Continuing Education Activity

Creative art therapy is a complementary therapy used to assist patients with serious illness to ameliorate symptom burden and adapt to the stressful life experiences associated with a life-limiting diagnosis. This activity reviews the definition of art therapy as defined by the American Art Therapy Association (AATA) and highlights personnel qualifications, techniques utilized, and application in palliative care patients.

Objectives:

• Review the definition of palliative care and art therapy.
• Describe the techniques and personnel needed for creative art therapy in palliative care.
• Summarize the clinical significance of art therapy in palliative care patients, including cancer sufferers, chronic heart failure, HIV/AIDs, dementia, and end-stage renal disease patients.
• Outline the importance of the an interprofessional approach involved in the care of a palliative care patient and the importance of integrating alternative therapies such as creative art therapy to improve patient outcomes for patients with serious illness.

Introduction

Palliative care medicine is the interprofessional subspecialty focused on relieving suffering and improving the quality of life in patients with serious illness as well as their families. Beyond the aspects of physical illness, palliative care -as defined by the World Health Organization- strives to implement “means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”[1] Due to the intense emotional and existential nature of a life-limiting illness, patients are increasingly turning to alternative and complementary therapeutic modalities to cope and find relief. Art therapy is a clinical intervention that utilizes the expressive qualities of art-making to improve physical, mental, and emotional well-being.[2]

As defined by the American Art Therapy Association (AATA) in About Art Therapy (2018), art therapy, as facilitated by a professional art therapist, is a therapeutic modality used over ongoing sessions to “improve cognitive and sensorimotor functions, foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills, reduce and resolve conflicts and distress and advance societal and ecological change.”[3] Creative art therapy has been used to assist patients and families in increasing self-awareness, ameliorating symptom burden, and adapting to the stressful life experiences associated with a terminal illness.[4] When curative therapies are no longer viable in the terminally-ill patient, alternative remedies such as creative art interventions that can improve quality of life are invariably relevant in medical domains that focus on patient’s comfort such as palliative and hospice care.[5]

Personnel

As required by the America Art Therapy Association (AATA), art therapists must obtain the minimum of a master's degree to satisfy entry-level qualifications. Advanced graduate studies include establishing foundations in psychology and creative arts. Certified personnel must also complete a rigorous hourly requirement of supervised practicum and clinical internship. After having met the educational requirements, board certification and licensing (depending on the state of practice) can be obtained through the Art Therapy Credentials Board.

Technique or Treatment

Standardized applications of art therapy in palliative care patients are not specific, and techniques are customizable to the ever-changing life of the patient.[6] Various settings- inpatient versus outpatient, individualized versus group therapy sessions- and different art therapy modalities -working with visual arts materials, drama therapy, dance/movement therapy, and music therapy -have been investigated. The use of different artistic media as a therapeutic tool offers patients an outlet for coping with physical, existential, emotional, and spiritual conflicts associated with their serious illness.[7]

Clinical Significance

Art and health have been a focus of human interest from the beginning of recorded history.[8] However, the effectiveness of art therapy in improving healing and quality of life moved to the forefront in the early 1990s. In 1992, Art that Heals represented one of the earliest movements involving creative arts as a complementary therapy in oncology patients. Breslow described a positive response to a comprehensive creative art initiative meant to reduce stress and facilitate coping in hospitalized cancer patients at UCLA Medical Center/Cancer Center.[9] At the turn of the century, the America Art Therapy Association (AATA) issued a mission statement proposing the organization’s pledge to advancing research in the field. Two decades later, an expansive body of research looking at the influence of art therapy in improving symptoms associated with severe illness and improving the quality of life exists. Researchers have studied several patient populations that commonly benefit in the realm of palliative care, including people living with cancer, chronic heart failure, HIV/AIDs, and dementia patients, and results are encouraging.

Cancer

Cancer patients invariably seek complementary therapies as adjuncts to their oncologic treatments. The average cancer patient reports up to a dozen symptoms, including fatigue, pain, anorexia, cachexia, dyspnea, and anxiety.[10] In this population, there exists ample evidence suggesting a benefit of art therapy in improving symptoms and enhancing well-being. Furthermore, other literature supports the benefit of art therapy for cancer patients at different stages of their illness, including post-treatment cancer patients, those in isolation after bone marrow transplant, and those undergoing radiation therapy.[11] One small observational study found an overwhelming reduction in global distress and “reduced pain, anxiety, ill-being, tiredness, sadness, and depression,” utilizing a modified version of the well-recognized Edmonton Symptom Assessment System (ESAS) self-assessment tool before and after each art-therapy session.[12]  Women with breast cancer have been a population of focus for identifying the healing power in art therapy.  Several randomized control trials have shown a recognized improvement in health-related quality of life, a decrease in symptoms of distress, improvement in coping skills in multiple psychosocial domains, future perspectives, and body image, and reductions in depression, anxiety, and somatic symptoms.[13][14][13][15][16][17]

Heart failure

Major cardiology societies have recently recognized the integration of palliative care in chronic heart failure patients and made recommendations for early palliative care involvement in the disease trajectory appear in ACCF/AHA guidelines.[18] Although the role of creative art therapy in heart failure does not have a clear definition, a small randomized study in Isreal looking at 20 patients with advanced heart failure found improvements in physical and emotional well-being, quality of life, and compliance.[18]

HIV/AIDs

Despite the advent of antiretroviral therapy, HIV/AIDS patients often seek alternative nonpharmacologic therapies to relieve debilitating symptoms associated with their chronic illness. Along with physical suffering, HIV/AIDs, patients can experience ample emotional suffering that accompanies the negative stigma associated with their disease. The AIDS Memorial Quilt served was one of the first objective forms of art therapy and emotional expression for those people living with HIV/AIDs.[19] Art therapy in HIV/AIDs patients has demonstrated a positive impact on emotional and physical well-being. One small, non-randomized group study found improvements in depression scores and health-related quality of life in 25 HIV/AIDs patients after participating in individual or group art therapy sessions.[5] Another randomized study found better coping mechanisms and perception of physical symptoms in those who participated in a one-hour art therapy session versus those who solely viewed a videotape on art therapy.[20]

Dementia

Dementia patients often suffer from debilitating neuropsychiatric symptoms that negatively impact their quality of life. Considering the limited efficacy in pharmacologic treatments for progressive dementia, non-pharmacologic alternatives are considered to be a valuable adjunctive approach, and there have been suggestions for an array of modalities.[21] In recent years, research has examined the impact of art therapy in dementia. Case studies and several small trials suggest that art therapy could benefit the quality of life,[22] perceptions of pleasure, improve social behavior and self-esteem, and engage attention in demented patients.[23] In 2006, one multicenter RCT investigated the use of group art therapy sessions in older patients with varying severities of dementia. Many observational measures assessed the emotional and behavioral status, and results suggested a positive change in some aspects of social interactions and mental alertness.

End-Stage Renal Disease

End-stage renal disease (ESRD) patients who commit to the highly demanding lifestyle of long term hemodialysis exhibit a lower health-related quality of life and increased rates of anxiety and depression, subsequently increasing the risk of non-adherence, increased symptom burden, and increased mortality. Although few high-quality studies have examined the effects of art therapy interventions in the ESRD population, some literature looking at the impact of music and other art-based therapies in hemodialysis patients found improvements in the perception of bothersome symptoms, including pain and itching. Improved treatment compliance, health-related quality of life, and reductions in anxiety and depression have also been reported.[24][25][26][27]

Enhancing Healthcare Team Outcomes

Managing patients with chronic, life-limiting illnesses can be challenging and complex and require the coordination of care across multiple disciplines. These patients invariably require a patient and family-centered interprofessional approach focused on managing complex symptoms of severe illness and addressing the physical, emotional, psychosocial, and existential components of suffering. Multiple large medical societies, including the World Health Organization (WHO), The National Comprehensive Cancer Network (NCCN), the European Society of Medical Oncology (ESMO), and the American Society of Clinical Oncology (ASCO) have all recognized the benefit. They recommend the integration of palliative care early in the disease trajectory.[28] However, opportunities to improve the integration of palliative care and a holistic approach utilizing complementary therapies (i.e., creative art therapy) exist.

Evidence-Based Approach

In the last two decades, there has been an emphatic shift in medical literature towards investigating the healing power of art in the realm of palliative care patients. Although the role of art therapy as an alternative treatment in these patient populations has expanded, and results are encouraging, the amount of quality evidence is sparse. Despite the literature implying the positive effects of art therapy on quality of life, coping mechanisms, and mental well being in patients with serious illness, results require cautious interpretation. Collectively the vast heterogeneity amongst the studies patient populations, clinical profiles, definition of art therapy, methods of randomization, sample sizes, study design, and indices measured yields low-quality evidence. Further research and extensive, high-quality studies are warranted to expand on the benefit of a holistic approach and utilization of creative art therapy to enhance patient-centered care and improve patient outcomes. [Level 2]