Significant symptom relief when cancer patients engage in art therapy

Anxiety, fatigue showed greatest improvement

New research shows that cancer patients who engage in one hour of art therapy show immediate improvement in eight of nine symptoms, with the greatest improvement noted in anxiety and tiredness.1

Art therapy provides a benign way for people to deal with their feelings, says Nancy Nainis, MA, ATR, LCPC, an expressive arts therapist with Northwestern Memorial Hospital in Chicago, IL.

For example, a patient who may find it too overwhelming to express his anger over his cancer diagnosis might be able to express his anger through his art.

"I had someone who created angry Easter eggs once, and a lot of feeling came out while he was making those eggs," Nainis recalls.

Nainis and co-investigators studied the impact of a one-hour art therapy sessions provided on an individual basis by Nainis on 50 patients at an inpatient oncology unit in a large urban academic medical center.

Most of the patients, within an age range of 19 to 82, had leukemia or lymphoma and had been diagnosed within the prior two to three years.1

Participants in the study included African Americans (26.5 percent), Hispanic/Latino (4.1 percent), and Asian (2 percent). About one-third were single, and 56 percent were married, while 10 percent were divorced.1

Using the Edmonton Symptom Assessment Scale (ESAS) and the Spielberger State-Trait Anxiety Index (STAI-S), investigators measured the patient's severity of nine symptoms, on a scale from zero to 10, both before and after the art therapy intervention. The symptoms included pain, tiredness, nausea, depression, anxiety, drowsiness, lack of appetite, their well being, and shortness of breath.1

With the exception of the symptom of nausea, there was a significant improvement noted in all of the symptoms after the art therapy intervention.1

"I was absolutely blown away by the results," Nainis says. "This was a pre/post test, so I don't know if the improvement was sustained a day or two, but immediately afterwards there was this positive reaction."

The symptoms of anxiety and tiredness were highly significant, making this the first study finding that art therapy energizes people, Nainis says.

"It was cute because the research assistant said, 'What do you do with the patients? I go in and do the pre-test and they're very tired and just lying there and can barely talk. Then I go back, and they're sitting up and their eyes are sparkling,'" Nainis recalls.

Creative activities can be very empowering, but more research is needed to find out more about the whys and hows, she says.

"Everyone knows distractions help patients, but does art therapy do more than that?" Nainis says. "We need to do more research to really know."

At the very least, art therapy distracts patients and helps them focus their minds on something besides their symptoms and illness, Nainis says.

"When people were asked how art therapy affected their quality of life, some people said it made them feel more worthwhile, and most people said it was fun and relaxing," Nainis says.

Nainis has ideas about why art therapy provided some symptom relief to the cancer patients, but she would like to see research continue with the purpose of determining how art therapy helps.

"We just wanted to see if there was credible evidence that art therapy impacted symptoms, and we didn't match what the patient chose to do with what their symptoms were," Nainis says.

Future research could look at the impact on symptoms of individual types of art therapy, she suggests.

For example, she has found that when patients wrap something, such as wrapping yarn around a stick, it helps with pain. And some patients find it helpful to engage in a repetitive activity, working with soft materials, such as cloth and yarn, Nainis says.

With the art project of taking broken pieces of glass and making mosaics, there is an emotional metaphor inherent in the art work, Nainis notes.

"It's like taking bits and pieces of your life and making something of it," she says. "You're giving meaning to your life, and this helps us cope spiritually, mentally, and physically."

For the study intervention, Nainis showed patients a cart that held a variety of materials, and they were asked to select what they wanted from the cart.

The art therapy supplies included cards and envelopes, jewelry and beads, clay, journals, sketch pads, collage materials, paper pulp masks, fancy papers, paints, feathers, finger paint, felt, stained glass, foam shapes, tempura, glitter glue, watercolor, glue sticks, rainsticks, magazines, stained glass sun catchers, pipe cleaners, stamps, sequins, wooden boxes, tissue paper, wooden frames, yarn, pencils, charcoal, pastel chalk, markers, pens, and oil crayons.1

Then Nainis followed a standardized script of introducing herself and explaining that the art project wasn't about talent, but about allowing oneself to try something new, Nainis says.

"I'd explain what the materials were and the possibilities," Nainis says. "Then, they selected a project, and I helped them with it."

Nainis had patients whose arm swelling was so severe that they couldn't manipulate the art objects on their own, so Nainis became their hands.

"So they'd pick a project and tell me what they wanted, and I would do it for them," she says.

"People tend to focus on images that are relevant to their issues," Nainis says. "One gentleman focused on a picture of a woman with a long neck, and that made him think of his wife."

The man talked about how much he cared for his wife and how his illness made him worried about what would happen with her when he died, Nainis recalls.

"We were able to talk about this issue because we looked at this picture that he chose to focus on," she says.

After patients selected their art goal, Nainis would ask more probing questions only when patients indicated they were interested, she says.

"A number of people would say, 'I just want to do this for fun, and then they'd ask me, 'If you were going to analyze this, what would you do?'" Nainis says. "I'd say, 'When you chose those colors were you thinking of anything in particular?' and then I'd take the image and put it on the wall so this would change their point of view and provide a different perspective."

Art therapy is a natural fit with hospice care, Nainis notes.

"What's wonderful about hospice is when you go into the home you have access to their photos and their things," Nainis says. "One hospice patient was teaching her art therapist crocheting stitches, passing on her legacy, knowing it would go beyond her."

Other hospice patients have enjoyed putting together scrapbooks and other arts and crafts items to leave a legacy for their families.

"They use these to express some fears," Nainis says.

For example, Nainis worked with a cancer patient who had incurable cancer and knew she was dying.

"We had a project where she and her four nephews made a mural, and they each made representations of themselves and of their aunt, and then we created an environment to place all these things," Nainis says. "It helped everybody see what their relationships were and how they felt about each other, and it was a marvelous vehicle to share their love and feelings."

The boys were between eight and 13 years, and at that age they typically find it hard to verbalize feelings, she notes.

But through their mural artwork they were able to express themselves as plants or animals and create a flower that represented their aunt, Nainis says.

"Their aunt made animals to show how she saw her relationship with them and who they were in her eyes," she adds. "They made this castle, and she was kind of in the center, and it was beautiful and a wonderful way to share their love."

The woman brought the mural home and died shortly after the experience, Nainis says.

"I can see art therapy as being really helpful in situations like hospice, where families are brought together and given a way to focus their feelings without being overwhelmed," Nainis says. "Then you have this art, this evidence, this piece you can keep together and look at years later."


1. Nainis N, et al. Relieving Symptoms in Cancer: Innovative Use of Art Therapy. J Pain Symptom Manage. 2006;31:162-169.