Effects of Self-Book© Art Therapy on Distress: Randomized Controlled Trial

Authors:
Donna Radl
Maureen Vita
Nancy Gerber
Edward J. Gracely
Joke Bradt

Title: The Effects of Self-Book© Art Therapy on Cancer-Related Distress in Female Cancer
Patients during Active Treatment: A Randomized Controlled Trial

Affiliations:
J. Bradt, N. Gerber, D. Radl
Department of Creative Arts Therapies, College of Nursing and Health Professions, Drexel
University, 1601 Cherry Street, Philadelphia, PA 19102, USA

M. Vita
Drexel University College of Medicine, Hahnemann Cancer Center, Department of Radiation
Oncology, 245 N. 15th Street, Philadelphia, PA 19102, USA

E. J. Gracely
Department of Family, Community and Preventive Medicine, Drexel University College of
Medicine, 2900 Queen Lane,Philadelphia, PA 19129, USA

Corresponding Author: Donna Radl, Ph.D.

info@expressivecounselingassociates.com
Expressive Counseling Associates
5 Great Valley Pkwy, Suite 210, Malvern PA 19355
Phone: 610-368-1090

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/pon.4758

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Abstract

Objective: National attention on patients’ cancer-related emotional distress produced a need

for evidence-based, psychosocial interventions in oncology care. The purpose of this study

was to evaluate the efficacy of Self-Book© art therapy for emotional distress and

psychological well-being of female oncology patients during active oncology treatment.

Methods: Sixty consenting women with cancer were randomly assigned to either a six-

session Self-Book© art therapy program or standard care. A repeated measures randomized

controlled trial design was employed. Data were collected using the Distress Thermometer

(DT), Perceived Emotional Distress Inventory (PEDI), Patient-Reported Outcomes

Measurement Information System (PROMIS) Brief Psychological Well-being test, and the

Functional Assessment of Chronic Illness Therapy - Spiritual Well-being (FACIT-Sp).

Measurements were obtained at baseline, week 3, week 6, and 1-to-2 months post-

intervention.

Results: Forty participants were included in the final analysis. No significant differences

between groups were found for the primary outcome measures: emotional distress and

psychological well-being. Greater improvements in Self-Book© art therapy participants’

spiritual well-being were found compared to the standard care control participants (p = 0.02).

Conclusions: Although no statistically significant differences were present between the

groups for the primary outcomes, several positive trends were noted. Thirty percent of Self-

Book© art therapy participants reported post-intervention emotional distress scores that were

below the abnormal range for emotional distress, compared with only 5% of standard care

control participants, suggesting that Self-Book© art therapy may have clinical value. Further

studies are recommended to better understand the therapeutic mechanisms of Self-Book© art

therapy for enhancing psychological well-being.

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Keywords: art therapy; emotional distress; existentialism; female cancer; oncology;

psychological well-being; spirituality

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Introduction

Addressing unmet psychosocial needs in people with cancer is an important goal in oncology

care [1]. In 2009, emotional distress was ranked as the highest of concerns for patients with

cancer in the United States [2]. It is estimated that up to 43% [3,4] of women diagnosed with

cancer experience abnormal emotional distress, defined as a score of ≥ 4 on the Distress

Thermometer [5] and as having “problems that can become disabling, such as depression,

anxiety, panic, social isolation, and existential and spiritual crisis” [1]. Emotional distress

affects four psychosocial domains in cancer patients: (1) psychological well-being involving

managing and processing loss, depression, and anxiety; (2) self-perception; (3) social needs

and family support; and (4) spiritual needs involving meaning-making and a sense of

purpose.

The NCCN [1] announced that oncology treatment programs will soon require a

psychosocial care plan in place for all patients who have been identified as experiencing

abnormal levels of emotional distress. The announcement spurred research into the safety,

efficacy and effectiveness of psychosocial support interventions with this population. This

need for evidence-based interventions produced a pivotal opportunity for complementary and

integrative health approaches such as medical art therapy [6].

Only a handful of art therapy clinical trials have been conducted with people with

cancer. A randomized controlled trial (RCT) with 111 women with breast cancer compared

the effects of an eight-week Mindfulness-Based Art Therapy (MBAT) group intervention

with a non-active control treatment arm on emotional distress and psychological well-being

[7]. The MBAT was aimed at facilitating verbal and nonverbal self-expression about the

cancer health threat, offering support and acquiring new coping skills. The results revealed

significant improvements in key aspects of health-related quality of life for the MBAT

compared to control participants such as mental composite score, general health, mental

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health, social functioning, and vitality. MBAT participants also reported greater reduction in

anxiety and depression than control participants. Likewise, significant improvements in

depression were found in a study examining the effects of a 4-session art therapy program on

patients undergoing chemotherapy. The art therapy intervention involved expressing one’s

feelings through painting [8]. A study examining the effects of a 5-week art therapy program

versus standard care with 42 postoperative breast cancer patients receiving radiation therapy

found significantly greater reductions in depression, anxiety and psychosomatic symptoms in

participants in the art therapy compared to control group [9]. A series of 5 individual art

therapy sessions resulted in significantly greater increases in the coping skills in art therapy

participants compared to the control treatment arm [10].

Another study examining the effects of art therapy on psychological well-being in 39

patients with cancer did not find significant improvements in self-expression and spirituality

in art therapy participants versus waitlist control participants [11]. The intervention integrated

positive psychology concepts and entailed four 60-minute individual therapy sessions over a

four-week period.

Finally, a small qualitative study, exploring the meaning-making process of two

breast cancer survivors participating in a clay-based art therapy approach [12] found that

patients’ post-surgical self-perceptions benefitted from “re-conceptualizing” their altered

body images in the context of their disease. The two women described that this reframing

process using clay helped them to accept their life-altering illness through reconstructing a

new meaning about the self.

This present study was based on a pilot study that explored the impact of an art

therapy intervention named Self-Book© art therapy on the quality of life of 22 newly

diagnosed breast cancer patients. Self-Book© is an art therapy process that integrates the

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concept of strengths and virtues from positive psychology in a 10-page visual book, created

over six individual sessions. Bookmaking, an approach in art therapy, affords the patient an

opportunity for self-expression using magazine collage to convey the patient’s life with

cancer in the here and now [13]. The therapeutic structure of the book is designed to help the

patient contain the difficult emotions that may emerge while the art therapist works with the

patient to validate the patient’s narrative [13].

The theoretical principles supporting Self-Book© art therapy are based on the concept

that the human mind tends to experience intrusive and avoidant stress response symptoms

when faced with adverse events, and that the creative, nonverbal process can help patients

reframe their illness in a way that helps them make sense of the adversity in a safe manner

[13,14]. Different than other psychotherapies, Self-Book© art therapy also focuses on self-

expression of thoughts and emotions into a tangible form, engendering feelings of self-

awareness [15]. This post-traumatic growth process is important for patients who are too sick

to continue with their normal responsibilities, such as work and other activities of daily

living, making life feel depressed and anxious [8]. A healthier sense-of-self transcends

through ongoing self-expression and meaning-making within the trilateral relationship

between the art, patient, and therapist [13,15].

Although the initial pilot study’s results indicated a worsening in the functional and

social well-being domains, there were statistically significant improvements in emotional

well-being. The study presented here was aimed at validating the efficacy of the Self-Book©

intervention and was open to patients diagnosed with all cancers. The guiding research

question was: Can the Self-Book© art therapy intervention help female oncology patients

decrease emotional distress and enhance psychological well-being during active cancer

treatment?

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Method

Design

A repeated measures two-arm parallel-group design was used. A sample size computation

conducted in G-Power 3.1 calculated a minimum of 54 participants needed to ensure

adequate (80%) power. This analysis was based on repeated measures ANOVA for two

groups and three measurement time points using a two-tailed test (week 3, week 6, and

follow-up). The criteria for this sample size was eta squared = 0.3, alpha at 0.05, power at

0.80. To account for a potential 24% attrition rate, a sample size of 72 participants was

deemed appropriate for this study. Similar studies report a wide range of attrition rates,

between 11% to 42% [9,16,17].

Ethical approval for conducting research using human subject participation was

obtained from Drexel University IRB. Patient participation was completely voluntary. All

prospective participants met the IRB approved inclusion/exclusion criteria and were

monetarily compensated for their time. After informed consent was obtained, participants

were randomly assigned, using a permuted block randomization schedule, to either the six-

session Self-Book© art therapy intervention group or the standard care control group. Data

were collected at four separate time points: Baseline, week 3, week 6, and 1-to-2 months

post-intervention.

Participants

Eligible participants were consented over a ten-month recruitment period. The

following inclusion criteria were used: (a) females receiving active oncology treatment at a

major urban hospital (inpatient or outpatient), (b) a score of ≥ 60 on the Karnofsky

Performance Status (KPS), (c) emotional distress score of ≥ 4 on the Distress Thermometer

[5], and (d) proficient in English. Exclusion criteria were: (a) significant vision impairment,

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(b) notable cognitive impairment and (c) major mental health disorder, as determined by a

licensed psychotherapist.

Self-Book© Art Therapy Intervention

The Self-Book© process includes the creation of a journal-style, self-reflective visual book in

a supportive relational context with an art therapist. The participant uses a magazine collage

medium to visually document and express their experiences. Single sections or pages of the

book related to a specific topic are added during each of six 50-minute art therapy sessions.

Each participant met with the art therapist in a private or semi-private environment on the

same day of her regularly scheduled oncology treatment. During the first five sessions, the art

therapist gave the participant an art therapy directive that addressed one of five self-related

themes with therapeutic objectives (Table 1). Finally, during the sixth session, the participant

was instructed to assemble and decorate the outside cover of her book.

Standard Care Control Group

For this study, standard care was defined as the treatment all oncology patients received

during radiation and chemotherapy treatments in the participating hospital. Upon admission

all oncology patients were handed a welcome packet containing a full-color brochure

explaining the support services that included art therapy, music therapy, the Look Good, Feel

Better event, massage therapy, and acupuncture. Once treatment started, doctors and nurses

routinely asked patients about their emotional distress and overall well-being, and referred

patients for psychosocial support services when necessary. Participants in both groups had

the option to receive any or all of the other complementary therapies. The only difference

between the standard care participants and the Self-Book© participants was that the

participants receiving standard care did not create a Self-Book©.

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Measures and Data Collection

The primary outcome of this study was emotional distress as measured by the Distress

Thermometer (DT) and the Perceived Emotional Distress Inventory (PEDI). The DT is a 0-10

numeric rating scale in the shape of a thermometer. It is widely used in oncology treatment

facilities [5]. The DT was used in this study to screen all participants and to measure ongoing

emotional distress before and after Self-Book© art therapy sessions. The National Cancer

Institute (NCI) states that cutoff scores of 4 and 5 are most commonly used in clinical trials

and approximately 40% of cancer patients report scores above this cutoff score.

The PEDI is a 15-item self-report questionnaire designed to measure the perceived

and present state of emotional distress in cancer patients. The score for the inventory ranges

from 0–45 points, with lower scores corresponding to lower levels of perceived emotional

distress. The PEDI was specifically developed for cancer patients in active treatment

designed to reflect the presence and severity of emotional distress and general mood

disturbance. The measure assesses anxiety, anger, depression and hopelessness making

distinctions regarding the expression and suppression of angry feelings. [18,19]. It has a

reliability coefficient of 0.91.

Secondary outcomes included psychological well-being and spiritual well-being.

Psychological well-being was measured using the Patient-Reported Outcomes Measurement

Information System (PROMIS) Brief Psychological Well-being test [20]. This 7-item

questionnaire inquires about general well-being. The score ranges from 7–35, with higher

scores indicating a healthier level of psychological well-being. The reliability coefficient

ranges between 0.85 and 0.97. [20]

The Functional Assessment of Chronic Illness Therapy - Spiritual Well-being

(FACIT-Sp) [21] was used to measure participants’ psychological well-being, emphasizing

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spiritual well-being. The FACIT-Sp total range is 0–156 with higher the score representing

greater well-being. Five quality-of-life domains are included in this scale: physical well-

being, social/family well-being, emotional well-being, functional well-being, and spiritual

well-being. Spiritual well-being was aimed at assessing a sense of meaning and peace in

illness. The FACIT-Sp demonstrates good reliability (0.85–0.88), validity, and sensitivity to

change [21,22].

For the Self-Book© art therapy participants, each of these measurements occurred

during their oncology treatment session, and before the start of the art therapy session on a

given measurement week. For the standard care control group participants, these

measurements occurred also during their oncology treatment session on that given week.

Data Analysis

Descriptive frequency analysis was performed to identify potential patterns related to the

missing data. For missing data, the scoring guidelines for each instrument were followed.

Descriptive statistics were used to create a demographic profile of the treatment and control

groups. Baseline equivalence between the two groups was examined by use of Chi-square

and independent group t-test.

Since data met the criteria for parametric statistics, a repeated measures, mixed

methods ANOVA was used to compare the two groups for changes in emotional distress and

psychological well-being over time. Post-hoc analyses were employed to determine the

location of between-group differences. Repeated measures analysis of covariance

(ANCOVA) was used to examine group differences after adjusting for baseline differences

when baseline differences were present. A repeated measures ANOVA was applied to

examine the within-group differences for the treatment group for emotional distress and well-

being over time (weekly measurements). All statistical computations were performed using

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the Statistical Package for the Social Sciences (SPSS) version: 22 [23] and Microsoft Excel

StatPlus, version: 14.2.3.

Results

Participant Characteristics

There were 220 patients referred to the study. Sixty women met the inclusion criteria and

were consented, enrolled, completed baseline measurements, and were randomized to either

the Self-Book© art therapy intervention group (n = 30) or to the standard care control group (n

= 30). Forty patients were included in the final analysis, as indicated in figure 1.

Participants in the Self-Book© art therapy and standard care control treatment arms

were comparable at baseline for socio-demographic and clinical characteristics (Table 2).

Quantitative Results

There were no statistically significant differences between the Self-Book© art therapy and

control participants for the primary outcome, emotional distress, nor for the secondary

outcome, psychological well-being. There were positive trends but no significant group by

time interaction effect for emotional distress (F[2.29, 87.25] = 1.37, p = 0.26). No group by

time interaction effect for psychological well-being was found (F[2.37, 90.10] = 2.47, p =

0.12). There was a statistically significant greater improvement in Self-Book© art therapy

participants’ spiritual well-being subscale compared to the standard care control participants

(F[1, 38] = 5.88, p = 0.02) (Table 3). Additionally, 30% of Self-Book© art therapy

participants reported post-intervention emotional distress scores that were below 4 on the

Distress Thermometer compared with only 5% of standard care control participants,

(Χ2 = 3.96, p = .047), suggesting that Self-Book© art therapy may offer some emotional

benefit.

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 We used repeated measures ANOVA (3-factor) to examine the effects of the

intervention on emotional distress and psychological well-being while adjusting for two

variables: cancer stage and age. Results revealed that psychological well-being had a group

by time interaction when controlling for age (F[2.85, 96.84] = 2.87, p = 0.04). Findings

suggest that the effect of Self-Book© art therapy treatment versus standard care control was

greater in the younger participants than in the older participants.

Discussion

This study evaluated the efficacy of Self-Book© art therapy for psychological needs of

female oncology patients during active treatment. Emotional distress scores improved in both

groups and improved slightly more in the Self-Book© art therapy group but this difference

was not statistically significant. There was no evidence of a treatment effect for Self-Book©

art therapy on overall psychological well-being in female cancer patients. However, the

spiritual well-being subscale of the FACIT-Sp revealed statistically significant greater

improvements in Self-Book© art therapy participants compared to standard care control

participants. The data also revealed that emotional distress scores of 30% of participants in

the Self-Book© art therapy intervention dropped below the cutoff point for emotional distress

(score < 4 on the DT) compared to only 5% percent of standard care control group

participants. Because the Self-Book© art therapy intervention included positive psychology

components, it is difficult to isolate at this time the specific variables responsible for the

results of this study.

Some explanations are possible for the study findings; first, the outcome measures

used in this study may not have captured the actual benefits of the intervention; second, the

study was underpowered due to recruitment challenges and time constraints. The small to

moderate treatment effect size suggest that given a larger study sample, significant between-

group differences may have been obtained.

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 Given that the initial Self-Book© pilot study found significantly improved scores in

emotional well-being, the lack of group differences for the primary outcomes in the current

study were unforeseen. An earlier art therapy study by Monti and colleagues reported

significant treatment effects of art therapy for emotional distress, demonstrating that art

therapy helped cancer patients confront fears about uncertainty and death [7]. This study used

a mindfulness-based art therapy intervention. It is possible that mindfulness-based practices

using yoga and meditation skills, such as in the Monti study, are better suited to target stress-

reduction [7].

It could very well be that Self-Book© art therapy addressed psychological issues other

than stress. The Self-Book© intervention seemed to effect abstract constructs such as feeling

an inner peace with life, feeling connected with others, feeling a sense of purpose and an

overall belief system that comprises existentialism [24]. These constructs are interwoven

throughout the five sections of the Self-Book© art therapy process:

1) Participants are asked to “create your safe place” – feeling safe is a foundational,

hierarchical need for basic human well-being [25]. A fear of death or cancer

recurrence feels unsettling and unsafe, but art therapy is known to be a safe haven

[10,13]. Through the use of magazine imaginary, participants recreate their own

personal safe place;

2) “Create your emotional supports” – during active treatment, patients report feeling

like a burden to friends and family causing them to alienate [4,17,26]. Yet a

critical need for cancer patients includes the necessity to feel connected with

others [24,26]. By asking a patient to create their emotional supports using art,

they are free to use their imaginations to reassess a stronger support system [13];

3) “Identify your inner strengths and virtues” – patients are encouraged to focus on

their positive attributes as opposed to pathology, helping them become more

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 aware of their own inner coping skills [27,28]. This third section is derived from

positive psychology. Positive psychology is a subfield of psychology that

examines how human beings grow in the face of adversity and is designed to treat

many psychosocial needs, namely spiritual needs [28];

4) “Express wishes for loved ones” – when patients express sincere wishes for

others, they are reminded of gratitude, and the need for attachment [29];

5) “Make a wish for yourself” – physical demands stemming from cancer can cause

emotional self-neglect [11,29]. The art making process gives patients the space for

quiet time to relax and to nonverbally communicate feelings through art

[11,13,30].

The finished Self-Book© serves as a transitional object [25], meaning the visual book can

later provide psychological comfort after treatment has ended, a difficult time of transition for

many patients [25,31].

An important limitation of our study was the small sample size due to logistical

reasons, timeframe constraints, and higher than anticipated attrition rates. Initially, 72 women

were targeted to ensure statistical power, but we did not achieve the desired sample size by

the end of the allotted data collection period. Study drop-out was primarily caused by cancer-

related co-morbidity, an unexpected rapid deterioration in physical health, and disease

severity including cancer deaths unrelated to the study. Additionally, harsh winter weather

conditions interfered with recruitment and treatment adherence. Yet, the small to moderate

treatment effect size suggest that given replication with a larger sample size, more robust

findings may have been achieved.

One explanation for the enhancement of spiritual well-being in the Self-Book© art

therapy study arm may be related to the fact that the study sample was predominately

African-American. Spiritualizing problems by defining difficulties as God’s will and trusting

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that cancer will be okay are coping skills frequently observed in African-American women

[32]. Certain aspects of the Self-Book© intervention may serve as a metaphor for spiritualized

beliefs. Specifically, the five directives of the Self-Book© might be interpreted as

follows: safe place might symbolize being in God’s hands; supports could symbolize the

church; strengths and virtues may have been a reminder of God-given gifts; wishes for

family, loved ones and self could have created feelings of closeness or reunification with a

higher power. FACIT-Sp scores indicate that Self-Book© art therapy participants over time

became more accepting of their cancer compared to the control group participants: they felt a

sense of peace and harmony; comfort and strength in faith or spiritual beliefs; and believed

that whatever happens with cancer, things would be okay. This benefit is important because

patients with greater confidence in being helped by a higher power tend to have a better

psychological adjustment to cancer [31,33-35].

In summary, although no statistically significant differences were present between the

groups for the primary outcomes, several positive trends were noted including greater

improvements in Self-Book© art therapy participants’ spiritual well-being compared to

standard care control participants. Spirituality is particularly crucial given the existential

nature of many questions raised by a cancer diagnosis and personal meaning to an individual

and their caregivers. This could possibly be explained by the fact that Self-Book© art therapy

activated positive coping strategies such as the meaning-making process. As the Self-Book©

art therapy process reframes intrusive thoughts, the negative impact of cancer is mitigated

decreasing emotional distress and enhancing spiritual well-being [36]. When this strategy is

utilized, patients are more able to cope with life-threatening challenges, decrease their overall

emotional distress, and gain acceptance of cancer. The benefit is that meaning-making during

the earlier stages of cancer may influence later opportunities for post-traumatic growth, a

sense of purpose, restoration of existential beliefs, and may help to improve the quality of life

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in cancer survivorship [36-38]. These findings are relevant to art therapy as the process of

creating, self-reflecting and meaning making are at the foundation of art therapy [13]. The

meaning-making process that emerges from the art therapy experience is the essential healing

factor [12]. These positive trends suggest that Self-Book© art therapy may provide

meaningful insight and fill an unmet psychosocial need that helps to increase spiritual well-

being in female oncology patients.

Study Limitations

This study was limited to female cancer patients to achieve a homogeneous population. The

population was not diversified -- 80% of the participants were African American. Population

limitations prevent the results of this research from being generalized to all oncology patients.

Furthermore, 72 women were targeted for this study to have adequate statistical power. This

study did not achieve the desired sample size by the 10-month endpoint for data collection,

due to attrition and recruitment challenges. There was limited funding which prevented

blinding of outcome assessments. Although the DT is widely used in oncology facilities to

quickly ascertain a patient’s emotional distress level during treatment, it may not be sensitive

enough to measure changes over time in a clinical intervention study. The DT was selected

due to its wide-spread use and quick assessment of emotional distress. However, the DT is

only a screening tool and inappropriate for diagnostic purposes, causing clinical limitations.

Lastly, the FACIT-Sp was selected because it is a psychometrically sound instrument yet

limited due to the lengthy questions that seemed to cause noticeable fatigue to many

participants.

Clinical Implications

These results may shed new light on the effects of Self-Book© art therapy on spirituality for

some patients in active cancer treatment. To gain a better understanding of the patient’s

experience of the intervention, a mixed methods research design is recommended for future

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Self-Book© art therapy trials. Additionally, future trials that employ standard care control

conditions, should restrict participants from using other complementary therapies, to better

isolate the effects of art therapy. It is recommended that future clinical studies measure

primary outcome variables such as inner peace, connectedness with others, sense of purpose,

acceptance or existential fear.

Conclusions

This study did not find statistically significant differences in emotional distress and overall

psychological well-being between participants in the Self-Book© art therapy intervention and

those in the control study arm. Nevertheless, the Self-Book© art therapy intervention did lead

to greater improvements in spiritual well-being compared to the control group. These results

are imperative given that the National Cancer Institute [2] states that spiritual well-being in

cancer patients remains an under-researched area. Furthermore, literature states that the

challenge for oncology care professionals is to find evidence-based interventions that

encourage women with cancer to develop a sense of spirituality or purpose [39]. This study is

to date, the only controlled art therapy study to provide evidence for a significant

improvement in spiritual well-being. It is recommended that further art therapy studies

examine the impact of specific art therapy interventions on spiritual well-being in cancer

patients. The Self-Book© art therapy intervention shows the connectedness between art

therapy, creativity, and spirituality involving meaning-making that leads to a renewed sense

of self.

Acknowledgements

The authors wish to express gratitude to developer Mary T. Donald for the use of the Self-

Book© art therapy intervention. Thank you to Dr. Lydia Komarnicky and the women with

cancer who participated in this study. This study was a dissertation submitted to the Ph.D.

faculty of Drexel University, USA by Donna Radl in partial fulfillment of the requirements

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for the degree of Doctor of Philosophy in March 2015. We thank committee members Dr.

Thomas Hardie for being instrumental in the initial concepts for this research and for his

statistical analysis consultation and Dr. Mark Moore for his insights into complementary and

alternative medicine research. Funding for this study was provided by a $20,000 match-grant

from the National Endowment for the Arts (NEA), Research: Art Works (grant #14-3800-

7007).

Conflict of Interest

The authors do not have a financial relationship with the organization that sponsored this

research. The authors have full control of all primary data and agree to allow the journal to

review our data if requested.

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Table 1. The Self-Book© art therapy intervention six-session curriculum.

Session Self-Book© Directives Self-Book© Therapeutic Objectives

(Administrated by a master-level, board
certified art therapist)
1 Using precut, categorized magazine images,  Become acquainted with the art materials.
create your safe place on the inside spread  Create a sense of personal safety.
of the Self-Book© blank segment. (Blank  Begin to establish a trusting relationship.
segment, scissors, magazine images, and  Experience privacy.
a glue stick are provided at each session.)
2 Using precut, categorized magazine images,  Identify and value supports.
identify your supports on the inside of the  Identify connections with others.
second blank segment.
3 Using precut, categorized magazine images,  Learn about positive psychology.
identify your strengths and virtues on the  Identify personal strengths and virtues.
inside of the third blank segment spread.  Explore self-awareness.
(A list of the 26 strengths and virtues from  Encourage reintegration of self.
positive psychology are offered to patients,  Initiate awareness of inner coping skills.
who then select 6 or 7 that she identifies as
belonging to her.)
4 Using precut, categorized magazine images,  Express positive well-being for those close
make a wish for people close to you and/or to self.
loved ones on the inside of the fourth blank  Explore personal connection(s).
segment spread.
5 Using precut, categorized magazine images,  Increase awareness of self-care.
make a wish for yourself on the inside of the  Sponsor ownership and gifting to self.
fifth blank segment spread.  Acknowledge self-empowerment and
autonomy.
 Engender hope of survival and personal growth.
6 Assemble and decorate your Self-Book©. Glue  Make meaning of personal choices.
the five segments together to form a book.  Celebrate progress.
Using colorful stickers, jewels, feathers, and  Create a transitional object.
anything that can adhere to the pages, decorate
your Self-Book©. Engage in a verbal response.

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 Table 2. Socio-demographic and clinical characteristics

Characteristics Self-Book© Art Therapy Standard Care P Value

Group Control Group
(n = 20) (n = 20)
Age (years):
Mean±SD 51. 95 ± 10.59* 52.30 ± 12.42 0.40

Race:
Black 16 (80%) 15 (75%) 0.59
White 2 (10%) 4 (20%)
Other 2 (10%) 1 (5%)

Cancer Type:
Breast cancer 8 (40%) 9 (45%) 0.55
Lung cancer 2 (10%) 1 (5%)
Gynecological cancer 2 (10%) 1 (5%)
Colon/rectal cancer 4 (20%) 1 (5%)
Leukemia/blood cancer 2 (10%) 3 (15%)
Lymphoma (CHL) 0 (0%) 1 (5%)
Other types of cancer 2 (10%) 4 (20%)

Cancer Stage:
Stage I 1 (5%) 4 (20%) 0.67
Stage II 3 (15%) 3 (15%)
Stage III 6 (30%) 6 (30%)
Stage IV 6 (30%) 4 (20%)
Unknown 4 (20%) 3 (15%)

Cancer Treatment:
Chemotherapy 12 (60%) 11 (55%) 0.83
Radiation 1 (5%) 2 (10%)
Chemotherapy and 7 (35%) 7 (35%)
radiation

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Table 3. Mean scores and standard deviation for primary, secondary and subscale outcomes

Outcomes Treatment Baseline (T1) Week 3 (T2) Week 6 (T3) Follow-up (T4)
Distress Self-Book©
6.20±1.64 5.55±2.35 4.30±2.68 3.80±2.73
Thermometer art therapy
Standard care
6.5±1.79 5.70±2.05 5.60±2.06 5.70±2.81
control
Perceived Self-Book©
15.45 ± 9.30 14.20 ± 9.84 10.40 ± 6.60 10.55 ± 8.65
Emotional art therapy
Distress Standard care
Inventory control 12.95 ± 8.51 13.40 ± 9.05 12.00 ± 8.04 11.80 ± 10.20

PROMIS- Self-Book©
20.95±4.90 19.05±6.01 20.65±4.94 22.90±5.38
Brief art therapy
Psychological Standard care
Well-Being control 22.15±6.10 20.05±5.09 19.95±7.04 20.00±5.85

FACIT —Sp Self-Book©

98.28±25.10 93.82±27.59 105.80±24.72 109.22±24.08
Total Score) art therapy
Standard care
100.16±25.35 101.71±28.51 101.88±25.78 102.76±31.79
control
FACIT Self-Book©
33.80±9.45 32.80±0.14 36.55±9.76 37.05±9.93
Spiritual art therapy
Well-Being Standard care
35.40±9.44 35.20±11.47 34.15±10.03 34.20±11.39
control
FACIT Self-Book©
14.90±5.81 15.40±5.65 18.05±5.14 18.85±4.29
Emotional art therapy
Well-Being Standard care
15.55±5.40 17.15±.38 17.05±4.54 17.00±6.36
control
FACIT Social Self-Book©
20.13±5.02 17.23±6.53 18.05±6.63 19.13±6.22
Well-Being art therapy
Standard care
19.36±.90 19.16±8.30 19.38±6.85 19.66±7.42
control
FACIT Self-Book©
16.55±5.74 16.20±7.56 18.55±6.01 18.70±5.61
Physical art therapy
Well-Being Standard care
15.75±6.86 16.30±7.78 16.65±6.43 16.75±0.51
control
FACIT Self-Book©
12.90±5.78 12.20±5.72 14.60±5.34 15.50±5.60
Functional art therapy
Well-Being Standard care
14.10±6.66 13.90±7.49 14.65±7.48 15.15±7.17
control

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Figure 1. Participant flowchart

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