therapy once weekly for one month These complementary therapy sessions w i ll be provided at no charge to you. If you participate in this study you will receive specific instruct i ons from your designated counse l or You w i l l be asked to f i ll out some questionnaires at the beginning and at the end of the study We hope you will benefit from the complementary mind-body art therapy experience and you will also be helping other women with breast cancer i n their journey! INTERESTED? Please contact : Ana Puig, MA, LMHC Call : (352) 514-0306 or (352) 392-0731, ext 228 14 4

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APPENDIX D INFORMED CONSENT Informed Consent to Participate in Research and Authorization/or Collection, Use, and Disclosure of Protected Health Information /RB# 331-2003 You are being asked to take part in a research study. This form provides you with information about the study and seeks your authorization for the collection u~e and disclosure of your protected health information necessary for the study. The Principal Investigator (the person in charge of this research) or a representative of the Principal Investigator will also describe this study to you and answer all of your questions. Before you decide whether or not to take part read the information below and ask questions about anything you do not understand. Your participation is entirely voluntary. 1. Name of Participant ( "Study Subject"): 2. Title of Research Study The Success of Art Therapy to Enhance Emotional Expression, Spirituality, and Psychological Well being of Newly Diagnosed Stage I and Stage JI, Breast Cancer Patients 3. Principal Investigator and Telephone Number(s) Ana Pui g M A. ( 3 5 2 ) 514-0306 ( 3 5 2 ) 3 9 2 -07 3 1 ex t. 22 8 14 5

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147' questionnaires are to find out how yo u are feel in g ( emotionally, mentally and sp irituall y) after the creative art therapy sess i ons The exit interview is to find ot~t w hat yo u thought of the art therapy experience. The last session includes the final art therapy experience which will be completed prior to answering the questionnaires and the exit interview The session questionnaires and exit interview will last approximately 90 minutes. If yo u are in the second treatment group durin g the last week of participation in the study, you will answer an exit interview. The interview is to find out what you thought of th e art therapy experience. The la s t session includes the final art therapy experience which w ill be completed prior to answering the exit interview. The session and ex it interview will last approximately 90 minutes 7. What are the possible discomforts and risks? There are no anticipated health risks or discomforts. You do not have to complete the questionnaires Throughout the study the researchers will noti fy yo u of new information that may become available and might affect your decision to remain in the study .. If you wish to discuss the information above or any discomforts y ou may experience you may ask questions now or call the Principal Investigator or contact persons listed on the front page of this form 8a. What are the possible benefits to you? There i s no direct benefit to yo u from answering the questionnaires It is possible that by participating in the complementary mind-body art therap y program yo u ma y be able to experience emotional r e lief and to cope more effectively with cancer. 8b. What are the possible benefits to others? It is possible that by comp l et in g the complementary mind-body art therap y program and answering th e questionnaires the information ga in e d from this study will help others und erstand the benefits of complementary mind-body art therapy and its effect on people. 9. If you choose to take part in this research study, will it cost you anything? T h ere are no known financial risks involved from participatin g in this study 10. Will you receive compensation for taking part in this research study? Yo u will not rec e iv e co mp e ns a tion for participating in this st ud y.

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Date : ----APPENDIXF DEMOGRAPHIC QUESTIONNAIRE Subject # ___ Name: Age: -------------------------Address: ---------------------------Ethnicity: African American Asian American Caucasian Latin American Native American Other Education: Did not complete High School High School Other ___ _ Associate of Arts or Science Degree Bachelor of Arts or Science Degree Master of Arts or Science Degree Doctor of Philosophy De gree Other If Other please specify : _________ _ Are you working outside the home ? No Yes If Yes: Full-time Part-time Who referred you to this study? -------------------Type of Breast Cancer: ____________ __ ________ Stage One Stage Two When did you find out yo u had breast cancer ? ______________ Have you eve r had any ex peri e nce with art therap y? No Yes If Ye s, Wh y, What and When ? ____________________ If Yes did yo u enjoy it ? No Ye s If Y es, do yo u think it was helpful ? No Yes What treatm e nt ha ve yo u r ece ived for y our brea s t cancer ? ___ _______ I s th e r e anythin g that yo u thi n.k i s important for th e inv es ti ga tor of this study to know about yo u ? ( Pl ease answer thi s qu est ion on the other s id e.) 1 53

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APPENDIX H POSTTEST COVER LETTER CONTROL GROUP Dear -----Enc l osed is the last envelope containing the final instructions questionnaires, and a return self-addressed stamped envelope so you can mail the materials to Ana Puig, according to the instructions provided. We hope that you will benefit from the complementary mind-body therapy you will soon begin receiving Thank you for being a part of this study and for your willingness to help us to help you and others like you We look forward to meeting with you. We will call you for your first appointment as soon as we receive the completed package. We hope that the findings of our study will help other women with breast cancer in their process of healing and coping with this illness Thank you. Sincerely Ana Puig 352-514-0306 352-392-0731 ext. 228 anapuig @ ufl.edu Enc: Envelope with Forms & Questionnaires Self-addressed Stamped Envelope 155

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APPENDIX I POSTTEST INSTRUCTIONS-CONTROL GROUP Please complete the items in this envelope in the order listed below. Thank you. CONTENTS OF ENVELOPE: 1. Questionnaire One 2. Questionnaire Two 3. Questionnaire Three 4. Return Addressed Envelope to Ana Puig INSTRUCTIONS: 1. Please complete Questionnaire One, Two, and Three 2. Place the completed Questionnaires (O ne Two and Three) in the envelope addressed to Ana Puig. 3. Mail the envelope to Ana Puig. THANK YOU. 156

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APPENDIXJ POSTT E ST COVER LETTER EXPERIMENT AL GROUP Dear ---------Enclosed is the last envelope containing the final instructions questionnaires exit interview form and a return self-addressed stamped envelope so you can mail the materials to Ana Puig according to the instructions provided. We hope that you have benefited from the comp l ementary mind-body creative art therapy you have received. We a l so hope that the findings of our study will help other women with breast cancer in their process of healing and coping with this illness. Thank you for being a part of this study and for your willingness to help us to help you and others like you. We wish you the best in mind body and spirit. Sincerely Ana Puig 352-514-0306 352-392-0731 ext. 228 anapuig @ ufl.edu Enc : Envelope with Forms & Questionnaires Self-addressed Stamped Envelope 15 7

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APPENDIXK POSTTEST INSTRUCTIONS-EXPERIMENT AL GROUP Please complete the items in this envelope in the order listed below. Thank you. CONTENTS OF ENVELOPE: 1. Questionnaire One 2. Questionnaire Two 3. Questionnaire Three 4. Exit Interview 5 Return Addressed Envelope to Ana Puig INSTRUCTIONS: 1. Please complete Questionnaire One Two and Three. 2. Please complete Exit Interview 3. Place the completed Questionnaires (One, Two and Three) and the Exit Interview in the envelope addressed to Ana Puig 4. Mail the envelope to A'na Puig. THANK YOU. 158

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If the subject does not believe in God or is agnostic ask that they delineate, through dra wi n g or painting what ever they believe in or si mpl y delineate their disbelief Follow-up Questions: 1. Could yo u explain what yo u have made and what that means to you? 2. How do yo u feel about what you have just made ? 3. Have you ever witnessed or seen God (or, your beliefs / disbeliefs) as you have delineated in yo ur rutwork? 16} Directive: "So me people believe that there is an opposite of God. If you believe there is an opposite force could you also draw or paint the meaning of that ?" Follow up with the same questions ; substitute words, as applicable. Session Four: Making Poetry Directive: Ask the subject to answer the following questions (Adapted from Crockett, 2000): If you were a __ what would you be? season precious stone sound musical instrument bird fairy tale character human era or period body / type of water time of day weather childhood game article of clothing magical/mystical creature tool feeling tr ee sce nt geograp hical feature movement bedding surface art medium body part flavor

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162 What is the color of your spirit? Directive: Ask the subject to write TWO POEMS using at least nine (9) items from her list; one about LIFE and one about DEATH. Follow-up Questions : 1. Would you please read the ( LIFE/DEATH ) poem out loud ? 2. What does the poem ~ay about yo ur beliefs of (LIFEIDEA TH)? 3. How did you feel when y ou wrote it ? 4. How do you feel now? 5 Did you learn something new about your self b y writing these poems?

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REFERENCES Achterberg J. (1992). Woman as healer Boston MA: Shambhala. Aldridge D. (1998) Life as jazz: Hope meaning, and music therapy in the treatment of life-threatening illness. Advances in Mind Body Medicine 14( 4), 27-282. Aldridge G. (1996) A walk through Paris": The development of melodic expression in music therapy with a breast-cancer patient. Arts in Psychotherapy, 23, 3, 207-223. American Cancer Society. (2001). Breast cancer facts &figures 2001-2002. Retrieved June 10 2003, from http: // www.cancer.org / downloads / STT/BrCaFF200l .pdf Andersen 8. (1992). Psychological interventions for cancer patients to enhance the quality of life. Journal of Consulting and Clinical Psychology 60, 4, 552-568. Andersen B. (2002). Biobehavioral outcomes following psychological interventions for cancer patients. Journal of Consulting and Clinical Psychology 70(3), 590-610. Andersen, B. L., Kiecolt-Glaser J. K. & Glaser R. (1994) A biobehavioral model of cancer stress and disease course. American Psychologist 49 389-404. Antoni M. H., Lehman J.M ., Kilbourn, K. M. Boyers, A. E. Culver, J. L., Alferi, S. M., Yount S. E ., McGregor B. A., Arena P. L. Harris, S. D., Price, A. A., & Carver, C S. (2001 ). Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychology 20(1), 20-32. Bailey S. (1997) The arts in spiritual care. Seniinars in Oncology Nursing, 13( 4) 242-247 Baron F. (1963). r e ativity and ps y chological h e alth. New York: Van Nostrand. Baron F. (1990). Cr e ativity and ps y chological h e alth : Origins of personal vitality and creative.fr ee dom Buffalo NY: Creative Education Foundation. Baum A. & Andersen 8. (Eds ). (2001 ). Ps y chosocial interv e ntion for cancer. Washington DC : America Psychological As ociation. Belitz C. & Lundstrom M. ( 1998). The pow e r of jlov1 : Practical ways to transform your life with m e aning/it! coincid e nce New York NY: Three Rivers Press 163

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BIOGRAPHI CAL SKETCH Ana I sa bel Pui g F i g ueroa was born in the city of Santurce on March 30 1963 and raised in th e va ll ey town s hip of Utuado in th e b ea utiful island of Puerto Rico. In 1980 upon gra du a tin g from hi g h sc ho o l she left her h o m e to pur s u e higher education in the United States She received her Bachelor of Arts degree in sociology from the University of Southwestern Louisiana in Lafayette She worked in a variety of mental health agencies and ps yc hiatric hospitals while pursuing her Master of Arts degree in counselor education from the U ni ve rsity of South Florida in Tampa. Her searc h for a professional identity has taken her on a journey through the states of Louisiana Florida and Oregon and for a short while to the South American city of Caracas, Venezuela. H e r clinical experiences inspired a desire to become a counselor educator thu s ex pandin g th e breadth of her clinical practice and applications. She arrived in Gainesville Florida w h e r e h e r famil y li ves committed to e arnin g a doctorate in counselor ed uc a ti on a nd mental h ea lth counseling. Ana i s a National Ce rtifi e d Co un se lor a nd a Lic e n se d Mental Health Counselor and Qualified Mental Health Co un se lin g Supervisor in th e s tat e of F lorida She was an ac ti ve member of th e educa ti o n comm itt ee of the Sp iritu a li ty a nd H ea lth Ce nt e r (S H C) at th e Un i vers i ty of F l o rid a until h e r gra duation in 2 004 and hold s th e fir s t certificate in s pirituality and h ea lth s tudi es i ss u e d by th e SHC. Ana s areas of s p ec i a l ty includ e th e app li cat i on of creativity and sp iritu a li ty to mental health counse lin g practice and r esearc h S h e is particularl y in teres t e d in h o li s ti c approac h es t o h ea lth and h ea lthcare es p ec iall y in 1 8 1

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the treatment of breast cancer patients. She hopes to contribute to counselor education through her ongoing work as a scholar practitioner in the field. Ana is happily partnered with Rebecca Anne Fields and they share a feline daughter named Maya. 182

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I cert i fy th a t I h a e rea d thi s tudy a n d t h a t i n m y opin i o n i t co n forms to acce pt a bl e t a n da rd s of c h o l ar l y p r ese nt a ti o n a nd i full y a d e q ua t e in sco p e a nd qua l ity, a a di sserta ti o n fo r th e d eg r ee of D oc t o r P e t e r A D S h e rr a rd C h a ir Assoc i a t e P rofessor of Co un se l o r E d ucat i on I ce rti fy th a t I h ave r ea d thi s st u dy a n d th a t in m y o p i ni o n it co n fo rm s t o accep t a bl e s t a nd a rd s of s ch o l a rl y pr ese nt a ti o n a nd i s full y a d e qu ate in sco p e a n d q u a li ty as a di sse r ta ti o n fo r th e d eg r ee of D o ct o r of Phil oso ph y. E ll e n S. Am a t ea Pro fesso r of Co un se l o r E du cat i on I c e rti fy th a t I h ave r ea d th is s tu dy an d th a t in m y o pini o n it co n fo r ms t o acce pt a bl e s t a nd a rd s of sc h o l a rl y pr ese nt a ti o n a nd i s full y a d e qu a t e in sco p e a nd q u a li ty, as a di sse rt a ti o n fo r th e deg r ee of D oc t or o f Phil osop h y C lini ca l P rofessor of P syc h o l ogy I ce rti fy th a t I h ave r ea d thi s tu dy a nd th a t in m y o pini o n it co n forms to acce pt a bl e s t a nd a rd s of c h o l a rl y pr ese nt at i o n an d i s full y a d e qu a t e in scope an d qu a li ty as a d isse rt a t io n fo r th e d eg r ee of D oc t o r of Ph i l osop h y. ~ --=~ -----Anne Se r a phin e A s i stan t P rofes o r of Ed u cat i o n a l P syc h o l ogy

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This dissertation was submitted to the Graduate Faculty of the College of ducation and to the Graduate chool and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy December 2004 Dean Graduate School

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