Healing Pathways: Art Therapy for American Indian Cancer Survivors

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<ul><li><p>Healing Pathways: Art Therapy for American IndianCancer Survivors</p><p>Elizabeth Warson</p><p>Published online: 4 February 2012# Springer Science+Business Media, LLC 2012</p><p>Abstract There is a paucity of research addressing qualityof life factors for American Indian and Alaska Native cancersurvivors. Complementary forms of therapy, such as arttherapy, are beginning to address quality of life factorsthrough the healing arts for cancer survivors. The purposeof this mixed methods pilot was to explore the effects ofculturally relevant art interventions on stress reduction forAmerican Indian cancer survivors and their family mem-bers. Forty-six adult participants attended one of three work-shops held within two settlements of the Coharie tribe andone southeastern urban tribal center. The data collectedconsisted of a pretest and posttest State-Trait PersonalityInventory (STPI) and artwork resulting from three directedinterventions. The artwork was analyzed using qualitativecoding methods; however, the scores from the STPI wereinconclusive because the inventory was determined to beculturally biased. While statistical significance was notachieved, the findings from qualitative coding reinforceda native concept of wellness focusing on the complexinteraction between mind, body, spirit, and context. Thispilot study also demonstrated how a community-drivenapproach was instrumental in the development of theoverall workshop format. An expansion of the pilotstudy is also presented with preliminary results availablein 2012.</p><p>Keywords Art therapy . Stress reduction . Cancer survivors .</p><p>Complementary therapies . Quality of life factors</p><p>Introduction</p><p>Health disparity has been a primary focus in NativeAmerican cancer research; in spite of this, gaps in theliterature on quality of life factors for American Indian/Alaska Native cancer survivors prevail [1]. Integrative prac-tices incorporating the biopsychosocial model have surfacedin western medicine in response to the traditional biomedi-cal perspective, offering a new paradigm in healthcare cen-tered on mindbody interaction and a means to address anarray of quality of life factors [2]. In recognition of the needfor mindbody interventions, the National Institutes ofHealths Office of Cancer Complementary and AlternativeMedicine has identified a number of alternative and com-plementary approaches to address quality of life factors; arttherapy is one such form of complementary therapy associ-ated with mindbody medicine [3].</p><p>In spite of these holistic efforts in western medicine, theNative American perspective on wellness is largely misun-derstood [4]. Wellness from a native or indigenous perspec-tive is more relationally based [4] focusing on theinterrelated concepts of mind, body, spirit, and context [5].This approach differs substantially from more westernizedlinear concepts of mindbody interaction in that spiritualityis central to understanding the mindbody connection [5].The notion of context is unique to native people, emphasiz-ing a collectivist worldview that native people share [6]: aperson is understood in relation to his or her family, tribalcommunity, history, culture, environment, work, and so on[5]. This worldview counters the rugged individualism ob-served in western secular culture, which places importance onautonomy and the belief that an individual can control his orher environment [6]. As such, wellness from a more holisticNative American perspective addresses quality of life factorsby achieving balance and harmony through the reciprocalrelationship between mind, body, spirit, and context [7].</p><p>E. Warson (*)George Washington University,Alexandria, VA 22314, USAe-mail: eawarson@gwu.edu</p><p>J Canc Educ (2012) 27 (Suppl 1):S47S56DOI 10.1007/s13187-012-0324-5</p></li><li><p>Art Therapy</p><p>Art therapy is a mental health profession that incorporatesart as a means for healing, personal growth, and an en-hanced quality of life. Art therapy is practiced in differentsettings with diverse populations using traditional and non-traditional art processes combined with different theoreticalapproaches from counseling. Specialized approaches, suchas medical art therapy, have led to the development of art-based psychosocial interventions for individuals experienc-ing acute and chronic illness. The efficacy of art therapywith the medically ill has been a focus in art therapy re-search, concentrating on variables such as pain manage-ment, increased self-expression, stress management, andenhanced quality of life [8].</p><p>Art therapy is rooted in many ancient traditions, and theuse of art and medicine is no exception. To the nativepeople, this is not an ancient practice but a way of life. Asa complementary form of therapy, medical art therapy hasdemonstrated significant lower ratings of depression, anxi-ety, and somatic symptoms with breast cancer survivors [9].Many novel approaches within the field of medical arttherapy have surfaced for cancer survivors, focusing onwellness-based models [10] and pain management [11].Innovative approaches such as mindfulness-based art thera-py (MBAT) incorporate mindfulness-based stress reductionwith visual forms of self-expression [10]. As the professionof art therapy continues to lay the ground work for mindbody interventions, a more relational approach to under-standing native concepts related to mind, body, spirit, andcontext is needed in healthcare settings [4, 5].</p><p>Art Therapy with American Indians and Alaska Natives</p><p>Native Americans have benefited from the use of expressivearts in therapy when culturally relevant [12]. Culturallyrelevancy extends beyond devising culturally appropriateinterventions; in tribal communities, it requires close collab-oration throughout. Because of the nonverbal focus in arttherapy, art therapists often assume a universalist stance inthat their work transcends cultural differences, and is there-by culturally appropriate. Because of the tremendous varia-tion between tribal communities, art therapists need toimmerse themselves in the community they are co-collaborating with in order to develop what Duran callsnative epistemology or a native way of knowing [13].Native epistemology is vital to developing lasting and re-ciprocal collaborative relationships that extend beyond de-veloping cultural sensitivity [13]. Although the cultural artsis an inherent part of Native American culture, art therapy isa relatively new modality in Indian Country and has beenwell received, when the art interventions are culturally rel-evant and co-constructed by members from the community</p><p>[14]. Without this degree of collaboration, there is no senseof ownership with the art-based interventions or for thatmatter the study. Because there is such a paucity of literatureon art therapy with Native Americans, little is known aboutbest practices.</p><p>Healing Pathways: Pilot Study</p><p>Method</p><p>The Healing Pathways pilot project was developed in 2006and implemented through funding from the Johnson andJohnson Foundation through the Society for the Arts inHealthcare and in partnership with the North CarolinaCommission of Indian Affairs. The aim of this mixed meth-ods community-driven project was to develop a culturallyrelevant art therapy workshop as a means of stress reductionfor American Indian cancer survivors and their family mem-bers in North Carolina. During this 1-year grant period,three workshops were conducted for two settlements of theCoharie and one urban intertribal center in CumberlandCounty. A total of 46 participants attended the three work-shops. No specific criteria were indicated with respect tocancer site, gender, current medical treatment, or duration oftime as a survivor. As a community-driven workshop, allgenerations were included whether they were cancer survi-vors or a family member who has been directly affected bycancer. A culturally relevant format for conducting the arttherapy workshops was one of the outcomes of this study.This feasibility study incorporated an emergent designallowing the advisory committee, comprising seven tribalmembers from the Coharie community, to provide constantfeedback and recommendations that were incorporated im-mediately following each workshop.</p><p>Advisory Committee</p><p>In collaboration with the North Carolina Commission ofIndian Affairs, the investigator was introduced to the com-mission members representing the nine tribes within NorthCarolina through a letter drafted by the executive directorGreg Richardson. In addition, the investigator attended acommission meeting to introduce herself in person anddiscuss the details of the study. Through these preliminarymeetings with the commission, an advisory committee wasformed; a commission member Sadie Barbour from theCoharie tribe was designated to assist with the workshops.Prior to forming the advisory committee, the investigatorpiloted her art interventions with Ms. Barbour to obtainfeedback about the cultural appropriateness of the art direc-tives for the community workshops. This meeting led to theformation of an advisory committee from the Coharie tribe</p><p>S48 J Canc Educ (2012) 27 (Suppl 1):S47S56</p></li><li><p>comprising seven members who were either cancer survi-vors or family members.</p><p>The advisory committee members participated in a work-shop prior to implementing the protocol in the tribal com-munities. Based on this workshop, three art interventionsand a warm-up exercise were agreed upon for the firstcommunity workshop. Committee members made addition-al recommendations to provide the art therapy workshopswith a more culturally relevant format for the Coharie eldercommunity, consisting of a kinesthetic warm-up clearingthe air with a feather, gestural drawings on large sheets ofpaper, a guided visualization drawing for stress and/or painmanagement, a response piece to the visualization draw-ing, and an open-ended closing piece. The inclusion of thepain management in the protocol was the most significantmodification, to attend the beliefs of the elders within thiscommunity. Additional recommendations included limitingthe amount of art supplies made available, the inclusion ofan opening and closing prayer, and an altar with ceremonialpieces specific to the tribal community.</p><p>To measure the effectiveness of these interventions onstress reduction, a 40-item self-report inventory, the State-Trait Anxiety Inventory (STAI), was included as a pretestand posttest measure [15]. There was some initial hesitationfrom the advisory committee and the NC Commission ofIndian Affairs about using this inventory because the lengthand the wording of the questions were not culturally specificfor American Indians. A suggestion was made to reduce thenumber of questions in half from the original 40 item self-report inventory, and a modified STAI, referred to as theState-Trait Personality Inventory (STPI), was acquired fromthe publisher.</p><p>Research Design</p><p>The mixed methods design incorporated a single-group pre-test and posttest with a qualitative content analysis of theartwork. Three separate workshops (3 h/workshop) were heldwithin two settlements of the Coharie tribe in addition to anintertribal urban site in Cumberland County. The workshopswere announced to the community at tribal meetings andculturally relevant flyers approved by the institutional reviewboard (IRB) were posted throughout the tribal center with thePIs contact information. The 3-h workshops were held at thetribal centers, and a healthy lunch and a raffle were providedimmediately following. The participants were apprised of thestudy individually and consented as a group using a five-pageIRB document. The pretest STPI was administered prior to theimplementation of the art intervention and the posttest STPI atthe conclusion of the workshop. The tribal representatives,who were trained by the PI to administer the tool, assisted withthis process by reading the questions aloud and assisting withtheir self-report scores based on a four-point Likert scale.</p><p>This study incorporated an emergent design enabling thePI to modify the art interventions throughout the study,based on feedback from the advisory committee. The firstworkshop with the Coharie tribe provided the environmentto explore a range of art materials and directed art tasks. Theresulting art interventions were modified for the secondworkshop and replicated again in the third workshop. Afollow-up member check was conducted to discuss theimpact of the workshop.</p><p>Data Collection</p><p>Workshop 1</p><p>The Coharie tribe assembled this group of 28 elder womenwho had overlapping health conditions (diabetes) or stress-related problems due to cancer. The workshop was formattedbased on the feedback from the advisory committee, consist-ing of clearing the air with a feather, kinesthetic drawing,visualization and corresponding depiction of stress or pain,and a response piece (medium of choice). The third open-ended task was not completed because of time constraints.The women were provided with a package of model magic (aself-hardening molding material) to experiment on their ownin addition to a visual journaling kit consisting of watercolorpencils, watercolor paper, eraser, and a paint brush.</p><p>Prior to the workshop, Ms. Barbour created an altar witha lit candle in the middle of the room to recognize those whohave passed on from cancer from the tribe. The eldestwoman in the room gave the prayer. The protocol for thisworkshop included a warm-up of clearing the air with awhite feather. This ritual was developed from the advisorycommittee and was culturally specific to the Coharie. Eachparticipant passed around a feather in a circle and drew inthe air. This warm-up was followed up with a gesturaldrawing on 1824-in sheet of gray paper tape on the wall.Participants were encouraged to make gestural marks in theair first (circle, up and down, and back and forth) beforereproducing these marks on the paper. Participants sat downat a grouping of tables to participate in a guided visualiza-tion drawing focusing on the depiction of stress or pain.Participants depicted their stress or pain using lines,shapes, and color in the center of the circle (prior to thisimplementation, we used an eastern-based mandala as a stim-ulus to work from and then modified this circular configura-tion to a healing circle [coined by Linda Burhanisstipanov]to make this drawing task culturally relevant). They wereencouraged to participate in breathing exercises to reflect onthis image and then rated their level of stress or pain on a 110scale (100highest level). Continuing with the breathing exer-cises, they visualized a lesser degree of pain or stress and wereencouraged to depict this in consecutive stages. Once they hadreached their lowest level, they verbally processed their</p><p>J Canc Educ (2012) 27 (Suppl 1):S47S56 S49</p></li><li><p>responses to this exercise. After they had identified an area intheir circle that they connected with, they were encouraged tocreate a response piece using a medium of choice. The STPIposttest was completed prior to breaking for lunch, again withthe assistance of the trib...</p></li></ul>


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