Clinical Study

Oncology 2020;98:216–221

Art Therapy Sessions for Cancer Patients: A Single-Centre Experience

Mathilde Gras a, b Elisabeth Daguenet b, c Christelle Brosse a Aurélie Beneton a

Stéphanie Morisson a

aDepartment of Supportive Care in Oncology, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France; bUniversity Department of Research and Education, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France; cDepartment of Haematology, Lucien Neuwirth Cancer Institute, Saint-Priest-en-Jarez, France

Received: October 2, 2019Accepted: October 14, 2019Published online: February 11, 2020

Dr. Stéphanie MorissonDepartment of Supportive Care, Lucien Neuwirth Cancer Institute 108 bis, Avenue Albert RaimondBP 60008 FR–42271 Saint-Priest-en-Jarez (France) stephanie.morisson @ icloire.fr

© 2020 S. Karger AG, Basel

[email protected]/ocl

DOI: 10.1159/000504448

KeywordsArt therapy · Cancer · Anxiety · Quality of life · Well-being

AbstractIntroduction: Cancer and anti-cancer therapies are often as-sociated with pain, loss of self-worth, anxiety, and depres-sion. Alternative therapies such as art therapy are available to improve patients’ quality of life, by reducing asthenia, de-pression, anxiety and pain. Objective: The aim of this study was to assess the effectiveness of art therapy, namely theatre and plastic art workshops, on well-being and quality of life of participants in the Lucien Neuwirth Cancer Institute. Methods: A prospective study was conducted at the Lucien Neuwirth Cancer Institute (France), between April 2018 and July 2018. Cancer patients followed at the Institute have been asked to participate in 10 2-h sessions, once a week, based on theatre and plastic art workshops. Self-report ques-tionnaires were used to evaluate both psychological and quality of life domains, but also satisfaction and well-being, before (pre-test) and after the last session (early post-test), as well as 1-month post-experimentation (late post-test). Re-sults: Among the 14 patients who were enroled, the QLQ-C30 questionnaire revealed a pre-test median score of 50.0, an early post-test score of 51.5, and the late post-test re-vealed a score of 48.0. The anxiety test revealed median

scores of 8.0 (pre-test), 6.0 (early post-test) and 6.0 (late post-test), respectively. The depression test reported median scores of 4.0 (pre-test), 5.0 (early post-test) and 6.0 (late post-test), respectively. The median well-being score difference observed between the beginning and the end of sessions is +2.13. The minimum satisfaction score observed is 3.50 out of 10, and the maximum is 10 out of 10. The median is be-tween 7.00 and 10.00. Conclusions: Art therapy sessions had an impact on patients’ welfare. We also reported a trend to-wards amelioration of quality of life that could probably be confirmed in a larger population, and potentially with a dif-ferent methodology. © 2020 S. Karger AG, Basel

Introduction

Cancer and anti-cancer therapies are often associated with life-changing impacts for patients: pain and other discomfort symptoms, body image modification, loss of self-worth, familial and social isolation, anxiety, and de-pression [1–7]. To help manage these issues, different treatments or options can be proposed, including drug therapies, psychological support, diet measures and/or social follow-up. Patients can also have access to comple-mentary therapies, such as relaxation, sophrology, hyp-notherapy, osteopathy, or acupuncture [8–10].

Art Therapy Sessions for Cancer Patients 217Oncology 2020;98:216–221DOI: 10.1159/000504448

Art therapy has been used in the care of cancer patients for many decades and it is increasingly used in oncology departments or palliative care units. It is based on the idea that creativity has a therapeutic effect, and that expression of fear, anxiety, and pent-up emotions could enhance well-being and quality of patients’ life. Art therapy is a real way of expression and communication for patients but also for their loved ones, utilizing creative modalities, including sculpture, drawing, and painting, theatre, and music ways. Through these methods, patients can share their lived experience and sensations to stand by their feelings. Art therapy sessions offer a time to communi-cate, to be listened to, to de-stress, and to enjoy, where the suffering subject feels recognized as a person and not as a patient anymore [11–13].

The use of art therapy in cancer care settings is increas-ingly noticeable over recent years. Interestingly, studies showed an improvement of quality of life (QoL), and a reduction of discomfort symptoms, such as asthenia, de-pression, anxiety and pain [14–23].

From a perspective of QoL amelioration, the Lucien Neuwirth Cancer Institute, in relationship with the Ligue Contre le Cancer, organized art therapy sessions for can-cer patients, who are followed at the Institute. Our aim was to assess the effectiveness of art therapy, namely the-atre and plastic art workshops, on well-being and QoL of participants.

Methods

Study Design and Study PopulationWe conducted a prospective study at the Lucien Neuwirth Can-

cer Institute between April 2018 and July 2018. Cancer patients receiving or having received chemotherapy and/or radiotherapy were eligible to participate: diagnosed with cancer, independently of the stage, aged ≥18 years, good performance status, could com-municate and understand the questionnaires, could attend the planned workshop sessions.

Art Therapy WorkshopsThe patients were trained, guided and monitored by two pro-

fessional art therapists. The study planned 10 2-h sessions, once a week, based on theatre and plastic art workshops. Each session comprised two parts: body and voice warm-up (i.e., respiratory exercises, movements, and voice games), individual or collective theatre and plastic art games (i.e., living painting improvisation, painting, corporal awakening). The end of each session was char-acterized by a sharing time on creations/works as well as a com-mon discussion on emotions felt before and after the activities.

Questionnaires and Data CollectionSelf-report questionnaires were used to evaluate both psycho-

logical and QoL domains before (pre-test) and after the last session

(early post-test), as well as at 1-month post-experimentation (late post-test). Psychological distress was assessed using the Hospital Anxiety and Depression Scale, a 14-item inventory comprising 7 anxiety-related symptoms and 7 depression-related symptoms. The QoL was rated with the EORTC-QLQ-C30 that encompasses 6 domains (i.e., physical function, role function, emotional func-tion, pain, fatigue, global health/QoL). All patients were also asked to express their expectations regarding these art therapy sessions and to indicate their concomitant treatments, in particular antalgic and anxiolytic treatments. Patient and study details were obtained from the medical records and interviews with the subjects. After the study period (14 weeks), no further follow-up was planned. Finally, we surveyed patients’ satisfaction before and after each ses-sion with a visual well-being scale, graduated from 0 (not satisfied at all) to 10 (fully satisfied), as a proxy to evaluate art therapy im-plementation at the Lucien Neuwirth Cancer Institute.

Statistical AnalysisThe descriptive statistics used were frequency or mean stan-

dard deviation. No statistical test was performed. Only a descrip-tive analysis of the results was carried out. Median values were given with their ranges.

Results

Baseline Characteristics of the PopulationAmong the 14 patients screened for this study, 14 pa-

tients were included, and most patients were women

Table 1. Baseline characteristics of the study population

Variables Number Percentage

Age, yearsMedian (range) 49.5 (25–71) –

SexFemale 12 85.7Male 2 14.3

Primary cancerBreast 6 42.9Lung 2 14.3Ovary 2 14.3

Upper aero-digestive tract 1 7.1Pancreas 1 7.1Intestine 1 7.1Myeloma 1 7.1

Professional activitySick leave 8 57.1Retirement 3 21.4Part-time job 2 14.3No job 1 7.1

Patient transportationPersonal vehicle 12 85.7Taxi 1 7.1Public transport 1 7.1

Gras/Daguenet/Brosse/Beneton/MorissonOncology 2020;98:216–221218DOI: 10.1159/000504448

(86%). Their median age was 49.5 years (range, 25–71 years). The main primary tumour location was the breast (n = 6, 42.9%), followed by the lung (n = 2, 14.3%) and ovary (n = 2, 14.3%). Most patients were on sick leave during art therapy session (n = 8, 57.14%), other ones were on retirement (n = 3, 21.4%), 2 participants were in part-time job (14.3%), and 1 participant had no job dur-ing the sessions (7.1%). Three different means of trans-portation were used by patients: personal vehicle (n = 12, 85.7%), taxi (n = 1, 7.1%) and public transport (n = 1, 7.1%). The detailed baseline characteristics are shown in Table 1.

Before, during, and 1 month after sessions, patients’ concomitant treatments were reported. They were main-ly anti-cancerous treatments whatever the observed pe-riod (n = 11, 73.4% in pre-test; n = 12, 66.6% in early post-test; n = 14, 82.3% in late post-test). The second mostly used treatment was analgesics (n = 2, 13.3% in pre-test; n = 4, 22.2% in early post-test; n = 2, 11.8% in late post-test). Finally, antidepressants and anxiolytics were less used (between 5.6 and 13.3% for antidepressants, and 0.0 and 5.6% for anxiolytics). Concomitant analgesic, anxio-lytic, antidepressant, and anti-cancerous treatments are reported in Table 2.

Art Therapy Sessions, Experiences and ExpectationsMost of the patients did not experience art therapy

(n = 9, 64.3%) before sessions. Motivations for participa-tion were numerous, such as changing one’s mind, meet-ing people, discovering art therapy, and expressing one’s feelings. Regarding the attendance to the sessions, only 2 patients attended all sessions (14.3%), while 5 patients were absent one time (35.7%). The other participants at-tended between 3 and 8 times. Reasons of non-attendance were diverse: medical appointments (n = 9, 34.6%), asthe-nia (n = 5, 19.2%), death of a relative (n = 2, 7.7%), pain (n = 1, 3.9%), or personal reason (n = 1, 3.9%). Of note, 1 patient was absent in 6 sessions because he did not feel comfortable with the group, probably due to his young age as compared to the other participants.

Effect of Art Therapy on QoL, Anxiety and DepressionAll patients taking part in art therapy completed the

questionnaires before the beginning of the sessions (pre-test), after the 10 sessions (early post-test), and 1 month after the end of art therapy sessions (late post-test). The results are presented in Table 3.

The QLQ-C30 questionnaire is an auto-evaluation, evaluating 5 functions, 9 symptoms, and global health state [24].

The median score obtained on pre-test is 50.0 with a standard deviation at 9.2. The early post-test median score is 51.5 with a standard deviation at 11.5, and the late post-test reveals a score of 48.0 with a standard deviation at 8.9.

The Hospital Anxiety and Depression Scale question-naires were also completed on pre-test, early post-test, and late post-test. A high “A score” reveals anxiety trou-bles, and a high “D score” reveals depression troubles. Each score is between 0 and 21.

The anxiety pre-test median score is 8.0 with a stan-dard deviation at 4.9. The median score in the early post-test period is 6.0 with a standard deviation at 4.2, and the late post-test median score is 6.0 with a standard devia-tion at 4.4.

The depression score is 4.0 with a standard deviation at 3.7 in the pre-test and 5.0 with a standard deviation at 3.0 in the early post-test period. To finish, the median score is 6.0 with a standard deviation at 3.6 in the late post-test period.

Total Hospital Anxiety and Depression Scale scores are 11.5 ± 7.6 in the pre-test, 12.0 ± 5.7 in the early post-test, and 14.0 ± 5.1 in the late post-test period.

Table 2. Concomitant treatments at the 3 assessment points

Pre-test, n (%)

Early post-test, n (%)

Late post-test, n (%)

Anti-cancer 11 (73.4) 12 (66.6) 14 (82.3)Analgesic 2 (13.3) 4 (22.2) 2 (11.8)Antidepressant 2 (13.3) 1 (5.6) 1 (5.9)Anxiolytic 0 (0.0) 1 (5.6) 0 (0.0)

Total 15 (100.0) 18 (100.0) 17 (100.0)

Table 3. Median questionnaires scores and standard ratios at the 3 assessment points

Pre-test Early post-test

Late post-test

QLQ-C30Total scores 50.0±9.2 51.5±11.5 48.0±8.9

HADSAnxiety scores 8.0±4.9 6.0±4.2 6.0±4.4Depression scores 4.0±3.7 5.0±3.0 6.0±3.6Total scores 11.5±7.6 12.0±5.7 14.0±5.1

HADS, Hospital Anxiety and Depression Scale.

Art Therapy Sessions for Cancer Patients 219Oncology 2020;98:216–221DOI: 10.1159/000504448

Well-BeingWell-being before and after each session is reported in

Figure 1. Differences were calculated: the minimal differ-ence observed is −8.5, meaning that the patient was in a worse mood than before the session. Maximum differ-ence observed is +8.0, and the median is +2.1.

SatisfactionFigure 2 represents global satisfaction for participants

at each session. The minimum observed is 3.5 out of 10, and the maximum is 10 out of 10. The median is between 7.0 and 10.0.

Discussion

This study revealed a trend towards QoL amelioration and a real satisfaction for participants, despite a small and heterogeneous population, and recruitment difficulties. Indeed, group constitution was time-consuming and has taken approximately 3 months.

The first difficulty was the homogeneity of the popula-tion. Different pathologies were represented (breast or lung), in accordance with data that we can find in the lit-erature [15, 16]. There were 12 women and only 2 men in art therapy sessions. Many studies showed that mostly women participate in art therapy sessions [16], explain-

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Before After Before After Before After Before After Before After Before After Before After Before After Before After Before After

Q1minmedianmaxQ3

Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9 Session 10

Fig. 1. Well-being before and after each session.

Q1minmedianmaxQ3

7.057.88

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Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9 Session 10

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Fig. 2. Global satisfaction for participants at each session.

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Gras/Daguenet/Brosse/Beneton/MorissonOncology 2020;98:216–221220DOI: 10.1159/000504448

ing the few prostate or lung cancers, frequently treated at our Institute [10]. However, the initial idea was to recruit only patients with cerebral tumours, because they often present communication difficulties, and art therapy could be a solution to enhance this point. Sharing the same pa-thology could also facilitate communication within the group. But the health state of this kind of patients worsens quickly and we were unable to form a group. Therefore, sessions were opened to all pathologies.

The second difficulty was the way of transport, because patients had to be able to come to sessions with their own transportation. Almost all patients took their personal ve-hicles to come. Patients should be in good health to drive and this could be a bias for recruitment: too weak people are not able to come to sessions, even if they would want to.

Three months were necessary to recruit enough partici-pants. During this time, many patients’ health state wors-ened, and they either cancelled their participation or came to sessions all the same, but impaired. Health state could explain important absenteeism. Indeed, it was difficult to obtain a full group for each session: this is the disadvantage of having a fixed day, because Thursday is probably not the day where most people are available. Furthermore, partici-pants were patients, so they had a lot of medical appoint-ments. One patient was regularly absent, because he felt younger than the other ones in the group: maybe the popu-lation was not enough heterogeneous concerning partici-pants’ ages. Interestingly, Koom et al. [17] and Bar-Sela et al. [18] also reported high absenteeism. Furthermore, pa-tients were mostly on sick leave during art therapy session (n = 8, 57.1%), and other ones were on retirement (n = 3, 21.4%), or in part-time jobs (n = 2, 14.3%).

Anxiety and depression scores were globally quite sta-ble, whereas in the literature, a depression score ameliora-tion [18, 22], or an amelioration on both scores is often observed [14, 16, 19, 21, 23]. More sessions might be nec-essary to observe this amelioration.

Concerning well-being, we can also report a good im-pact. Indeed, median and maximum scores were globally improved after each session. Last but not least, maximum scores of well-being increased after each session, and min-imum scores enhanced for all sessions, excepted for ses-sions 4, 5, 6, and 7. It was neither the same patient at each session who chose the minimum score, nor the same pa-tient at one session who put the minimum before and after the session. This could mean that some sessions were more liked than other ones, and patients did not prefer the same sessions. It could come from different expectations, as previously mentioned: “change one’s mind, meet peo-ple, discover art therapy, and express one’s feelings.”

Well-being score amelioration was associated with an important global satisfaction, with medians between 7 and 10, and results always equal to or higher than 5, sug-gesting that patients were quite satisfied. Forzoni et al. [11] reported in their article that 94% of participants de-scribed their art therapy experience as “helpful.” Indeed, these data have clinical implications, as they showed that art therapy may be useful to support patients during the stressful time of chemotherapy treatment. Different pa-tients used it to fulfil their own different needs, either be-cause there is a need to relax (improved mood) or to talk (self-narrative) or to visually express and elaborate emo-tions (discovering new meanings).

Regarding pain, Lefèvre et al. [21] reported a signifi-cant pain reduction. This reduction was not reported in our study, because among the selected population, no participant presented pain: only 3 patients out of 14 used analgesics at baseline. One month after the sessions, only 1 patient still took analgesics. So, few patients were in pain, or with uncontrolled pain. Only one absence was due to pain.

Sessions proposed by the professionals included paint-ing and theatre. Other art therapy session types might be more suitable to enhance QoL, and to decrease stress and anxiety, such as music therapy [25]. By diversifying the offer, workshops could also become more attractive for patients.

Despite the beneficial impact on QoL (QLQ-C30 score amelioration) in the present study, further investigations on a larger population might be necessary to confirm that, as observed in other studies such as those by Koom et al. [17] on 50 patients, Svensk et al. [20] on 41 patients, or Bozcuk et al. [22] on 48 patients. Our population of 14 patients might have been too small to observe a signifi-cant difference.

Conclusion

Art therapy sessions have been appreciated by pa-tients, who reported high satisfaction and high well-being scores. We can conclude that art therapy sessions have a positive impact on patients’ welfare. We also reported a trend towards QoL amelioration. Yet, this has to be con-firmed in a study with a larger population, and poten-tially with different workshops, such as music therapy. Pain investigation is another endpoint to follow. Collec-tive efforts have to be put to permit access to these work-shops for all patients, in order to promote art therapy as a novel and efficient supportive care in routine praxis.

Art Therapy Sessions for Cancer Patients 221Oncology 2020;98:216–221DOI: 10.1159/000504448

Acknowledgements

We would like to thank the Ligue Contre le Cancer Loire that allows us to set up art therapy sessions. Many thanks to the Marche Bleue association that recruited two art therapists, Anne Jalard and Camille Chaslot, who performed art therapy sessions. These pro-fessionals took time to constitute groups, and to answer partici-pants’ questions. They were really appreciated by the patients.

Statement of Ethics

The patients’ oral consent was systematically obtained. All per-formed procedures were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. The institutional ethics committee approved the survey.

Disclosure Statement

The authors have no conflicts of interest to declare.

Funding Sources

The “Ligue Contre le Cancer Loire” offered to “Marche Bleue” the financial support to hire art therapists for leading art therapy sessions in the Lucien Neuwirth Cancer Institute.

Author Contributions

Mathilde Gras, Elisabeth Daguenet and Stéphanie Morisson wrote the present article. Christelle Brosse, Aurélie Beneton and Stéphanie Morisson organized the financial demand and the orga-nization of art therapy sessions.

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