Clin Rheumatol (2007) 26:1523–1525
DOI 10.1007/s10067-007-0619-9
BRIEF REPORT
Patients’ perspective: lupus in patients’ drawings
Assessing drawing as a diagnostic and therapeutic method
Katarzyna Nowicka-Sauer
Received: 19 March 2007 / Revised: 20 March 2007 / Accepted: 22 March 2007 / Published online: 20 April 2007
# Clinical Rheumatology 2007
Abstract This is the first report from a qualitative research
on lupus patients’ perspective expressed in the disease
drawings. The aim of the study was to examine the variety
of ways of illness perception and experiences among
systemic lupus erythematosus (SLE) patients. The goal
was also to assess the utility of drawing as an unconven-
tional research method as well as a therapeutic means.
Participants were 38 women with SLE. Patients attended
‘My life’ courses addressed to the lupus patients held in
2000–2002. During the psychological group sessions,
subjects were asked to draw their disease and then to
comment on their pictures. There were no time limits. The
participants were ensured that their drawing abilities had no
meaning. Despite initial hesitation, all of the patients drew
their pictures. This report presents three lupus patients’
drawings. Analysis of disease pictures reveals that they are
the priceless source of information on patients’ perspective
and make many dimensions of living with the disease
uncovered, especially psychological. This unconventional,
nonverbal method allows patient to know and realize one’s
emotions and feelings. From health professionals’ point of
view, the advantage of drawing as a research method is the
possibility of gaining much information that cannot be
gained from interview or traditional tests alone. Drawing is
a ‘good beginning’ to talk, it makes the patients open up to
share their emotions, views, and experiences. Thus, it can
be the useful therapeutic method. It can also prevent health
professionals from schematization in approach to the
patients with the same diagnosis.
K. Nowicka-Sauer (*)
Department of Family Medicine,
Medical University of Gdansk,
ul. Debinki 2,
80-211 Gdansk, Poland
e-mail: kpsauer@amg.gda.pl
Keywords Patient perspective . Professional-patients
relation . Psychology . Systemic lupus erythematosus
Introduction
No two women will have the same presentation of the
disease... (Kristin L. Wiginton)
Systemic lupus erythematosus (SLE) is a ‘special’
disease because of the variety of symptoms and differences
in its beginning and course. In describing lupus, both health
professionals and patients use the word ‘unpredictability’.
Many authors emphasize the necessity of the individual
approach to the patients’ problems, including psychological
[1, 2]. It seems vital considering the fact that many lupus
patients report anxiety, depression, anger and attribute these
symptoms to SLE [3]. Moreover, a recently published study
revealed that psychological needs of lupus patients are still
unmet [4]. These should make us focus on the ‘unphysical’
aspects of living with the disease.
Researchers indicate that disease perception influences
patients’ emotions, behavior, health care needs, and expec-
tations and causes differences in attitude, coping, and
functioning among patients with similar ‘objective’ clinical
illness picture [2]. Illness perception can be a better
predictor of future damage [5] and health status [6] than
objective factors. Many authors claim that patients’ views
are crucial when considering their attitude to the illness,
treatment, and cooperation with health professionals [1–3].
The perception of the disease is a measurable phenom-
enon. The methods most frequently used to assess illness
perception are verbal tools [3, 7, 8]. However, the
usefulness of these methods is indubitable; they may leave
some dimensions covered. Among nonverbal methods,
1524 Clin Rheumatol (2007) 26:1523–1525

Fig. 2 ‘Lupus has attacked

Pictorial Representation of Illness and Self Measure (PRISM) many parts of my body.
[2] and drawing are worth mentioning. Up to date, adult Sometimes it’s hard to bear it,
patients’ drawings analysis has not been widely described in especially during flares.... It’s
also a fear: What will
the literature [7, 9, 10, 11], although the study by Broadbent
happen next?’ (BG, 50)
et al. [7] revealed that drawings proved better predictors of
subsequent health status than medical indicators.
The lack of studies focused on lupus patients’ drawings
became the inspiration to share my experiences.

Materials and methods

Thirty-eight women with SLE attending psychological

sessions of ‘My life’ courses [12] were asked to draw their
disease with no time limits. Every woman had the same
Discussion
colors to choose. The participants were ensured that their
drawing abilities had no meaning. Patients were also asked
The comparison of lupus to hydra made by Isenberg and
to comment on their pictures.
Horsfall [13] seems to be consistent with patients’ views.
The drawings reflect the heterogeneity of clinical presenta-
tions and variety of symptoms as well as the ‘expansiveness’
Results
and ‘aggressiveness’ of the disease. They seem to express
‘known’ as well as ‘experienced’ lupus symptoms.
Figures 1, 2, and 3 are the lupus patients’ drawings that
The analysis of disease drawings from the patient’s as
seem to represent the main aspects of their living with the
well as psychologist’s point of view revealed some benefits
disease.
of using drawing as a research as well as a therapeutic
method.
First of all, drawing is an unconventional task that makes
the patients think about their disease in a different way, far
from medical view. It makes them concentrate on ‘feeling’
and ‘experiencing’ the disease. Sometimes, it is the very
first look into the mind, to realize one’s emotions and to
express them in a completely ‘free’ way, with no
judgement. Although we are used to verbalizing our
thoughts and feelings, sometimes, it can be easier to
express them in the visual way. Drawing can be especially

Fig. 3 ‘My illness is like a

monster which sometimes bites,
but it still has ‘human shape’
because I hope it will be
‘humane’ for me’ (CR, 52)

Fig. 1 ‘My illness had...still has...many faces: In the beginning I used

to cry a lot, I was young and my appearance was the most important
thing. I was angry, sad.... These teeth represent the horrible pain I used
to suffer. Now I accept my disease.... Nevertheless, sometimes these
stages come back’ (JJ, 44)
Clin Rheumatol (2007) 26:1523–1525
useful for patients with communication difficulties. It is a
good ‘beginning’ to talk about the illness that makes the
vast majority of patients open up to share.
Asking patients to express their feelings goes far towards
increased patients’ trust. The higher the level of trust, the
more successful the cooperation with health care providers,
which may result in better treatment regimen compliance
and better health status.
It seems that this method allows to discover intangible
areas and offers the possibility of assessing patients’ views
in many dimensions, e.g., disease perception, its under-
standing, intrusiveness, subjective unpredictability, and
living with it. In a short amount of time, this method gives
us more information, both about psychological and physical
disease burdens, than we can gain from conventional
methods or interview alone [11]. Drawing, together with
traditional, standardized tests, can be an important source of
priceless information on how the illness can be experienced
and felt and how it influences patients’ emotions and
behaviors [10, 11]. My observations are consistent with
Guillemin’s [10] who claims that, despite some disadvan-
tages, drawing, as a research method, is a means to gain the
insight into a patient’s world and a source of information
about many aspects of illness.
The use of drawing can also change the health
professionals’ perception of the individual patient, free
from schematic thinking or ‘frames’. The openness in
health care providers can prevent schematization in think-
ing about patients with the same diagnosis.
Finally, the patients’ drawings are used by the author in
medical students’ education—patients’ views expressed in
the drawings are incredibly tangible. Students’ reactions
after the presentation of patients’ pictures suggest that they
are really moved. I argue that conventional method, like
book or teacher’s description of lupus symptoms, are not
followed by such reactions.
In the light of this article, the sentence cited in the
beginning [1] seems to have two different meanings. First,
it reflects the variety of symptoms and clinical pictures of
SLE. Second, in more general context, it can also express the
fact that every patient has his/her own illness perception and
can ‘feel’ and ‘experience’ it in his/her own specific way.
Recently published studies revealed that lupus patients
did not feel understood by their physician [14]. If disease
1525
drawing could be helpful in changing this view and in
improvement of understanding of patients’ psychological
status, it is definitely worth using.
Acknowledgment I am grateful to all the lupus patients attending
our lupus course meetings. Their experiences and views are the source
of priceless knowledge.
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