Arts & Health

An International Journal for Research, Policy and Practice

ISSN: 1753-3015 (Print) 1753-3023 (Online) Journal homepage: https://www.tandfonline.com/loi/rahe20

An art therapy group intervention for cancer

patients to counter distress before chemotherapy

Rossana L. De Feudis, Giusi Graziano, Tiziana Lanciano, Manuela Garofoli,

Andrea Lisi & Nicola Marzano

To cite this article: Rossana L. De Feudis, Giusi Graziano, Tiziana Lanciano, Manuela Garofoli,
Andrea Lisi & Nicola Marzano (2019): An art therapy group intervention for cancer patients to
counter distress before chemotherapy, Arts & Health, DOI: 10.1080/17533015.2019.1608566

To link to this article: https://doi.org/10.1080/17533015.2019.1608566

Published online: 02 May 2019.

Submit your article to this journal

Article views: 51

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=rahe20
ARTS & HEALTH
https://doi.org/10.1080/17533015.2019.1608566

An art therapy group intervention for cancer patients to

counter distress before chemotherapy
Rossana L. De Feudis a, Giusi Grazianob, Tiziana Lanciano c
, Manuela Garofolia,
Andrea Lisid and Nicola Marzanoa
a
Departmental Unit of Medical Oncology, ‘San Paolo’ Hospital, ASL BA, Bari, Italy; bScientific Direction,
‘Giovanni Paolo II’ Cancer Institute IRCSS, Bari, Italy; cDepartment of Education, Psychology,
Communication, ‘Aldo Moro’ University of Bari, Bari, Italy; dPsychological Services, ‘Giovanni Paolo II’
Cancer Institute IRCSS, Bari, Italy

ABSTRACT ARTICLE HISTORY

Background: The aim of this study was to investigate the feasi- Received 16 February 2018
bility and effectiveness of a single group session based on art Accepted 27 March 2019
therapy (AT) for adult cancer patients to reduce anxiety and dis- KEYWORDS
tress before anticancer treatment. Cancer patients; art therapy;
Methods: A non-randomized pre-post study design was adopted. anxiety; psychosomatic
Sixty-two patients took part in one of twenty-seven “one-off” distress symptoms;
sessions held over a four-month period. Sixty-six patients, who chemotherapy
simply received routine medical treatment, served as the control
group (CG).
Results: The intervention was appropriate to patients’ needs and
feasible in the context of their routine medical care. In contrast to
the CG, the intervention group(IG) participants demonstrated
a decrease in symptoms of anxiety, drowsiness and tiredness.
Conclusions: The intervention proved suitable to the medical
routine of patients’ care. The clinical implications of the AT proto-
col and future research aimed at testing it vs. a different type of
psychosocial intervention in a randomized controlled study are
discussed.

Introduction
Receiving a cancer diagnosis is a highly distressing, traumatic event. Many studies have
reported how anxiety and psychosomatic symptoms of distress negatively affect
patients’ view of, and reactions to, treatments (Grassi et al., 2013; Henselmans et al.,
2010; Holland, 2013). It has also been documented how psychological support may
reduce anxiety, foster effective coping strategies, decrease depression and improve
quality of life (Daniels & Kissane, 2008; Faller et al., 2013; Jacobsen & Jim, 2008).
However, there are some limitations to implementing routine, psychological interven-
tions within a medical oncology unit. Many limitations are due to the stigmatizing beliefs
and concerns about psychological help (Costantini et al., 2015; Holland, Kelly, & Weinberger,
2010) others are due to the difficulty of integrating the requirements of a psychological

CONTACT Rossana L. De Feudis r.defeudis@eidesis.net; r.defeudis@outlook.it

This manuscript reports original data. Portions of the data were presented in poster format at the National Conference of
SIPO (Italian Society of Psycho-Oncology), in Turin (Italy), in November 2015.
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 R. L. DE FEUDIS ET AL.

setting and practice with medical and nursing daily routine (Holland, 2013; Jacobsen & Jim,
2008; Schofield, Carey, Bonevski, & Sanson-Fisher, 2006). Still, another significant impedi-
ment lies in the difficulty of verbally processing the emotional reaction due to the traumatic
impact of cancer. As van der Kolk (1994) affirms, the emotional reaction to trauma is mostly
non-verbal and it is primarily manifested through visual and bodily sensations. As a result,
many patients put aside their emotional distress, which may turn into some kind of bodily
symptoms, especially during their involvement in cancer treatment. One of the most
distressing phases, along the trajectory of cancer, is undergoing chemotherapy (CHT). In
fact, several patients report an increase of anxiety and somatic complaints before accessing
their CHT session, which, in turn, may influence treatment outcome (Aranda et al., 2012; Liu
et al., 2012; Waller, Forshaw, Bryant, & Mair, 2014). There is, therefore, an evident demand for
the development of effective, psychosocial interventions that can be implemented on site,
during patient stays, and that can benefit a broad range of people, overcoming the
aforementioned limitations. A few studies have explored the usefulness of a single session
of AT with cancer patients (Grulke, Bailer, Stahle, & Kachele, 2006; Luzzatto, Sereno, & Capps,
2003; Nainis et al., 2006) reporting distress amelioration. Although the evidence that art
programs on hospital units with more than 5 days average lengths of stay are beneficial
(Sonke et al., 2015), there are gaps in research regarding the effectiveness of such programs
in out-patients units, where length of stay is very short (i.e., a few hours).
Following the above considerations, the present study intended to investigate if a brief
psychosocial intervention, based on a creative, metaphoric approach, such as AT, could
benefit adult patients in counteracting the stress of accessing their treatment session.

Theoretical framework
AT is a form of non-verbal, metaphoric communication that can help patients express
and process thoughts and emotions otherwise difficult to put into words.
Medical AT grew in part from the belief that art expression taps the unspoken and in
part from the clinical work of art therapists with a variety of patient populations in medical
settings (Malchiodi, 2013). It has been defined as the clinical application of art expression
and imagery with individuals who are physically ill (Liebmann & Weston, 2015), are
experiencing bodily trauma or undergoing invasive or aggressive medical procedures,
such as surgery or CHT (Bar-Sela, Atid, Danos, Gabay, & Epelbaum, 2007; Forzoni, Perez,
Martignetti, & Crispino, 2010). As such, AT is considered a form of complementary and
alternative medicine (CAM) (Malchiodi, 2013). In fact, images are a bridge between body
and mind, their meaning deriving from personal history and experience, as well as from
the specific setting in which they emerge (Hass-Cohen, 2008).
The two overviews in this field (Geue et al., 2010; Wood, Molassiotis, & Payne, 2011)
attest the benefits of AT with cancer patients, regardless of heterogeneity in samples
and settings. However, the high variance in study designs makes comparison difficult.
A few randomized controlled studies (RCSs) (Bar-Sela et al., 2007; Joly et al., 2016; Öster
et al., 2006; Svensk et al., 2009) deal primarily with women with breast cancer. Reduction
of anxiety and mood improvement, lessening of stress, enhancement of self-esteem,
better coping and quality of life are reported in both individual (Nainis et al., 2006; Öster
et al., 2006; Svensk et al., 2009) and group formats (Joly et al., 2016; Luzzatto & Gabriel,
2000; Monti et al., 2006).
 ARTS & HEALTH 3

Overall, the literature review points to the effectiveness of AT programs with cancer
patients. Yet, it also highlights a need for systematic studies and a research gap regarding
the benefits of such programs during patients’ short stay for medical treatments.
Following these considerations and the theoretical framework exposed, a program
based on a single AT group session was implemented to help cancer outpatients
counter the stress of accessing their CHT session. Given the specific population and
the limited time available, an RCS was deemed unfeasible. Therefore, a non-randomized
comparative design was adopted in order to examine the intervention feasibility during
medical routine, in a short time span, and its effectiveness in ameliorating patients’
anxiety and psychosomatic distress.

Art therapy-based group intervention

The AT session lasted an average of 90 min and was held inside the Medical Oncology
Out-Patient Unit of “San Paolo” Hospital of Bari1 (hereafter: Unit). A pre-arranged room
for AT was equipped with a table for maximum of eight people, watercolours, pastels
and pencils, drawing paper, canvas, paint brushes, soft background music. The session
was carefully structured in order to suit the medical organization of the Unit. In fact, the
time-span was consistent with the amount of waiting time between patient admissions
to the Unit and the beginning of their medical routine. Physicians and nurses were
involved in the careful planning of the project, in order to avoid interference with
medical procedures, therefore protecting them from potential distractions. They were
informed about participants, so that they could retrieve the patient, if needed for some
medical procedure.
The first author, a psychotherapist with expertise in AT2 and psycho-oncologist team
member of the Unit, conducted all sessions, held twice a week, over a four-month
period. Patients were mixed in gender, age and cancer diagnosis, their number varying
from four to eight. At the start of each session a brief introduction was given, clarifying
that drawing ability was irrelevant to the experience; in fact, participants were encour-
aged to follow their own spontaneity and imagination in the art expression. Patients’
metaphoric communication through images and sharing of meaning among group
members were privileged, rather than artwork psychological interpretation.
The AT intervention focused on three main aspects: (1) the production of sponta-
neous artwork; (2) the eliciting of individual self-reflections connected to the artwork; (3)
a shared meaning-making within the group.
The AT group session is atypical of general AT practice, given its “one-off” nature that
precluded building up a therapeutic relationship over time. In fact, the different treat-
ment schedules and residential distances of the patients from the Unit prevented an
ongoing group therapy with the same participants. The sessions were carefully struc-
tured in terms of providing a therapeutic experience of completeness, so that partici-
pants would leave with no sense of discomfort for unfinished business. The
psychotherapist worked on several levels: using personal resonance and metaphoric
communication to shape the therapeutic feedback while integrating the individual,
creative artwork into the group meaning-making process.
Confidentiality and clear definition of the IG boundaries within the Unit served the
purpose of facilitating intimacy among participants. The thematic analysis of the patients’
4 R. L. DE FEUDIS ET AL.

artworks and narratives, as well as the in-depth account of the group process, are beyond
the purpose of this manuscript and will be the topic of another paper.
Both IG and CG individuals, who revealed clear psychological symptoms or who made
a specific request, were further given the opportunity of a personalized, psychological
support, at the end of the session.

Aims and hypotheses

The aim of this study was to evaluate the feasibility and effectiveness of an AT intervention for
cancer patients in the oncology unit, during medical routine. Individuals who participated in
one of twenty-seven “one-off” AT sessions (besides receiving routine medical treatment) vs.
individuals who received routine medical treatment alone were compared. According to the
findings of the aforementioned literature, the following hypotheses were made:

Hypothesis 1. The intervention will be acceptable to patients and feasible in the context
of their routine medical care.

Hypothesis 2. Compared to the CG, IG participants will demonstrate greater reductions

in symptoms of anxiety and psychosomatic distress, at post-intervention.

Methods
Design
A non-randomized pre-post study design was adopted. The intervention was implemen-
ted in the Unit. It consisted in 27 “one-off” sessions, held biweekly from February to
May 2015. Each participant only took part in a single session. There were two points of
measurement: participants received questionnaires before starting the intervention (pre)
and upon completing it (post). Patients waiting for their medical treatment on different
days of the week served as CG.

Participants
Among all consecutive cases at the Unit, 140 patients accepted to participate in the
study, within a four-month period. All of them were Southern Italian, resident in Puglia,
had a cancer diagnosis (or cancer recurrence) and were receiving outpatient cancer-
related procedures. Exclusion criteria were terminal state, major psychiatric disorder or
major sensorial impairment, significant cognitive deficits, insufficient education to com-
ply with testing requirements.

Measures
Anxiety and psychosomatic distress symptoms were assessed using the State-Trait
Anxiety Inventory-Form Y (STAI-Y) and the Edmonton Symptom Assessment Scale-
 ARTS & HEALTH 5

Revised (ESAS-R). Furthermore, participants in the IG answered two open-ended ques-

tions about satisfaction with the intervention.

Demographic data
Age, residency, marital status, education, employment status were collected on
a separate form. Diagnosis, disease stage and anticancer treatment were obtained
from patients’ medical chart review and physician consultation.

Anxiety
The Italian version of the STAI-Y (Spielberger, Pedrabissi, & Santinello, 2012), originally
developed by Spielberger, Gorsuch, and Lushene (1970) was used to assess anxiety. The
STAI-Y is a 40-item, self-report questionnaire, rated on a 4-point Likert-like scale (1 = not
at all, 2 = somewhat, 3 = moderately so, 4 = very much so) that differentiates “state
anxiety”, defined as a transitory emotional state, and “trait anxiety”, defined as
a relatively stable, personality trait. Internal consistencies for the State Anxiety scale
have ranged from .89 to .96. Total scores for state and trait range from 20 to 80. The
STAI-Y has shown stability, test–retest reliability, internal consistency, and has been
validated by numerous studies, including those that involved people with cancer
(Aitini et al., 2007; Eskelinen & Ollonen, 2011; Nainis et al., 2006). Within the sample of
this study, the internal consistency, measured by Cronbach’s alpha, was 0.91 for the STAI
Trait (STAI-Y T) scale and 0.94 for the STAI State (STAI-Y S) scale.

Psychosomatic distress
The revised Italian version of ESAS was used to assess patients’ symptoms of psychoso-
matic distress in the moment (i.e., “state distress”). ESAS-R was developed for use in
palliative care, but it has been validated in other populations, including people with
cancer (Chang, Hwang, & Feuerman, 2000; Moro et al., 2005), and it is feasible for pre–
post-test self-administration, in a short time span. ESAS-R measures 10 different distres-
sing symptoms on a 10-point Likert-type scale ranging from 0 to 10 where 0 = absence
of symptoms and 10 = the worst possible symptoms. Patients were asked to rate the
severity of each of the following symptoms: pain, tiredness, nausea, depression, anxiety,
drowsiness, lack of appetite, general well-being, shortness of breath, other problems.
The scale “lack of appetite” was eliminated because it was considered inappropriate in
the context of assessing pre–post-test “state distress” before patients’ chemotherapy
session.

Suitability
Satisfaction with the intervention was evaluated by asking each participant to rate, on
a four-point scale (0 = none, 1 = a little, 2 = quite enough, 3 = very much), two open-
ended questions: (1) Did the art therapy session influence your overall well-being? (2)
Did you feel comfortable in the group session?. Participants were also encouraged to
add personal remarks to explain their answers.
Integration within the Unit was evaluated in terms of:

● time – did the AT session interfere with medical and nursing patients’ care?
6 R. L. DE FEUDIS ET AL.

● burden – did the AT session add some extra strain on the staff of the Unit?
● acceptance – were the oncologists and nurses willing to support and integrate the
AT intervention with their usual practice?

Procedure
Ethical approval was obtained by the Ethical Committee of ASL BA1. For recruiting
participants, the study was introduced in person by the psychotherapist to the patients,
at the time of their admission to the Unit. Two days a week, patients were invited to the
AT session, while waiting to initiate their routine medical treatment. The CG was formed
by patients waiting for their routine treatment on different days of the week. All of them
were reassured that denial to participate would not interfere with their medical treat-
ment and possible research implications discussed. All participants were given written
information about the study and provided written, informed consent prior to taking
part. All of them were asked to complete self-administered pre-test questionnaires (STAI-
Y State and Trait, ESAS-R). The patients in the IG completed post-test questionnaires
(STAI-Y State, ESAS-R and open-ended questions) at the end of the AT session. To match
the time between pre- and post-test completion between groups, CG participants were
asked to complete the post-test questionnaires (STAI-Y State, ESAS-R) at the same time
interval as the IG participants (i.e., about 90 min from the pre-test). The patients of both
groups who did not complete their post-test questionnaires were excluded from the
study. The scoring guidelines for each instrument were followed for missing data.

Data analysis
Baseline characteristics of the IG and CG were calculated, and the results were expressed
as medians and interquartile range (IQR) for continuous and ordinal variables and as
frequencies and percentages for categorical variables. Comparisons of socio-demographic
and clinical parameters between the two groups of interest were performed with the
Mann–Whitney and the Pearson χ2 test or Fisher’s Exact test, when appropriate.
To test the effectiveness for the AT intervention, STAI-Y State and ESAS-R scores
were entered in 2 × 2 mixed design ANOVAs, with the Pre-Post as within-subjects
variable, and the Group (IG vs. CG) as between-subjects variable. The effects were
controlled for gender and factors clinically associated with cancer type and illness
severity (metastatic vs. non-metastatic cancer) (De Feudis, Lanciano, & Rinaldi, 2015).
The statistical significance was achieved at a p-value <0.05. All the analyses were
performed using the Statistical Analysis System software (release 9.4)

Results
Sample characteristics
After exclusions and incomplete data, there were 59 patients in the IG and 56 patients in
the CG (see Figure 1)
The median age at baseline of the participants in the study was 59 (IQR = 49–68)
years. Fifty-six of the patients were in the CG [Mage = 58 (IQR = 49.5–67)] and 59 were in
 ARTS & HEALTH 7

Total consecutive Total consecutive

cases for IG n=70 cases for CG n=70

Did not meet Did not meet

inclusion criteria n=8 inclusion criteria n=4

Incomplete posttest: Incomplete posttest:

- left group to attend - left group to attend
CHT session=1 CHT session n=4
- no reason given n=2 - no reason given n=6

Completed pre and Completed pre and

post tests n=59 post tests n=56

Figure 1. Diagram of the inclusion criteria for intervention and comparison groups.

the IG arm [Mage = 62 (IQR = 42–69)]. Gender distribution was inclined towards a female
component with 88 women vs. 27 men. However, they were evenly distributed in the
two groups. Cancer diagnoses varied and were distributed between the two groups as
shown in Table 1.
The two groups (IG vs. CG) were balanced in regard to age (p = .592), gender (p =
.415), residency (p = .775), education (p = .293), marital status (p = .473), employment
status (p = .108). They were also similar in terms of their clinical medical characteristics:
type of cancer (p = .470), metastasis (p = .068), having surgery (p= .669), present
treatments (p = .2187); and personality characteristics regarding anxiety: STAI-Y Trait
(p = .131).
Table 1 presents the socio-demographic and clinical characteristics for the interven-
tion and control groups. The values are expressed as frequencies (%) and median (IQR).

Intervention feasibility
The majority of participants in IG (89.83%) perceived AT as having a positive influence
on their overall well-being. Four persons (6.78%) reported only a minor effect and one
person no influence at all (1.69%). Spontaneous comments included: feeling more
relaxed (50.85%), focusing the attention on something creative and positive (27.2%),
sharing with others (10.17%). Most patients felt at ease (94.91%) during the AT experi-
ence. Three of them did not feel comfortable because they did not value themselves
skilled enough for artwork.
The intervention format was considered appropriate by the other staff members, since
neither did it interfere with the procedures of medical routine nor added strain on personnel.
8 R. L. DE FEUDIS ET AL.

Table 1. Sociodemographic and clinical characteristics.

Characteristics IG CG P-value
Number(%) or median(IQR) 59 56
Age 62(42–69) 58(49.5–67) .592
Gender .415
Male 12(20.34) 15(26.79)
Female 47(79.66) 41(73.21)
Residency .775
City of Bari 16(27.12) 12(21.43)
Province of Bari 33(55.93) 34(60.71)
Region Puglia 10(16.95) 10(17.86)
Education .293
Primary 15(25.42) 11(19.65)
Junior High 25(42.37) 18(32.14)
High school 16(27.12) 20(35.71)
University 3(5.08) 7(12.5)
Marital status .473*
Single 7(11.86) 8(12.73)
Married 50(84.75) 43(78.18)
Separated/Divorced/Widowed 2(3.39) 5(9.09)
Employment status .108*
Housewife 29(49.15) 19(33.93)
Unoccupied 1(1.69) 0(0)
Occupied 12(20.34) 21(37.50)
Retired 17(28.81) 16(28.57)
Type of cancer .470*
Respiratory trait 2(3.39) 4(7.14)
Gastrointestinal 12(20.34) 12(21.43)
Urinary and genital 3(5.08) 3(5.36)
Gynecological 6(10.17) 3(5.36)
Breast 36(61.02) 31(55.36)
Other 0(0.00) 3(5.36)
Metastasis .068
None 39(66.10) 25(44.64)
One organ 15(26.13) 23(41.07)
More than one organ 5(8.47) 8(14.29)
Previous Surgery .669
No 4(6.78) 5(8.93)
Yes 55(93.22) 51(91.07)
Previous Radiotherapy .129
No 50(84.75) 41(73.21)
Yes 9(15.25) 15(26.79)
Present Medical Treatment .2187*
Chemotherapy 43(72.88) 42(75.00)
Biological therapy 5(8.47) 2(3.57)
Hormone therapy 3(5.08) 3(5.39)
Combination therapy 8(13.56) 5(8.9)
Other 0(0.00) 4(7.14)
STAI-Y Trait 43(33–51) 36(31–45) .131
* Fisher’s Exact test.

Intervention effectiveness
Concerning the anxiety measure, as shown in Table 2, the main effect of the Pre–Post
was found to be significant with an overall reduction of the anxiety at post (p = .027)
and the two-way interaction was found to be significant (p = .021). Simple effect
analyses confirmed that the AT intervention effect occurred for participants in the IG,
not in CG: the level of anxiety significantly decreased at post only for IC group (IGPre =
 ARTS & HEALTH 9

Table 2. ANOVAs on the measures of anxiety and psychosomatic distress symptoms.

(a) (b) (a x b)
IG (n = 59) CG (n = 56) Pre-Post Group Pre-Post*Group
Pre Post Pre Post
Measures M (SD) M (SD) p M (SD) M (SD) p F (223) p F (223) p F (223) p
STAI-Y
State 44.32 37.10 .002 41.79 41.93 .951 4.96 .027 1.26 .264 5.37 .021
(12.59) (11.01) (12.54) (12.61)
ESAS
Shortness of breath 1.51 .80 .107 1.88 1.20 .134 5.01 .026 .27 .601 0 .957
(2.36) (1.75) (2.94) (2.40)
Other problems 1.42 .59 .000 1.34 .93 .071 4.5 .035 .05 .830 .52 .474
(2.57) (1.57) (2.52) (2.03)
Anxiety 3.44 1.90 .004 2.61 2.09 .346 7.41 .007 .26 .612 1.83 .177
(3.33) (2.50) (3.03) (2.66)
Wellbeing 2.46 1.61 .066 1.88 1.59 .545 2.99 .085 .86 .355 .73 .393
(2.71) (2.03) (2.73) (2.45)
Depression 2.34 1.47 .078 1.41 1.13 .569 2.77 .098 2.62 .107 .7 .403
(2.92) (2.32) (2.72) (2.60)
Pain 1.76 1.29 .308 1.79 1.52 .575 1.26 .262 .01 .908 .1 .755
(2.64) (2.32) (2.63) (2.49)
Nausea .56 0.52 .874 0.57 0.46 .692 .16 .686 .05 .821 .03 .871
(1.68) (1.56) (1.37) (.97)
Drowsiness 2.54 1.37 .033 2.20 2.68 .390 .8 .372 .67 .414 4.62 .033
(3.28) (2.30) (2.94) (3.24)
Tiredness 2.90 1.61 .011 2.75 2.88 .809 2.69 .102 1.05 .307 3.97 .047
(2.90) (2.37) (2.57) (3.04)

44.32 (SD = 12.59), IGPost = 37.1 (SD = 11.01) p = .002). The main effect of the Group was
not found to be significant.
Concerning psychosomatic distress symptoms, as shown in Table 2, the main effect of the
Pre-Post was found to be significant for the indices of shortness of breath (p = .026), other
problems (p = .035), and anxiety (p = .007), exhibiting a significant decrease at post. The two-
way interaction was found to be significant for tiredness and drowsiness measures (p = .047
and p= .033, respectively). Simple effect analyses confirmed that the AT intervention effect
occurred for participants in the IG, not in CG: the level of tiredness improved significantly at
post only for IC group (IGPre = 2.90 (SD = 2.90); IGPost = 1.61 (SD = 2.37); p = .0.11) as well as the
level of drowsiness (IGPre = 2.54 (SD = 3.28); IGPost = 1.37 (SD = 2.30); p = .033). The main effect
of the Group was not significant for any psychosomatic distress symptoms.

Discussion
The present study was aimed at examining the feasibility and the preliminary effec-
tiveness of a psychosocial brief group intervention, based on AT, for adult patients in
active anticancer treatment. Statistically significant reduction in anxiety and psycho-
somatic distress symptoms (drowsiness and fatigue) were found for the IG as com-
pared to the CG. These results present empirical support to the growing body of
literature suggesting that positive outcomes can follow from addressing patients’
distress before initiating treatment (Traeger, Greer, Fernandez-Robles, Temel, & Pirl,
2012; Waller et al., 2014).
Consistent with the primary aim of the study, the majority of participants in the IG
seemed to appreciate the experience, as their answers about satisfaction denote. A few
10 R. L. DE FEUDIS ET AL.

started to use art-making at home as a means to cope with their negative emotions. This
brief intervention was effective in managing anxiety and psychosomatic distress symp-
toms (anxiety disorders would require treatment with more lasting effects). It was
suitable for people with various diagnoses, ages and education. Furthermore, it proved
flexible enough to be incorporated on site, during patient stays, therefore addressing
a wider range of patients. The involvement of oncologists and nurses into the AT session
planning facilitated the acceptance and the integration within the Unit of this uncon-
ventional procedure, at the point that it became part of the usual patients’ care, even
after the end of the research project.
Consistent with the second hypothesis of the study, compared to CG, the IG partici-
pants demonstrated statistically significant decrease in symptoms of anxiety in the post-
test evaluation, as measured by the STAI-Y State. Our prediction of a greater reduction in
terms of anxiety in the IG group than the CG was in fact supported by the significant
two-way ANOVA interaction term.
The AT session had a significant influence on somatic complaints as well. “Tiredness”
and “Drowsiness” were the most affected symptoms by the intervention. The two groups
were balanced at baseline in terms of socio-demographic and clinical characteristics
(Table 1). The ANOVA analysis confirmed that the IG experience explains statistically
significant lessening of psychosomatic symptoms even adjusting for gender, cancer type
and illness severity (metastatic vs. non-metastatic cancer).
However, caution should be taken when inferring conclusions.
Although for logistical reasons, the adoption of convenience samples may be com-
mon in studies of AT with cancer patients (Geue, Richter, Buttstädt, Brähler, & Singer,
2013; Puetz, Morley, & Herring, 2013; Wood et al., 2011), the absence of randomization is
an important limitation that restrains from generalizing results. Another limitation is
a CG that was not involved into a different kind of psychosocial intervention.
Furthermore, a critical issue is the short time between pre- and post-measurements,
due to the need of integrating the AT program within the patients’ medical routine. Far
from being exhaustive and despite its limitations, the current study yields some immedi-
ate consequences for clinical practice and future research.
Clinical practice guidelines in cancer include early assessment and management of
emotional distress as benchmarks for quality care. An asset of this study is the accrual of
a heterogeneous sample of patients in terms of solid cancer diagnosis and severity,
medical treatment, health status, and socio-demographic variables.
Supportive group therapy has been documented as a form of psychosocial intervention
useful at addressing emotional needs and decreasing distress (Faller et al., 2013). However,
group psychotherapy can be implemented only after the end of medical treatment, since
the time schedule of CHT for each patient varies according to each individual condition and
treatment protocol, thus affecting the participation in psychotherapy.
This study tried to face the challenge of implementing an effective program in an out-
patients unit, during short stay, addressing a wide variety of cancer patients, yet
providing a therapeutic experience in a single session. Given the short time-span, art
therapy appeared as a method of choice both to access personal issues (overcoming
sociocultural and psychological barriers) and to achieve therapeutic gain through crea-
tivity and metaphoric communication. Multiple studies have demonstrated the effec-
tiveness of art therapy interventions in the context of cancer care, but few have
 ARTS & HEALTH 11

provided findings that help bridge the gap between clinical care and research the way
this study does.
In terms of research contribution, these results bear some interesting considerations
regarding the impact of AT not only on anxiety but also on somatic complaints (i.e.,
fatigue and drowsiness) in cancer patients. It is well known that symptoms of fatigue,
depression, and sleep disturbance frequently co-occur in people with cancer, leading to
speculation about common, underlying, mechanisms (Bower et al., 2011; Brown &
Kroenke, 2009; Jim et al., 2013; Liu et al., 2012; Thornton, Andersen, & Blakely, 2010).
Therefore, it is possible that fatigue and drowsiness improve when anxiety reduces. It is
interesting that similar results regarding mood and fatigue are reported by studies
inquiring into the usefulness of the creative expression of internal thoughts and emo-
tions (Bar-Sela et al., 2007; Carlson & Garland, 2005; Daykin, McClean, & Leslie Bunt, 2007;
Joly et al., 2016; Monti et al., 2006). Instead, psycho-educational interventions for cancer
patients in active medical treatment, although useful for satisfaction and knowledge, do
not seem to have a significant impact on fatigue (Aranda et al., 2012; Waller et al., 2014).
Although patients’ self-distraction and relaxation might be expected to have
a positive impact on their perception of pain, this variable was not affected by the AT
intervention. This is consistent with other studies that report a positive impact of AT on
fatigue but not as such on pain (Bar-Sela et al., 2007; Joly et al., 2016; Monti et al., 2006).
Hence, the results of this study seem to point towards the direction that
a psychological intervention focused on processing visual and bodily sensations may
help patients counteract the stress of the traumatic impact of cancer, therefore partially
relieving fatigue and drowsiness. Future research should aim at testing this hypothesis
by comparing the AT intervention format vs. a psycho-educational group or vs. other
types of CAM interventions in an RCS.
In summary, this analysis provides encouraging initial data regarding the AT inter-
vention’s potential for reducing symptoms of psychosomatic distress before routine
medical treatment. Replication of the study with different therapists delivering the
intervention would allow assessment of whether outcomes can be achieved with
different therapists. Although there are some limitations, the results support the effort
to further investigate the effectiveness of this intervention protocol. Specifically, this
study’s results spur new ideas regarding the usefulness of a more structured type of AT
program, aimed at relieving psychosomatic distress before chemotherapy. An extension
of this study would be to investigate if the reduction in anxiety and fatigue pre-
chemotherapy predicts the subsequent experience of chemotherapy. Clinicians need
to deliver research-tested interventions to help people with cancer cope effectively and
maintain their quality of life.

Notes
1. “San Paolo” Hospital is one of the main general hospitals of ASL BA (Local Healthcare
Agency), a large Community Healthcare Institution that covers the entire Province of Bari
(about 1,210,000.00 inhabitants) and that includes several general hospitals and outpatient
health-care facilities. The Medical Oncology Out-Patient Unit serves a population of adult
patients with solid cancer, coming from the entire Region of Puglia, Southern Italy. It is
12 R. L. DE FEUDIS ET AL.

equipped with a psycho-oncology service, made by a clinical psychologist and psychology

trainees.
2. In Italy, only psychologists and medical doctors can go through a psychotherapeutic train-
ing and become certified, licensed psychotherapists. In the early ’80s, during her MFT
studies in the USA, the first author had the great opportunity to take two courses with
Dr Myra Levick. Ever since, she has continued to study and practice art therapy, applying it
in various psychotherapeutic settings, including cancer patients. In other countries (i.e.,
North America) a certified, licensed art therapist would have delivered the art therapy
intervention here described.

Acknowledgments
We would like to thank the people who volunteered as participants, as well as the oncologists,
nurses, psychology trainees, support staff and the Hospital Volunteers Association (AVO-Bari) for
their collaboration to the project.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This paper was not funded.

ORCID
Rossana L. De Feudis http://orcid.org/0000-0001-8385-2900
Tiziana Lanciano http://orcid.org/0000-0001-6533-1052

References
Aitini, E., Sempreboni, A., Aleotti, P., Zamagni, D., Cavazzini, G., Barbieri, R., . . . Vivorio, B. (2007).
Anxiety levels in cancer patients and “life sound” experience. Tumori, 93, 75–77.
Aranda, S., Jefford, M., Yates, P., Gough, K., Seymour, J., Francis, P., . . . Schofield, P. (2012). Impact of
a novel nurse-led prechemotherapy education intervention (ChemoEd) on patient distress,
symptom burden, and treatment-related information and support needs: Results from
a randomized, controlled trial. Annals of Oncology, 23, 222–231.
Bar-Sela, G., Atid, L., Danos, S., Gabay, N., & Epelbaum, R. (2007). Art therapy improved depression
and influenced fatigue levels in cancer patients on chemotherapy. Psycho-Oncology, 16,
980–984.
Bower, J. E., Ganz, P. A., Irwin, M. R., Kwan, L., Breen, E. C., & Cole, S. W. (2011). Inflammation and
behavioral symptoms after breast cancer treatment: Do fatigue, depression, and sleep disturbance
share a common underlying mechanism? Journal of Clinical Oncology, 29, 3517–3522.
Brown, L. F., & Kroenke, K. (2009). Cancer-related fatigue and its associations with depression and
anxiety: A systematic review. Psychosomatics, 50, 440–447.
Carlson, L. E., & Garland, S. N. (2005). Impact of mindfulness-based stress reduction (MBSR) on
sleep, mood, stress and fatigue symptoms in cancer outpatients. International Journal of
Behavioral Medicine, 12(4), 278–285.
Chang, V. T., Hwang, S. S., & Feuerman, M. (2000). Validation of the Edmonton Symptom
Assessment Scale. Cancer, 88, 2164–2171.
 ARTS & HEALTH 13

Costantini, A., Grassi, L., Picardi, A., Brunetti, S., Caruso, R., Nanni, M. G., . . . Marchetti, P. (2015).
Awareness of cancer, satisfaction with care, emotional distress, and adjustment to illness: An
Italian multicenter study. Psycho-Oncology, 23. doi:10.1002/pon.3768
Daniels, J., & Kissane, D. W. (2008). Psychosocial interventions for cancer patients. Current Opinion
in Oncology, 20, 367–371.
Daykin, N., McClean, S., & Leslie Bunt, L. (2007). Creativity, identity and healing: Participants’accounts of
music therapy in cancer care. Health: An Interdisciplinary Journal for the Social Study of Health, Illness
and Medicine, 11(3), 349–370.
De Feudis, R., Lanciano, T., & Rinaldi, S. (2015). Coping strategies of Southern Italian women predict
distress following breast cancer surgery. Europe‘S Journal of Psychology, 11(2), 280–294.
Eskelinen, M., & Ollonen, P. (2011). Assessment of general anxiety in patients with breast disease
and breast cancer using the Spielberger STAI self evaluation test: A prospective case–Control
study in Finland. Anticancer Research, 31, 1801–1806.
Faller, H., Schuler, M., Richard, M., Heckl, U., Weis, J., & Kuffner, R. (2013). Effects of psycho-oncologic
interventions on emotional distress and quality of life in adult patients with cancer: Systematic
review and meta-analysis. Journal of Clinical Oncology, 31, 782–793.
Forzoni, S., Perez, M., Martignetti, A., & Crispino, S. (2010). Art therapy with cancer patients during
chemotherapy sessions: An analysis of the patients‘ perception of helpfulness. Palliative and
Supportive Care, 8, 41–48.
Geue, K., Goetze, H., Buttstaedt, M., Kleinert, E., Richter, D., & Singer, S. (2010). An overview of art
therapy interventions for cancer patients and the results of research. Complementary Therapies
in Medicine, 18, 160–170.
Geue, K., Richter, R., Buttstädt, M., Brähler, E., & Singer, S. (2013). An art therapy intervention for
cancer patients in the ambulant aftercare – Results from a non-randomised controlled study.
European Journal of Cancer Care, 22, 345–352.
Grassi, L., Johansen, C., Annunziata, M. A., Capovilla, E., Costantini, A., Gritti, P., . . . Bellani, M. (2013).
Italian Society of Psycho-Oncology Distress Thermometer Study Group. Screening for distress in
cancer patients: A multicenter, nationwide study in Italy. Cancer, 119, 1714–1721.
Grulke, N., Bailer, H., Stahle, S., & Kachele, H. (2006). Evaluation of an art therapy offer for oncological
patients in an acute hospital: A pilot study. Musik-, Tanz- Und Kunsttherapie, 17(1), 21–29.
Hass-Cohen, N. (2008). Partnering of art therapy and clinical neuroscience. In Hass-Cohen & R. Carr
(Eds.), Art therapy and clinical neuroscience (pp. 21-42). London and Philadelphia: Jessica Kingsley
Publishers.
Henselmans, I., Helgeson, V. S., Seltman, H., deVries, J., Sanderman, R., & Ranchor, A. V. (2010).
Identification and prediction of distress trajectories in the first year after a breast cancer
diagnosis. Psychology & Health, 29, 160–168.
Holland, J. C. (2013). Distress screening and the integration of psychosocial care into routine
oncologic care. Journal of National Comprehensive Cancer Network, 11, 687–689.
Holland, J. C., Kelly, B. J., & Weinberger, M. I. (2010). Why psychosocial care is difficult to integrate
into routine cancer care: Stigma is the elephant in the room. Journal of the National
Comprehensive Cancer Network, 8, 362–366.
Jacobsen, P. B., & Jim, H. S. (2008). Psychosocial interventions for anxiety and depression in
adult cancer patients: Achievements and challenges. CA: a Cancer Journal for Clinicians, 58,
214–230.
Jim, H. S., Jacobsen, P. B., Phillips, K. M., Wenham, R. M., Roberts, W., & Small, B. J. (2013).
Lagged relationships among sleep disturbance, fatigue, and depressed mood during
chemotherapy. Health Psychology, 32, 768–774.
Joly, F., Pasquier, D., Hanzen, C., Heutte, H., Levy, C., Le Tinier, F., . . . Allouache, D. (2016). Impact of
Art Therapy (AT) on fatigue and quality of life (QoL) during adjuvant external beam irradiation
(EBI) in breast cancer patients (pts): A randomized trial. Annals of Oncology, 27, vi497–vi521.
Liebmann, M., & Weston, S. (Eds.). (2015). Art therapy with physical conditions. London and
Philadelphia, PA: Jessica Kingsley Publishers.
14 R. L. DE FEUDIS ET AL.

Liu, L., Rissling, M., Natarajan, L., Fiorentino, L., Mills, P. J., Dimsdale, J. E., . . . Ancoli-Israel, S. (2012).
The longitudinal relationship between fatigue and sleep in breast cancer patients undergoing
chemotherapy. Sleep, 35, 237–245.
Luzzatto, P., & Gabriel, B. (2000). The creative journey: A model for short-term group art therapy
with post treatment cancer patients. Art Therapy: Journal of the American Art Therapy
Association, 17, 265–269.
Luzzatto, P., Sereno, V., & Capps, R. (2003). A communication tool for cancer patients with pain: The
art therapy technique of the body outline. Palliative and Supportive Care, 1, 135–142.
Malchiodi, C. (Eds.). (2013). Art therapy and health care. New York, NY: Guilford Press.
Monti, D. A., Peterson, C., Shakin Kunke, E. J., Hauck, W. W., Pequignot, E., Rhodes, L., &
Brainard, G. C. (2006). A randomized controlled trial of mindfulness-based art therapy (MBAT)
for women with cancer. Psycho-Oncology, 15, 363–373.
Moro, C., Brunelli, C., Miccinesi, G., Fallai, M., Morino, P., Piazza, M., . . . Ripamonti, C. (2005).
Edmonton symptom assessment scale: Italian validation in two palliative care settings.
Supportive Care in Cancer : Official Journal of the Multinational Association of Supportive Care
in Cancer, 4. doi:10.1007/s00520-005-834-3
Nainis, N., Paice, J. A., Ratner, J., Wirth, J. H., Lai, J., & Shott, S. (2006). Relieving symptoms in cancer:
Innovative use of Art Therapy. Journal of Pain and Symptom Management, 31, 162–169.
Öster, I., Svensk, A. C., Magnusson, E., Thyme, K. E., Sjõdin, M., Aström, S., & Lindh, J. (2006). Art
therapy improves coping resources: A randomized, controlled study among women with breast
cancer. Palliative and Supportive Care, 4, 57–64.
Puetz, T. W., Morley, C. A., & Herring, M. P. (2013). Effects of creative arts therapies on psychological
symptoms and quality of life in patients with cancer. JAMA Internal Medicine, 173, 960–969.
Schofield, P., Carey, M., Bonevski, B., & Sanson-Fisher, R. (2006). Barriers to the provision of
evidence-based psychosocial care in oncology. Psycho-Oncology, 15, 863–872.
Sonke, J., Pesata, V., Arce, L., Carytsas, F. P., Zemina, K., & Jokisch, C. (2015). The effects of arts-in-
medicine programming on the medical-surgical work environment. Arts & Health, 7(1), 27–41.
Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Test manual for the state trait anxiety
inventory. Palo Alto, California: Consulting Psychologists Press.
Spielberger, C. D., Pedrabissi, L., & Santinello, M. (2012). STAI state-trait anxiety inventory forma Y:
Manual. Firenze: Giunti O.S.
Svensk, A. C., Öster, I., Thyme, K. E., Magnusson, E., Sjödin, M., Eisemann, M., . . . Lindh, J. (2009). Art
therapy improves experienced quality of life among women undergoing treatment for breast
cancer: A randomized controlled study. European Journal of Cancer Care, 18, 69–77.
Thornton, L. M., Andersen, B. L., & Blakely, W. P. (2010). The pain, depression, and fatigue symptom
cluster in advanced breast cancer: Covariation with the hypothalamicpituitary-adrenal axis and
the sympathetic nervous system. Health Psychology, 29, 333–337.
Traeger, L., Greer, J. A., Fernandez-Robles, C., Temel, J. S., & Pirl, W. F. (2012). Evidence-based
treatment of anxiety in patients with cancer. Journal of Clinical Oncology, 30, 1197–1205.
van der Kolk, B. (1994). The body keeps the score: Memory and the evolving psychobiology of
post-traumatic stress. Harvard Review of Psychiatry, 1, 253–265.
Waller, A., Forshaw, K., Bryant, J., & Mair, S. (2014). Interventions for preparing patients for
chemotherapy and radiotherapy: A systematic review. Supportive Care Cancer, 22, 2297–2308.
Wood, M. J., Molassiotis, A., & Payne, S. (2011). What research evidence is there for the use of art
therapy in the management of symptoms in adults with cancer? A systematic review. Psycho-
Oncology, 20, 135–145.