Art Therapy as Supportive-Expressive Therapy in Breast Cancer Treatment / Art terapija kao suportivno-ekspresivna terapija u liječenju karcinoma dojke Lea Milutinović1, Marijana Braš2,3, Veljko Đorđević3 1 University of Zagreb School of Medicine, Student Society for Neuroscience, Zagreb, Croatia, 2Zagreb University Hospital Centre, Department of Psychological Medicine, Zagreb, Croatia, 3University of Zagreb School of Medicine, Centre for Palliative Medicine, Medical Ethics and Communication Skills, Zagreb, Croatia / 1Sveučilište u Zagrebu, Medicinski fakultet, Studentsko društvo za neuroznanost, Zagreb, Hrvatska, 2Klinički bolnički centar Zagreb, Klinika za psihološku medicinu, Zagreb, Hrvatska, 3Sveučilište u Zagrebu, Medicinski fakultet, Centar za palijativnu medicinu, medicinsku etiku i komunikacijske vještine, Zagreb, Hrvatska Aims: Art therapy as supportive-expressive therapy is gaining increasing importance in psycho-oncology. The aim of this paper is to describe the experience of participating in art therapy of a patient with breast cancer and to review the literature regarding the effectiveness of art therapy during breast cancer treatment. Methods: The participant undergoing medical treatment for breast cancer was treated at the Clinical Hospital Centre Zagreb, at the Department of Psychological Medicine. A therapeutic approach was used to analyze the patient’s data. Review of the literature in the field of art therapy in psycho-oncology was done, with a particular focus on the approach to patients with breast cancer. Results: Studies have found that breast cancer diagnosis has a large impact on the emotional, cognitive and social functioning of women. It is important to develop strategies to strengthen coping mechanisms in women with breast cancer and help them express often-repressed emotions. The main point of supportive-expressive therapy includes mourning the losses that cancer brings and adapting to a changed body image. Expression in art gives emotions a form and a color instead of just the physical or psychological symptoms. Conclusion: The literature and this case show that art therapy has a lasting effect on a large spectrum of symptoms related to breast cancer and its consequences as well as on self-knowledge and self-realization of the patient. Therefore, art therapy can be used as a highly effective approach to provide breast cancer patients with better quality of life and psychological support while giving them freedom to express themselves and add meaning to their days. / Art terapija dobiva sve veće značenje u psihoonkologiji. Cilj ovog rada je opisati iskustvo pacijentice na kojoj se provodila art terapija te napraviti pregled literature o učinkovitosti art terapije u pacijentica s karcinomom dojke. Metode: Pacijentica koja se liječila od raka dojke liječena je i kod psihijatra u Klinici za psihološku medicine Kliničkog bolničkog centra Zagreb. Analizirani su prikupljeni podatci o pacijentici prije, tijekom i nakon terapije. Napravljen je pregled literature u području psihoonkologije s posebnim naglaskom na primjenu art terapije kod onkoloških bolesnika. Rezultati: Istraživanja su pokazala kako rak dojke značajno utječe na emocionalno, kognitivno i socijalno funkcioniranje žena. Također rezultati pokazuju kako je važno poticati mehanizme obrane kod pacijentica koje boluju od karcinoma kako bi uspjele pokazati osjećaje koji su potisnuti. Glavni ciljevi ove suportivno-ekspresivne terapije su proraditi žalovanje za gubitcima koje donosi teška bolest kao i prilagodba na promijenjenu sliku tijela. Ekspresija u umjetnosti daje simptomima formu I boju te se oni više ne moraju konvertirati u fizičke ili psihološke tegobe. Zaključak: Literaturni podatci i analiza slučaja pokazali su kako art terapija ima dugodjelujući učinak na veliki spektar simptoma vezanima uz rak dojke i njegove posljedice. Također, uočen je pozitivan utjecaj na samospoznaju i samoaktualizaciju pacijenata. Zbog toga se art terapiju može koristiti kao visoko učinkovit pristup u pružanju psihološke pomoći pacijenticama oboljelima od raka dojke, koji omogućava ekspresiju emocija i bolju kvalitetu života. PROFESSIONAL PAPER / STRUČNI RAD Soc. psihijat. | 45 (2017) | 262-269 ADDRESS FOR CORRESPONDENCE: KEY WORDS / KLJUČNE RIJEČI: Marijana Braš, MD Art therapy / Art terapija University Department of Psychological Breast cancer / Rak dojke Medicine, Psycho-oncology / Psihoonkologija Clinical Hospital Centre Zagreb, Psychotherapy / Psihoterapija Kišpatićeva 12 10 000 Zagreb, Croatia Tel: +38 59 8223 323; Fax: +38 5 1233 5818 E-mail: marijana.bras@kbc-zagreb.hr INTRODUCTION ART THERAPY Over the past few decades, art therapy in The therapeutic use of art within the context psycho–oncology has been gaining increas- of a professional relationship with patients ing importance (1). Health care professionals who have experienced disease, trauma or are continuously exploring new creative ap- difficulties in their life is called art therapy proaches for providing psychological help to (4). Creation of art can assist a person in com- cancer patients and survivors. A person diag- municating their emotional or psychological nosed with a malignant disease often develops problems through the use of imagery (5). In overwhelming feelings that are challenging to cancer patients, from the perspective of a express by usual means. A cancer diagnosis holistic approach, creative expression has and treatment entail profound changes in peo- the potential to address the mental, social, ple’s lives that require significant adjustment physical and spiritual issues regarding their and extensive coping skills (2). The diagnosis current state. Addressing their concerns can of cancer can generate great fear of pain, of help decrease psychological stress and have dying, of economic and social changes and a positive impact on the immune system and dependence (3). Burdened with the reality of overall functioning of the body (1,2). Studies a shortened or painfully altered life, patients have shown that approximately more than have the need to channel emotions into nu- one–third of cancer inpatients and a quar- merous forms of expression. For patients, art ter of outpatients suffer from psychological therapy allow them to express what is deep comorbidity (6). Art therapy helps patients inside them, emotions that cannot be com- with a malignant disease express experienc- municated with words alone, while alleviating es that are hard or impossible to put into their symptoms and giving them psychological words and is suitable for patients with var- support. This paper describes and discusses ious diagnoses, ages and levels of education effects of art therapy in patients undergoing (1,7,8,9). Review of the literature showed the art therapy during breast cancer treatment, significant effect of this type of psychothera- through review of literature as well as a case py, despite the heterogeneity in samples and report and analysis. study designs (1,10,11,12,13,14,15,16). Several studies confirmed how art therapy helps cancer patients by reinforcing positive coping L. Milutinović, M. Braš, V. Đorđević: Art Therapy as Supportive-Expressive Therapy in Breast Cancer Treatment. Soc. psihijat. Vol. 45 (2017) Br. 4, str. 262-269. 263 264 behavior while increasing the sense of con- After surgery, chemotherapy, radiotherapy trol (17,18,19). Surveys carried out by an in- and hormone treatments, women with breast terdisciplinary research team demonstrated cancer describe extensive changes to their statistically significant reductions in cancer bodies, such as wounds, pains, body hair loss, symptoms with a lower score in depression, extreme fatigue, nausea and vomiting, lack of anxiety, somatic and general symptoms for appetite, lymphedema, adverse effects on the the therapy group compared to the control radiated skin, postmenopausal symptoms and group (20). Differences were also observed weight problems (1,32). Numerous side effects in increased efficiency in communication can make a woman feel alienated from her and relationships, processing of traumatic body (29,33). Multiple cross–sectional studies experiences and reduction of negative ef- have found that women with breast cancer re- fects of disease and treatment (12,14,15,20). port fatigue, pain, tiredness, depression, anx- Studies have also shown that psychological iety and a failing self–esteem (34,35). Women support and art therapy have a positive im- with breast cancer reported significantly more pact on the outcome of the cancer treatment insomnia, appetite loss, and diarrhea with sig- (21,22,23,24). An increase in self–esteem and nificantly lower scores related to emotional, cohesion, strengthening self–identity and sig- cognitive and social functioning compared nificant improvement in global health, was- with the general population (36). The scores found (12, 25). were measured at the time of the diagnosis Art therapy also helps patients’ families and caregivers by reducing stress and decreasing anxiety (26,27). Furthermore, through artistic expression, healthcare professionals can be educated to better understand the participants’ emotional experiences. and one year after the operation. Nearly half of women with early breast cancer have depression, anxiety or both depressive and anxious symptoms during the first year after diagnosis (24). Women with breast cancer often report feelings of fear as well as loneliness. They describe that other people do not know how to com- BREAST CANCER SYMPTOMS municate with them and share their concerns. A standard issue is worrying about the people Breast cancer diagnosis has a great impact on the overall health and functioning of women (28). Associated with visible feminine aspects of the body, breast cancer represents the threat of disfigurement, disability, fear of loss of intimacy and love and reduced self–esteem (29). The medicalized breast is decontextualized from the whole of the bodies and lives of women and from their personal and cultural around them being too emotionally involved. Constant efforts to spare other people’s feelings can cause isolation in women with breast cancer (1,37,38). Repressed emotions have a huge role in dealing with cancer treatment, so it is important to develop strategies to strengthen coping resources in women with breast cancer and help them express often– repressed emotions (39,40). meanings (30). The cultural discourse of breast cancer may lead to feelings of stigma, marginalization and disempowerment. The loss or alteration of a breast poses a threat to a wom- BREAST CANCER AND ART THERAPY en’s perception of self and feminine identity, Art therapy has been found to help confront especially aspects like sexuality and mother- experiences of loss, physical changes, social hood (31). relations affecting and existential questions L. Milutinović, M. Braš, V. Đorđević: Art Therapy as Supportive-Expressive Therapy in Breast Cancer Treatment. Soc. psihijat. Vol. 45 (2017) Br. 4, str. 262-269. in women with breast cancer (16,41,42). A symptoms, stress and trauma and improve randomized controlled study, as well as other cognition (46). The art object in art therapy studies, showed a significant increase in total helps the patient to hold onto a sense of self health, physical and psychological states and while at the same time working with potential- improved quality of life during art therapy in ly distressing feelings. The objects represent a women undergoing cancer treatment (1). Stud- form of communication between the therapist ies demonstrated a significant positive differ- and the patient, creating a language for the ence within the art therapy group concerning unconscious and unknown to become con- future perspectives, body image and systemic scious and to mobilize deepening self–aware- therapy adverse effects as well as decreased ness and therapeutic change. Cognitive ana- levels of stress and improved self–esteem lytic therapy supports change through various and overall health (1,25,43). Additionally, art processes. However, a central route is through therapy has an effect on overcoming feelings ”knowing“. Art therapy also creates change of hopelessness and gaining control over the in different ways, but the primary way is by situation (25). Improvement in relationships, ”working through“, i.e. the emotional process- specifically in communication with family and ing of past events which allows further devel- friends after taking part in art therapy, has opment (5). The therapy process stimulates been demonstrated (13). Art therapy could of- the neurons in various ways. First, during the fer an opportunity for women with cancer to movement of the body in the process of paint- describe their experiences and give these in- ing, which physically expresses emotions that terpretations acceptance and legitimacy. That are reaffirmed in the reflection on a product or may translate into a greater sense of control in image, and in the relation between patient and the new life situation (44). therapist (35). The process is a psycho–educational and psychodynamic, helping ego and unconscious material to be integrated. It takes PROCESS OF ART THERAPY action and reflection in art therapy to promote The fundamental belief on which the use of in the current situation (5,35). Furthermore, art therapy is based on is that the creative pro- understanding the vulnerability of oncology cess in the creation of art is life–improving and patients and being able to address their needs healing and that it relieves symptoms associ- is essential for any therapeutic intervention ated with cancer (41). Art creation has been to be successful. Thus, it is important for the said to facilitate expression of an individual’s art therapist to help patients overcome their deepest emotions (11). Art therapy is regarded apprehension and to feel comfortable. When as psychotherapy that can be used for pro- the patient’s goals are the guiding factor in the cessing the emotional trauma and stress (45). art therapy session, the art therapist needs to It can help patients recover hope and develop be vigilant to notice if and when these inten- goals and discover that they want to have a tions change. Repressed emotions, especially fulfilled life despite the diagnosis (37). The fo- anger, appear to be one of the risk factors for cus of supportive–expressive therapy includes cancer (47). It may be that this population of mourning the losses that cancer brings and patients is more inclined to avoid self-expres- adapting to a changed body image (35). Cre- sion than other groups. Often, underlying feel- ation of art and reflecting on the process and ings triggered by the process of art making can outcome can enhance patients’ awareness cause a shift in the focus of the session. What of self and others, induce better coping with starts out as a distraction from problems re- the participant’s process of self-understanding L. Milutinović, M. Braš, V. Đorđević: Art Therapy as Supportive-Expressive Therapy in Breast Cancer Treatment. Soc. psihijat. Vol. 45 (2017) Br. 4, str. 262-269. 265 266 lated to cancer can become an outlet for more day, and by the end of treatment, she painted profound emotions. In this situation, the art about 200 pictures. After the treatment, she therapist’s experience and knowledge of ther- had written diaries in which she described apeutic techniques and understanding of met- the psychological states that she was in dur- aphor allow the patient to process the complex ing past events and emotions she was expe- issues that emerge (8). Regression analysis riencing before, after and during the painting suggested that creative expressions give the process. During treatment, she sought a psy- somatic symptoms a form and a color instead chiatrist, was in a psychiatric day hospital of just the physical or psychological symptoms and participated in support groups for women (48). In art therapy, the picture lasts. It can be suffering from breast cancer. After the end of focused and felt and be seen and touched as treatment and with the help of a psychiatrist, well as moved (49). The picture is there in rela- she published an exhibition of the pictures and tion to feelings and thoughts, even afterwards, their analyses and records from the diaries af- like a transitional phenomenon (50). In the art ter the process of therapy. therapy sessions, the painter can always look at their own expression in forms, figures, lines and colors to recognize different emotions and thoughts from time to time and to identify emotional or cognitive alterations on the paper. It is believed that the mirror neurons provide intersubjective consciousness that aims to internalize the therapeutic relationship to give the patient a new pattern to relate to oneself or the picture and others, such as the therapist (35,51). The process promotes the patient’s understanding of self and the current situation (52). Using art expression significantly contributed to psychotherapy and facilitated the cancer therapy of the patient. The patient began to paint because she wanted her own space and a safe place, a place in which she felt free. She felt like a frightened child, and painting helped her to feel secure, like being in a mother’s womb again. When asked about the pictures, the patient stated that they were made spontaneously and without advance planning, and the through them, she learned about herself. She believed that she had repressed emotions for a large part of her life and that painting helped her come in contact with them, recog- CASE ANALYSIS nize them and express them. After diagnosis, she described feelings of being trapped in her In this article, we share the remarkable sto- body, horror, despair, loneliness, irreconcil- ry of the patient M.S., who participated in art ability of diagnosing and denial, exhausting therapy during and after her illness as a form fear, paralyzing thoughts and an inability of expressing herself and a coping mecha- of normal functioning, all of which she was nism for severe mental and emotional dis- unable to express and communicate to oth- tress. Although she painted and wrote poems er people. She believed that she was not able and novels her whole life, the disease inspired to cope with negative emotions before the art her creative forces in an entirely new way. therapy, that she only suppressed and rejected Learning about her experience influenced and them and that the painting helped her to free encouraged all the members of our medical them through creative work, writing and con- team, including doctors, students and other versation with a therapist and other people. patients. The painting was started after she re- During the process of art therapy, she became ceived the diagnosis of malignant disease. She capable of talking about the problems that she painted daily, sometimes even five paintings a had with herself, the disease, treatment and L. Milutinović, M. Braš, V. Đorđević: Art Therapy as Supportive-Expressive Therapy in Breast Cancer Treatment. Soc. psihijat. Vol. 45 (2017) Br. 4, str. 262-269. outcome of cancer. With the help of a thera- found relaxation, solace, calm, catharsis and pist, she recognized the fear of rejection and healing in the process of painting, as well as also came back into contact with the trauma strength to fight a disease and continue with of abuse suffered in early childhood, as well as an extremely severe cancer therapy. We also the trauma with her ex-husband. looked at the effect of art therapy on relieving The paintings restored balance in her life, provided psychological and emotional support and reduced her poor moods, and she began to notice more positive things in life and focus more on introspection. After diagnosis, when she felt like she was losing control of her life and mental condition, painting gave her back a sense of control, hope and desire to live. She accepted the transience of life and the inevitability of death, while valuing life more. She stated that her psychic structure had changed, and had, with apparent growth and development, become more tolerant, wiser, compassionate and altruistic. Of somatic symptoms, she had nausea, vomiting, pain in the arm on the side where the operation has been and headaches. She painted when she was in pain, and after painting the pain was eased in the hand and shoulder and as well as in the head. After the treatment, she continued to paint and says that she now paints pictures that are completely different from those she painted then. When looking at the old pictures, she recalls the emotions of that time that are now gone. The patient would recommend this kind of treatment and psychiatric help to all patients who undergo a similar experience. symptoms of cancer and side effects of cancer treatment, such as pain in the right arm after breast surgery, fatigue, nausea, headache, depression and anxiety. The patients reported that the art therapy increased the will to live, the desire for healing and effectiveness in communication in relationships and social functioning. Furthermore, art therapy increased the motivation of the patient to engage inpainful and intimate content and explore unconscious conflicts, as well as the will to use that material in the therapeutic process with the therapist. During the process of art therapy, our patient was inspired to talk openly about her problems, including the trauma in her childhood and trauma with her ex-husband. Restoration of positive defense mechanisms can increase self-confidence and sense of control and expression of repressed emotions and conflicts without using words. Through her art, she found the way to see herself, her history, physical and mental health and disease in a liberating and different way. She got in touch with her emotions and traumas and overcame them, which helped her with mental and physical healing and emotional stability. This facilitating potential of art therapy can be advantageous for those whose difficulties are emotionally dissociated CONCLUSION or repressed for whatever reason (5). The un- Studies found that cancer patients expressed es in a way that it does less readily through difficulty in coping and adapting to the dis- words. The layers of possible meanings found ease (35). Art therapy significantly improved in artwork can assist elaboration of a sense patients coping strategies. One of the purpos- of self. Patients also advanced significantly in es of art therapy is to make, through allevia- personal growth, self-expression, self-actual- tion of symptoms, pain, sorrow and suffering ization and communication with the therapist more bearable. Art therapy can be a vehicle for as well as with family members and friends. the expression of the pre-verbal and non-ver- Artworks helped with the development of a bal impression (5). Our patient, in her words, reflective self, non-verbal communication conscious achieves expression through imag- L. Milutinović, M. Braš, V. Đorđević: Art Therapy as Supportive-Expressive Therapy in Breast Cancer Treatment. Soc. psihijat. Vol. 45 (2017) Br. 4, str. 262-269. 267 268 and increased sense of self. Art also assisted The literature and this case show that art ther- patients in learning how to be more open and apy has a lasting effect on a large spectrum of how to see things in different ways. symptoms related to breast cancer and its consequences as well as on self-knowledge and ”Painting made me feel like I am still self-realization of the patient, while improv- able to create something great, that I’m ing the overall quality of life. Furthermore, art not just a person with cancer. During creation encourages vision, hope and imagina- the process of painting I felt safe and tion, all of which nurture the healing process secure as if I was a child in my mother’s (4). Therefore, art therapy can be used as a womb again. I wasn’t thinking about highly effective approach to give our patients the disease. The disease was becom- the best quality of life, give psychological sup- ing smaller and smaller as my feeling port while giving them freedom to express of self-worth grew bigger and stronger.“ themselves and add meaning to their days. REFERENCES 1. Svensk AC, Öster I, Thyme KE. Art therapy improves experienced quality of life among women undergoing treatment for breast cancer: a randomized controlled study. Eur J Cancer Care 2009; 18: 69-77. 2. Geue K, Richter R, Buttstadt M. An art therapy intervention for cancer patients in the ambulant aftercare � results from a non-randomised controlled study. Eur J Can Care 2013; 22: 345-52. 3. 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