Abstract
Background
This hospital-based art-making support group for female adult cancer patients was set up in 2009. Participants meet weekly for art and craft activities, which are facilitated by a psychiatrist. The group is open-ended and participation is voluntary. There are currently around 150 participants in total.
Objectives
This qualitative study explores patient experiences in a hospital-based art-making support group.
Methods
15 semi-structured qualitative interviews were conducted. The participants were all female, predominantly Chinese Singaporean, and had been diagnosed with either breast cancer or a gynaecological cancer. A constructivist phenomenological research paradigm was adopted. Thematic analysis was conducted to identify, analyse and report patterns in the data.
Results
Three overarching themes and corresponding subthemes were identified: Benefits and challenges of journeying through cancer as a group (supporting one another, maturing relationships, interpersonal conflict, death and illness in the group), increased personal well-being (increased emotional well-being, personal growth and reduced social isolation) and going beyond group-based art-making (value of non-art-making activities, artistic development beyond the group).
Conclusion
Our findings demonstrate that art-making support groups may enhance the emotional, psychological and social well-being of patients with cancer. The group experience has provided participants with emotional, informational and experiential support, though participants cited the need to accept interpersonal conflict and grief over fellow participants’ illness and death. Potential areas for future study include the impact of interpersonal dynamics on cancer support groups, the impact of cultural factors on participants’ interactions and the skills required of group facilitators to manage conflict, grief and anxiety amongst participants.
Introduction
Psychological distress is common in individuals with cancer, who have to cope with the diagnosis of cancer, treatment, effects of the illness and treatment, as well as the fear of recurrence. 1 Psychosocial support has been associated with decreased levels of distress, anxiety and depression in patients with cancer. 2
Art-making programmes are one form of psychosocial support for such patients. Art-making involves creating art or craft alone or in a group and focuses on expression of emotion and identity. 3 A 2018 review of studies on art-making for patients with cancer concluded that art-making programmes provide opportunities for patients with cancer to seek support, learn more about themselves and engage in an enjoyable activity that distracts them from their pain and illness. Art-making provides participants with opportunities to enhance self-worth through achievement and overcoming challenges, 4 and to maintain a social identity that resists being defined by cancer. 5 Art-making has also been linked to a decrease in cancer treatment-related symptoms; it has been suggested that this may be linked to the distraction provided by art-making. 6
While other studies have examined the benefits of art-making programs for cancer patients, this is the first study to explore patient experiences in an Asian art-making cancer support group. Cultural beliefs and practices are known to affect patients’ choice of psychosocial support in cancer care 7 ; for instance, expressing emotional issues to strangers is a phenomenon that many Chinese cancer patients are unfamiliar with. 8 It would be interesting to see if this is reflected in our participants’ narratives, as it may potentially influence interactions within the support group.
Methods
This hospital-based art-making support group for female adult patients with cancer was set up in 2009. Participants meet weekly for art and craft activities, which are facilitated by a psychiatrist. The group is open-ended and participation is voluntary. Art materials are provided at no cost to the participants, who are encouraged to work on their artworks at their own pace. Participants are introduced to various media, such as oil painting, acrylic painting and decoupage. Each session lasts approximately 3 hours. 10 participants are present at each session on average; there are currently around 150 participants in total.
Demographic characteristics of participants a (n = 15).
aData are presented as number (percentage) of subjects unless otherwise stated
Each participant took part in one semi-structured interview conducted by a study team member, who used a topic guide (Annex A) as a framework for the interview. Participants were interviewed about their experiences in the group. Three researchers (E.S, F.Y and J.T) conducted the interviews separately. E.S conducted eight interviews, F.Y conducted four interviews and J.T conducted three interviews. The researchers were colleagues of the psychiatrist who facilitated the weekly art-making sessions and were aware that participants might be reluctant to speak about negative experiences. To mitigate this, the study participants were reassured that their responses would remain confidential, and would not affect their participation in the group.
All interviews were audio-recorded and transcribed. The duration of the interviews ranged from 30 minutes to 1.5 hours. The interviewers took field notes during the interviews and prepared verbatim transcripts. Participant identifiers were removed from the transcripts, and participants were assigned a reference code. Transcripts were returned to the participants for checking. The researchers familiarised themselves with the data by transcribing the interviews themselves and reading each transcript several times before analysing each transcript.
A constructivist phenomenological research paradigm was adopted, as this allowed participants’ experiences to be constructed into holistic perspectives. Thematic analysis was conducted to identify, analyse and report patterns within the data. 9 Data analysis began after several interviews had been transcribed. Microsoft Excel was used to facilitate coding of the data. Codes were generated solely from the collected data and from these codes, tentative themes were derived by identifying patterns of repeated words, phrases and ideas. The themes were then reviewed and refined; themes with little supporting data were removed, while some themes were combined and where appropriate, subthemes were identified. Two researchers (E.S. and F.Y.) coded the data independently and discrepancies were discussed until a consensus was reached. No further interviews were conducted after the 15th interview as data saturation had been reached; no new codes, themes or data were identified during analysis of the final interview.
Once data analysis was completed, the results of the analysis were shared with the study participants to allow for respondent validation.
Results
Themes and subthemes.
Theme 1: Benefits and challenges of journeying through cancer as a group (N = 107)
Participants spoke about the positive and negative aspects of the group experience. Positive aspects included the availability of support, as well as relationships which evolved into friendships. Challenges included interpersonal conflict and groupmates’ illnesses and death. (i) Supporting one another (n = 53) Participants reported that their fellow group members provided emotional, informational and experiential support. Participants felt comfortable confiding in their peers in their group, who were fellow cancer patients, as they felt understood by them. Participants exchanged information on self-care, which they found difficult to discuss in detail with healthcare professionals. Participants who had lived with cancer for longer often provided advice to participants who had been newly diagnosed with cancer.
Participant 3 (P3): “All the girls are cancer patients, patients here, so you find that it is different from outsiders, public people. We talk about the same things, you know. It is like, you have cancer, I have cancer. We exchange notes, comfort each other, learn from each other.”
P10: “As old-timers, we give them advice. How to cope with pain, comfort them, because some of them are still going through treatment. The newcomers know that people here are having the same thing, they have gone through it before, and they see how we survived, how we enjoy our life, so they tend to follow us.” (ii) Maturing relationships (n = 26) Participants often bonded informally over artwork before progressing to forge deeper friendships. The informal nature of participants’ interactions came as a relief to some participants, who were not initially comfortable with sharing their feelings. Members were careful to respect newcomers’ need for personal space. Despite the informal nature of the participants’ interactions, over time, many participants forged friendships with one another.
P9: “The new ones, you have got to give them a lot of space. Because they need to accept that we’re all here with the same thing, and some are more private, you know? Don’t want to talk. So, we have got to give them a lot of time to accept us. If you remember, the women would have wigs. Some of them felt so comfortable, they used to hang up their wigs onto that pole. And that is when we find out that they are comfortable. If they were to take their wigs off and start painting, start yakking, that means they were comfortable.”
P5: “There’s no forced sharing. It is not the touchy-feely kind. I’m quite a private person. My innermost feelings, I keep them to myself. So I told myself, it is not bad here. It is basically the doing of the art, not like “ok, tell me about yourself”. We come in, do art, then we start talking. People here are very nice. I made friends.” (iii) Interpersonal conflict (n = 18) Study participants spoke about having to manage conflict with fellow group members. They accepted that conflict was inevitable in a group setting and coped with it by trying to be empathetic and forgiving.
P15: “Disagreements happen, for sure. There can be many reasons. Cancer patients can be temperamental. They may over-react to small things. So, we have to be understanding and tolerant. People who are ill are usually short-tempered, they may be more irritable. But if we see that there are others who are understanding, we will tone down. That’s helpful.”
P6: “You know, not everybody can get along. Somebody said that I was neglecting my work. I got so offended. I raised my voice. Because of that, she didn’t want to talk to me. Along the way, I learnt to be more forgiving. Later on, after discussing with another person, we sort of slowly softened. Now, at least, we do chit chat a bit.” (iv) Illness and death in the group (n = 10) Illness and death were viewed as inevitable occurrences; participants shared that the cancer relapses and death of other group members triggered reflections about their own mortality. Participants spoke about accepting death and illness as part of their cancer journey, and resolved to treasure their lives.
P6: “You hear about how some (pause) didn’t pull through, or some who are having a relapse. You also question (pause) the probability for you know, each of us even though we have gone on for 5 years, 6 years. We have to treasure every moment that we have.”
P14: “From the time I joined, about six or seven members have passed on. Whenever I find out that someone has passed on, I do feel very sad, because we interacted. I start thinking that the same thing will happen to me; it is only a matter of time. I don’t know when it will happen. I just have to accept it.”
Theme 2: Increased personal well-being (N = 151)
Participants spoke about how the group’s activities fostered positive emotions, encouraged personal growth and reduced social isolation. (i) Increased emotional well-being (n = 36) Participants reported that group’s activities fostered positive emotions such as a sense of enjoyment and calm. Participants frequently reported that when they concentrated on art-making activities, they tended to worry less about their illness and symptoms.
P9: “I had such good laughs. I was so excited. Umm. What am I going to paint? How do I want it to look? How should I colour it? (Laughing) It brought me a lot of excitement. I enjoyed it.”
P2: “I don’t know if it is the effect of chemo. It is very irritating, you have to contend with the tingling sensation on your feet, and the bone. So even though it is for a time, it helps you to forget everything, just focus on what you’re doing.” (ii) Personal growth (n = 78) Almost all of the participants shared that the group’s activities gave them a sense of direction and purpose, and contributed to their personal growth. Participants spoke about how they experienced an increase in self-esteem as they developed greater mastery in art. In particular, participants derived a sense of achievement from exhibiting and selling their artworks at participant-led fund-raising events. Participants also shared that art-making provided an avenue for self-expression, and helped them to develop personal qualities such as patience and perseverance.
P14: “Art has taught me patience. That’s the most important. And not to be scared of failure. Because at first, when you start, it is a blank canvass. When you start you feel that it doesn’t resemble anything, and you have to keep correcting it, keep modifying it, till you see results. You have to keep adjusting things slowly until you’re satisfied. You get a sense of accomplishment after you have finished the painting. Sometimes you really feel like giving up, but you see that as you make modifications, it does work.”
P8: “We come here, we really do something that is meaningful. Like now we are going to do an art exhibition, which I think is very good, considering that all of us are not professionals. It is an achievement.” (iii) Reduced social isolation (n = 37) Participants appreciated the company of their peers, and highlighted that the group decreased their sense of isolation. Many participants continued to stay in the group because of the close friends they had made there.
P11: “Most of us, we (pause)get really depressed, and we need friends around us. Your family is out at work. So here people can keep you company, then (pause)it is not so bad.”
P6: “If, if I go home (pause) I’m staying alone, it is all the four walls only. I switch on the TV, and I’m by myself you know. But if I come here and join the group, I can be part of it, you know. Slowly, you make friends.”
Theme 3: Going beyond group-based art-making (N = 41)
Participants shared that they enjoyed the opportunities to participate in non–art-making activities organised by the group, and honed their art-making skills outside formal group sessions. (i) Value of non-art-making activities (n = 16) Participants shared that they benefited from non–art-making group activities, such as introductory sessions to mindfulness and excursions to art exhibitions.
P13: “Once Dr C taught us mindfulness. That helped a little. For instance, we can do deep breathing. I do that myself. I do think it is helped.”
P14: “Whenever they bring us out, I’m the happiest. They brought us to see art exhibitions, to the National Museum. It is nice to see other exhibitions, because I get to see others’ works, and learn about their painting styles.” (ii) Artistic development beyond the group (n = 25) Participants shared that while the group might have sparked their interest in art, they devoted much time to developing their skills in art outside group sessions. Many participants described their journey in art as a self-directed one, characterised by personal discovery, experimentation and practice. Several participants shared that they had initiated art-related projects and events outside the group, using skills they had first learnt in the group.
P3: “I got the interest and I started from there. I practised and practised, and I got my own stuff to practise on at home. One of the girls who has cancer, she goes with me to the library. So, at the library, we talk about it, exchange notes, draw. You look at mine, I look at yours, then we ask each other, you know, what we can do to make it better (pause)so your interest grows from there, you just want to improve each time.”
P4: “I got interested, then I made earrings and I teach my friends as well. And now I actually run a workshop in my church. So, we’re all helping, a group of us. Like this morning, every Thursday we’ll come together and we’ll make. And we’re making to raise funds. We’re going to have a sale.”
Discussion
The results of this study are consistent with the findings of a 2018 review on the benefits of art-making in cancer care, 4 which identified three main benefits of art-making programmes: increased self-knowledge through expression and creativity, increased group support and enjoyable distraction from pain and illness.
Well-being comprises emotional, psychological and social aspects 10 and the participants’ narratives suggest that this art-making support group has addressed these. Emotional well-being has been conceptualised as an interaction between frequent positive affect, infrequent negative affect and life satisfaction. 11 Study participants reported an increase in positive affect (feelings of joy and calm during group activities) and a decrease in negative affect (distraction from anxiety and distress from physical symptoms). With regard to psychological well-being, purpose in life and personal growth have been identified as important contributing factors. 12 Participants reported that they derived a sense of purpose from art-making, and from working together to prepare for exhibitions. They reflected that the process of art-making facilitated personal growth, by cultivating qualities such as patience and perseverance. Participants also experienced an increase in self-esteem as they gradually developed mastery in art.
Participants reported that the experience of journeying through cancer as a group helped them to cope with cancer. Study participants cited their commonality as a key factor that contributed to their sense of being understood. Of note, Yalom identified universality (feeling that one’s problems are shared with others) as one of 12 therapeutic factors in the group process. 13 Within a group of peers who had similar illness experiences, participants found emotional, informational and experiential support. Studies on cancer support groups have concluded that patients tend to view the emotional and experiential support of fellow cancer patients as the most helpful components of their group experience. 14 Experiential support is defined as a relationship with someone who has gone through a similar illness and can provide first-hand insight into the illness. 15 Patients who have experienced cancer are well-placed to understand and support their peers’ evolving needs; Bell et al. described cancer support group participants’ initial preference for information on cancer and its treatment, which was subsequently replaced by a need for support and friendship, and a desire to help others. 16
Of note, participants reported that relationships with fellow participants matured over time. They spoke about focusing on art-making and preferring not to share their emotions initially, though they forged close friendships with one another over time. This is an interesting finding that has not been described in previous studies, which focused on art-making groups in Western countries. It has been observed that many Chinese cancer patients are unfamiliar with expressing emotional issues to strangers 8 and this could have been one reason why some participants appreciated the fact that the group facilitators focused on art-making, and did not enforce the sharing of experiences and emotions.
Participants spoke of the need to accept interpersonal conflict in the group. Few studies have explored cancer support group participants’ reactions to interpersonal conflict. It has been suggested that evaluations of cancer support groups should explore the impact of interpersonal dynamics on the extent of perceived support. 17 It has also been suggested that measures of perceived support, such as those reviewed by Wills and Shinar, 18 can be administered to track the relationship between facilitators’ observation of group dynamics and the psychological support received by members. 17
Participants also spoke about having to cope with death and illness in the group. It has been found that cancer support group attendees find it challenging to cope with the difficult experiences of fellow group members, and that some participants experience survivors’ guilt upon the passing of their group members. 19 Ussher et al. similarly described how progressive illness and death of fellow cancer support group members can pose one of the most difficult challenges within a support group, though group members eventually accept illness and death as part of the cancer support group experience. 20 Our study echoes these findings, and suggests that support group facilitators should be attuned to feelings of grief and anxiety when there is death or illness in the group.
It is worth considering the factors that have sustained this art-making support group over the last 12 years. Participants frequently reported that they remained in the group because it offered them social support and increased their personal well-being. Equally importantly, participants reported that they enjoyed the unique aspects of the group, such as the participant-led exhibitions and artwork sales, as well as introductory sessions to mindfulness and excursions to art exhibitions. Study participants spoke frequently about how the annual exhibitions and sales, in particular, fostered a sense of achievement, as the funds raised from these events allowed participants to help raise funds for charitable causes. These events also enabled participants to share their artwork with a larger audience, which further contributed to a sense of accomplishment. The group’s focus on art-making also suited participants who preferred not to have to share their feelings with others when they first joined the group. Indeed, cancer support groups should consider participants’ preferred format and needs, so that they can remain effective and appealing. 21
Our findings should be considered within the context of its limitations. The results of the study represent the experiences of a convenience sample of participants, and do not describe the experiences of all group participants. In particular, the researchers were not able to interview participants who had left the group; such participants might have had negative experiences which could not be explored in this study.
The results of this study are nonetheless encouraging. Our findings demonstrate that this art-making support group enhanced the emotional, psychological and social well-being of the study participants, and that the group experience provided participants with emotional, informational and experiential support. Potential areas for future study include the impact of interpersonal dynamics on cancer support groups, the impact of cultural factors on participants’ interactions in support groups, as well as the skills required of support group facilitators to manage conflict, grief and anxiety in such groups.
Footnotes
Acknowledgements
The authors would like to thank all participants for their continued support and contributions towards the study. They would also like to express their gratitude to Ms Isabel Heng, whose administrative support has been invaluable.
Authors contributions
ES and FY conducted a literature survey, conceived the study, designed the topic guide and carried out data analysis. ES, FY and JT recruited study participants and carried out the semi-structured interviews. All authors reviewed and edited the manuscript, and approved the final version of the manuscript.
Declaration of conflict of interest
The Authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Availability of data and materials
The datasets generated and analysed during the study are available from the corresponding author.
Ethical Approval
Ethics approval was obtained from the Singapore Health Services Institutional Review Board (CIRB reference number 2018/3196)
Informed Consent
Written informed consent was obtained from all study participants.
