Healing Pathways: Art Therapy for American IndianCancer Survivors

Elizabeth Warson

Published online: 4 February 2012# Springer Science+Business Media, LLC 2012

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.

Keywords Art therapy . Stress reduction . Cancer survivors .

Complementary therapies . Quality of life factors

Introduction

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 mind–body interaction and a means to address anarray of quality of life factors [2]. In recognition of the needfor mind–body interventions, the National Institutes ofHealth’s 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 mind–body medicine [3].

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 mind–body interaction in that spiritualityis central to understanding the mind–body 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].

E. Warson (*)George Washington University,Alexandria, VA 22314, USAe-mail: eawarson@gwu.edu

J Canc Educ (2012) 27 (Suppl 1):S47–S56DOI 10.1007/s13187-012-0324-5

Art Therapy

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].

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 mind–body interventions, a more relational approach to under-standing native concepts related to mind, body, spirit, andcontext is needed in healthcare settings [4, 5].

Art Therapy with American Indians and Alaska Natives

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

[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.

Healing Pathways: Pilot Study

Method

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.

Advisory Committee

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

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comprising seven members who were either cancer survi-vors or family members.

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.

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.

Research Design

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.

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.

Data Collection

Workshop 1

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.

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 18×24-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 1–10scale (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

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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 tribal representatives. In addition to araffle, a gift of a visual journaling set was provided and the PIprovided a visual example and a brief introduction to visualjournaling, along with written guidelines. Participants wereencouraged to draw, paint, or collage in their journals for atleast 5 min a day as a means of reducing stress.

Workshop 2 and 3

Prior to the second workshop, I reviewed the audio andvideo tapes to modify the format. The advisory committeereviewed these modifications and supported the revisedformat for the second workshop with another settlement ofthe Coharie tribe. The modifications included fewer choicesregarding art media and the “clearing the air” warm-upwithout a follow-up gestural drawing, because it was notperceived as being purposeful enough. Gray paper was usedfor all drawing tasks as many of the participants displayed apreference for white media. The healing circle interventionremained unchanged with the exception of the inclusion ofgray paper. The response intervention to the healing circleexercise was narrowed down to a predrawn circle on watercolor paper to use with a watercolor set vs. broad range ofart materials. The model magic self-hardening clay was usedas a closing intervention, in lieu of an open-ended task. Thesecond workshop consisted of ten Coharie elder women andmen. The modified protocol was piloted with this commu-nity and with the feedback from the advisory committee, itwas decided that the format was culturally relevant andacceptable to replicate. Group 3 consisted of an intertribalsite which included eight female cancer survivors and fam-ily members from the Lumbee, Cherokee, WaccamauSiouan, and Coharie tribes. The protocol from the secondworkshop was replicated in a standardized manner: initialworkshop consisting of “clearing the air” warm-up exercise,healing circle drawing, “response” painting, and an intro-duction to visual journaling, and the follow-up workshop:“clearing the air” warm-up exercise, review of visual jour-nal, creating a cover for the visual journal, and a “response”clay task.

Data Analysis

State-Trait Personality Inventory

The STAI is an inventory that has high validity in studieswith medical ill patients [15]. This inventory was reviewedand modified three times to provide more culturally appro-priate wording. This art therapist consulted with the

publisher to obtain guidance during this modification pro-cess. The final version was a condensed version referred toas the STPI comprising 17 questions, as opposed to 40questions with the STAI. The final modification resulted inomitting two questions that were perceived as duplicationsby the participants and an easier to read format. In spite ofthe modifications, the scoring system (four-point Likertscale) presented a challenge because most participants werecompleting the inventory as a dichotomous rating systemand inadvertently reverse the numbers to reflect the oppositeof their intention. Participants from all three groups statedthe wording was confusing and were not receptive to com-pleting the postassessment as a result. The inventories werenot rated nor considered in a more formal analysis becauseof the degree of difficulty completing these. The advisorycommittee also expressed concern that the STPI was biasedand that the analysis from the inventories could bemisleading.

Qualitative Analysis

The artwork resulting from the 46 participants from threecommunity workshops was analyzed using an inductiveapproach to open coding from grounded theory [16] andmapping techniques from situational analysis [17]. The opencoping was conducted by creating lists of words describingformal art qualities symbolic content, and narrative themesthat emerged from the artwork. The mapping technique wasa second level of coding, clustering observations in radialmaps, “situating” the dominant themes in context to theparticipants’ worldview. Three dominant themes resultingfrom the two levels of coding: an emphasis on pain man-agement; narrative depictions of nature and human figures;and a personal, symbolic approach to color use. The advi-sory committee reviewed the findings from each workshopand provided additional feedback to provide more of acontext.

The emphasis on pain in the healing circle interventionwas observed in 87% of the art productions. This focus onpain and stress levels was indicated by the advisory com-mittee who made the recommendation to include the optionof pain. The color associated with pain was red or black forall of the pain-related healing circles. A target configuration,created using concentric layers of color, was the most com-mon design for the healing circle (Fig. 1). The color associ-ated with less pain or stress was consistently white or alighter hue of color; 100% of the healing circles incorporat-ed five colors or more, resulting in a vibrant effect.

The narrative depiction of nature and human figuressurfaced in the “response” painting. Participants were askedto look at a section of their healing circle and create a“response” painting. Approximately 30% of the participantsopted to continue to focus on pain, observed in the depiction

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of red monochromatic human figures with emphasized inte-riors (layered paint) suggestive of the source of pain (Fig. 2).

The narrative themes corresponded with the storying pro-cess, and stories of cancer survival and events from

Fig. 1 Healing circle drawing(top). Healing circle “response”painting (bottom)

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everyday life were indicated symbolically through the paint-ing and clay process. Cultural images reminiscent of dreamcatchers surfaced during the painting process and served as ametaphor for weaving parts of their lives together (Fig. 3).

A consistent use of personal and symbolic use ofcolor was evident in all the art-based interventions. Theuse of color became a dominant theme because themajority of the art productions included a full range ofprimary and secondary colors. The symbolic meaning ofcolor was explored in terms of collective meaning, suchas white representing “purity” as well as personal mean-ing, evident in one participant’s depiction of a yellowcancer cell (Fig. 4). What was most observable was thevibrancy of the colors reinforced through repetitiousmarks and dashes reflective of patterns of beading andstitching from quilting (Fig. 5). Color also served as acatalyst for the storying process; participants were liter-ally “speaking” through color to tell their story.

Follow-up Interviews

Two separate interviews were conducted as a form of amember check with a mother/daughter pair who had partic-ipated in the Coharie workshops. The mother was a cancersurvivor and the daughter her caregiver. They requested thatI join them for lunch at their family farm to discuss theirvisual journals that were presented to them at the end of theworkshop. Over the course of several months, these womenhad been maintaining a daily visual journal, recording

Fig. 2 “Response” painting: “I fell now [pain]” (top). “Response”painting (pain, bottom)

Fig. 3 Dreamcatcher images (top and bottom)

Fig. 4 Cancer cell

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thoughts, observations, and feelings. Both reported thatvisual journaling gave them an opportunity to spend timeto themselves away from other responsibilities. This “mem-ber check,” along with other reports from tribal representa-tives, and requests from the communities for additional“books” suggested that visual journaling was becoming anaccepted practice within this tribal community.

Discussion

The aim of this mixed methods study was to provide a cultur-ally relevant art therapy workshop to promote stress reductionfor cancer survivors and their family members. Statisticalsignificance was not achieved based on the pretest and posttestSTPI because as the study progressed, it became apparent thatthe inventory was not transferable to southeastern AmericanIndian tribes. Moreover, the North Carolina Commission ofIndian Affairs as well as the advisory committee had concernsfrom the beginning about the use of this instrument within

their tribal communities. The qualitative analysis was limitedwith respect to evaluating the research question, and it is notknown to what extent the interventions had an effect on stressreduction. What resulted from this study was a culturallyrelevant workshop format that could be replicated in a largerstudy. Using an emergent design and community-drive ap-proach, this format was modified to embrace the mind, body,spirit, and context associated with Native American wellness[5] by embracing the importance of prayer, art making, story-ing, and community. The results of this study reinforced aNative American concept of wellness-based mind, body, spir-it, and context [5] evident in the three domains from thecoding analyses. More specifically, the emphasis on painreflected a body-based awareness. Originally, this pain em-phasis was presumed to be connected with the Christianbeliefs associated with this particular community, in that oncea person has given their life to Christ, there are no worries (S.Barbour, personal communication, June 1, 2006). The con-centration on pain during the healing circle exercise as well asthe continuation of the pain theme in the “response” paintingalso seemed to indicate a highly interrelated mind–body con-nection: thoughts, feelings, perceptions, and somatic sensa-tions are simultaneously experienced vs. compartmentalizedas either stemming from one’s mind or body. This conceptwarrants further research as it seems to counters a morewestern secular perspective that somatic experiences can bepathological in nature. Little is known about the implicationsof an interrelated concept of wellness based on mind, body,spirit, and context in western medicine [5].

The storying process elicited through the art process seemedto string together mind, body, spirit, and context; withoutstorying many of these images would have been reduced tocolorful decorative patterns, devoid of meaning. Storytelling iscentral to indigenous cultures as a part of an oral tradition ofteaching, sharing tribal knowledge, as well as a source ofentertainment and inspiration. The storying process in qualita-tive research—specifically narrative inquiry—is a method ofexploring the deeper layers of meaning making. Although thiswas not a narrative inquiry, the storying process was central tothe study and yet a separate aspect of the study that could notbe observed in context to the artwork nor recorded in a self-report inventory. In addition to the storying process, anotherunanticipated outcome was the self-guided visual journalingthat was being sustained after the completion of the work-shops. The impact of this intervention that was intended moreas a gift than a formal intervention in addition to the storyingprocess became a primary consideration in a follow-up study.

Healing Pathways Study

This expanded study was supported by an institutional re-search grant (IRG-08-091-01) from the American Cancer

Fig. 5 “Response” painting (patterning, top). Healing circle drawing(patterning, bottom)

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Society, to The George Washington University CancerInstitute and a community grant from the Mayo CancerClinic’s Spirit of EAGLES program. The workshop formatstemming from the Healing Pathways pilot study is current-ly being replicated in tribal communities throughout NorthCarolina. The aim of this project was broaden to provide aculturally relevant art therapy intervention as a means topromote a sense of wellness (through stress reduction), thuseffecting quality of life factors for American Indian cancersurvivors from North Carolina tribes. The study is currentlybeing conducted throughout North Carolina, and modifica-tions to the research design and an overview of the stan-dardized format for the workshops is indicated in themethods section.

Method

This replication was expanded to include total of 14 arttherapy workshops (7 initial and 7 follow-up) for approxi-mately 300 American Indian cancer survivors and theirfamily members (average of 21 participants per workshop)from 5 rural and urban North Carolina tribal communities:Coharie (two settlements), Waccamau Siouan (two settle-ments), Occaneechi Band of the Saponi Nation, andCumberland County Indian Association (urban intertribalcenter). American Indian cancer survivors and their familymembers from North Carolina will be included in this study;children, adolescents, adults, and elders will be included inthis study as part of the community-driven focus. A waiverof documentation was approved for this study because of thedifficulty consenting the participants during the pilot using afive-page consent form.

Modifications to the Research Design

A grounded theory approach from qualitative researchreplaced the mixed methods design because of the storyingemphasis from the pilot as well as the limitations experi-enced with the self-report measure. The workshop formatwas expanded to include a follow-up workshop incorporat-ing visual journaling exercises and clay work. Visual jour-naling was also included as a self-guided interventionbetween the two workshops, spaced approximately 4 weeksapart. A clay intervention using red ceramic clay rather thanself-hardening clay was added as the final art interventionbased on the recommendation from the pilot study advisorycommittee. The replicated design also considered a morethorough rationale for each of art-based intervention. Aspart of the community-driven approach, a five-member ad-visory committee was assembled including providers,

professionals, and scholars from the Lumbee Nation andCoharie tribe.

Data Collection

Preliminary Workshop

As a warm-up activity for the first intervention, participantsare asked to “clear the air” with a white turkey feather.Within the NC tribes, white signifies “purity” and was anacceptable choice for this purpose. This process entailsmoving a feather in a circular manner, up and down, andback and forth: the dominant hand first and then the non-dominant hand. This exercise was an outcome from the pilotstudy and in combination with a traditional prayer ceremo-ny, and is how we center participants in body, mind, spirit,and context before our workshops begin. The focal part ofthis workshop was the guided visualization and depiction ofstress or pain. This form of visualized was devised fromsimilar psychoneuroimmunology (PNI) interventions; PNIfocuses on the relationship between psychological processesand the immune system [18]. Visualization is one techniquethat PNI specialists use to help reduce perceptions of painand levels of stress. The inclusion of art with this techniquewas meant to enhance the effects through experientialmeans. Participants depicted their stress or pain using lines,shapes, and color in the center of the circle. They wereencouraged to participate in breathing exercises to reflecton this image, rating their level of perceived stress or painon a 1–10 scale (100highest level). Continuing with thebreathing exercises, they were prompted to visualize a lesserdegree of pain or stress, depicting these responses in con-secutive stages or layers moving toward the outside of thecircle. Once they had reached their lowest level, they ver-bally processed their responses with the group. The breath-ing exercises were included in the protocol based on theeffectiveness of mindful breathing from the MBAT study[10]. This researcher also completed training in mindfulnessmeditation to fully integrate this practice.

Although related experiences, the rationale for focusingon both stress and pain stemmed from the pilot study be-cause of the interrelationship between mind, body, spirit,and context [5]. After they had identified an area in theirhealing circle that they felt connected with, they were di-rected to create a watercolor painting within a predrawncircle (same size as circle used in guided visualization). Inart therapy this is referred to as “response” painting, that isyou are literally responding metaphorically to a visual imageor stimulus to deepen the experience. Ideally, the participantwould be elaborating on his or her experience with stress orpain while the fluidity of the watercolor painting wouldinduce a state of flow [19]. Flow experiences are

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intrinsically motivated and imply such a deep level of con-centration that the stressors of everyday life are not in one’sconscious mind. Our aim was to elicit this state of flowthrough the soothing quality of watercolor painting andallow participants to experience a self-induced state ofrelaxation.

At the end of the first workshop, a brief introduction tovisual journaling was provided along with a handout ofbasic guidelines. Participants were encouraged to work intheir journals (both artwork and written reflection) for up to5 min a day until the follow-up workshop. Visual journalingwas an unexpected outcome from the pilot study. Originally,we handed out visual journals at the end of the study toencourage personal art making. Small-scale journals (5×7)were provided to encourage brief entries rather than feelingthe need to use up all of the paper. Because of this, wedecided to focus on visual journaling in both workshops andas a self-guided process between workshops. Specific artdirectives were not provided so we could track the themesthat emerged from this process.

Follow-up Workshop

The workshop began with the same warm-up of “clearingthe air” and saying a prayer for those whose lives have beenaffected by cancer. Again, this set the stage for the focus ofthe group. A discussion of the visual journals was facilitatedby this investigator. She encouraged the participants todiscuss specific entries and to identify themes or patternsthat were apparent to the group. Once identified, the partic-ipants were encouraged to create a cover for their journalusing natural materials. Supplemental journals were provid-ed to encourage participants to continue this process. Theclay task as a final intervention was introduced. We used redclay, per the request of tribal members, as it resembles thenatural clay from this community. My co-facilitator SadieBarbour recommended clay as a final intervention based onthe receptiveness of this medium from a needs assessmentthat we conducted with the youth from her community [14].Participants were asked to reflect on a theme from either theworkshop or visual journaling to elaborate on through theclay process. Art supplies were provided at the end of bothworkshops to encourage ongoing personal art making as aform of self-care.

Method of Analysis

The artwork and audio recordings from the workshops willbe analyzed using a qualitative coding software programNVivo*9© [20]; findings will be made available in 2012when the study is completed. This qualitative coding pro-gram will enable the researcher to cross-reference the

descriptive memos and content tally from the artwork withthe transcriptions created from the audio recorded work-shops. This approach was considered in lieu of statisticalanalysis based on the emphasis on the storying processobserved during the pilot study. The coding software willassist in providing more of context for the relationshipbetween the art making and storying process. The expectedoutcome of the coding analysis is twofold: to understand theinterplay between Native American wellness and quality oflife factors and to develop a hypothesis that could be testedin a larger efficacy study.

Conclusion

Developing partnerships to foster a collaborative relation-ship is key to any study being conducted with diversegroups of people. This was certainly my experience duringthe inception of the feasibility study. Although I am anAmerican Indian researcher, this does grant me automaticaccess to tribal communities; relationships must be nurturedand sustained over time to conduct meaningful research.Moreover, knowing the native epistemology of a particulartribe is vital to developing sustainable practices. Culturalrelevancy is just one aspect of a study that cannot be ap-plied, and in cancer care what is required is developing anunderstanding of the complexity of Native Americanwellness.

Conflict of Interest The author declares that she has no conflict ofinterest.

References

1. Burhansstipanov L, Gilbert A, LaMarca K, Krebs LU (2002) Aninnovative path to improving cancer care in Indian Country. PublicHealth Rep 116(5):424–433

2. Spiegel D, Classen C (2000) Group therapy for cancer patients.Basic Books, New York

3. Office of Cancer Complementary and Alternative Medicine(OCCAM) (n.d.) Categories of CAM therapies. http://www.cancer.gov/CAM/. Accessed 06 Jan 2007

4. Hodge DR, Limb GE, Cross TL (2009) Moving from colonizationtoward balance and harmony: a Native American perspective onwellness. Soc Work 54:211–219

5. Cross T (1997) Understanding the relational worldview in Indianfamilies [part I]. http://www.nicwa.org/Relational_Worldview/.Accessed 05 Jan 2011

6. Sue WS, Sue D (2008) Counseling the culturally different: theoryand practice, 5th edn. Wiley, Hoboken

7. Cross T (2001) Spirituality and mental health: a Native Americanperspective. Focal Point 15:37–38

8. Malchiodi C (1999)Medical art therapy with adults. Jessica Kingsley,Philadelphia

J Canc Educ (2012) 27 (Suppl 1):S47–S56 S55

9. Thyme KE, Sundin EC, Wiberg B, Oster I, Astrom S, Lindh J(2009) Individual brief art therapy can be helpful for women withbreast cancer: a randomized controlled clinical study. Palliat Sup-port Care 7:87–95

10. Monti DA, Peterson C, Shakin-Kunkel EJ, Hauck WW, PequignotE, Rhodes L, Brainard G (2006) A randomized, controlled trial ofmindfulness-based art therapy (MBAT) for women with cancer.Psychooncology 15:363–373

11. Camic PM (1999) Expanding treatment possibilities for chron-ic pain through the expressive arts. In: Malchiodi C (ed)Medical art therapy with children. Jessica Kingsley, Philadel-phia, pp 43–62

12. Herring RD (1997) The creative arts: an avenue to wellness amongNative American Indians. J Humanistic Educ Dev 36:105–113

13. Duran E (2006) Healing the soul wound: counseling with Ameri-can Indians and other Native Peoples. Teachers College Press,New York

14. Basto E, Warson E, Barbour S (in press) Exploring AmericanIndian adolescents' needs through a community-driven study. TheArts in Psychother

15. Spielberger CD (1983) Manual for the State-Trait Anxiety Inven-tory (STAI). Consulting Psychologists Press, Palo Alto

16. Creswell JW (2007) Qualitative inquiry and research design:choosing among the five traditions. Sage, Thousand Oaks

17. Clark AE (2005) Situational analysis: grounded theory after thepostmodern turn. Sage, San Francisco

18. Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R (2002) Psy-choneuroimmunology: psychological influences on immune func-tion and health. J Consult Clin Psychol 70:537–547

19. Csikszentmihalyi M (ed) (1992) Optimal experience: psychologi-cal studies of flow in consciousness. Cambridge University Press,Cambridge

20. NVivo*9 (n.d.). http://www.qsrinternational.com/products_nvivo.aspx. Accessed 09 Feb 2011

S56 J Canc Educ (2012) 27 (Suppl 1):S47–S56