The healing canvas

SIX women sat at a table covered with colored pencils and pastels, each of them focused on drawing a house with rooms representing their emotions and desires.

Susan St. Jon, 63, made an abstract sketch of an African jungle home, with a circle of blank space in the center of the page. It reminded her of a vacation house in which she’d watched wild animals creep dangerously close. The white space, she surmised, was a window onto her uncertain future. “Wherever it’s going to take you, it’s going to take you,” she said, “regardless of what you do.”

The assignment was part of an art therapy support group at UCLA’s Ted Mann Family Resource Center. On this, St. Jon’s third bout with cancer -- the disease has spread from her breast to her brain and lungs -- she’s struggling to decide whether to pursue chemotherapy or give up the battle. “I’ve already come to terms with death,” she said. “I won’t panic, and I won’t be pushed.”

Art therapy harnesses the creative process to explore such difficult issues. It’s been used to treat mental and physical health problems for more than 50 years and is offered in schools, hospitals, prisons, hurricane shelters and private practice. But only now are scientific studies beginning to show its effectiveness.

In art therapy, patients express their feelings not just through discussion, but through drawing, painting and sculpting. That’s why this type of therapy is thought to be especially helpful for people who have difficulty articulating feelings -- including children and those suffering from Alzheimer’s disease, strokes and post-traumatic stress disorder. However, much of the research has centered on cancer patients. In a pilot study funded by the National Institutes of Health, cancer patients who received eight weeks of group treatment sessions of mindfulness-based art therapy (a combination of meditation and art therapy) reported a significant decrease in distress, anxiety and depression. They also reported significantly improved quality of life and vitality.

The study of 111 women, published last fall in the Journal of Psycho-Oncology, did not determine whether the art therapy or meditation component was most beneficial, but “one informs the other,” said study author Daniel Monti, director of the Center of Integrative Medicine at Thomas Jefferson University in Philadelphia. “The two sort of work together.”

A Northwestern Memorial Hospital study of 50 men and women published in January in the Journal of Pain and Symptom Management found that an hour of art therapy significantly reduced a broad spectrum of cancer-related symptoms such as pain, anxiety, exhaustion, depression, loss of appetite and shortness of breath. Patients rated symptom severity on a scale of 0 to 10 before and after treatment; only nausea was unaffected.

“A lot of people look at art therapy with suspicion. Is it just a diversion, doodling or baby-sitting?” said American Art Therapy Assn. director Cathy Malchiodi. “With research, doctors are seeing how much progress patients are making, and they realize it’s not just entertainment.”

That’s not to say that art therapy is for everyone. Although therapists emphasize that patients don’t need any artistic talent to reap benefits, some people feel uncomfortable expressing themselves through art. In the Northwestern study, 63 patients who were approached declined to participate. Some were too sick, but at least one person had tried art therapy before and simply didn’t like it. Others prefer tackling problems on an intellectual level, sometimes finding the emotions stirred up by art therapy difficult to tolerate.

“It’s not really my cup of tea,” said UCLA cancer support group member Caren Desacoff, 54, whose drawing of a house triggered memories of her unhappy childhood. She left the group early after starting to have a seizure. “I shouldn’t have been there. I really did feel kind of overwhelmed. I was going into a really dark place.”

Most members of the UCLA group, however, described art therapy as relaxing, energizing and cathartic. “It was the most important nonmedical thing I did,” said breast cancer survivor Kerry Smallwood, 49, who attended for more than a year. “It was very powerful how the artwork accessed deeper emotions, things that were unconscious, things that you didn’t necessarily think to talk about.”

Monti, who conducted the NIH-funded study, is currently overseeing another five-year study comparing mindfulness-based art therapy with talk-based support groups for 339 breast cancer patients. It is the largest comprehensive study on art therapy to date. Already, pilot data suggests that the art therapy is more effective in reducing stress and depression.

The reason, Monti posits, is that meditation and art making, when combined with discussions about the meaning of the art and the feelings evoked, engages more of the brain than merely talking. “It provides a means of conceptualizing and expressing the illness experience and ways to cope,” he said.

Monti also plans to perform brain imaging research on a subgroup of cancer patients in the study to determine precisely how art therapy might affect the circuitry of the brain.

Brain matters

Psychiatrists already have strong theories about how art therapy works, especially as it relates to trauma treatment. Allan Schore, associate clinical professor of psychiatry and biobehavioral sciences at UCLA’s School of Medicine, says that traumatic and stressful memories are stored in the right hemisphere of the brain, which processes emotions, visual and nonconscious information.

The left brain controls logical thinking and verbal skills. But for therapy to be effective, “it has to get into the right brain,” Schore said. Creating art is a fast way to access the right brain and the emotions stored there.

“Saying I’m scared and angry is one thing. Taking a crayon and scribbling on a piece of paper is a visceral way of not just saying it, but experiencing it,” said Jan Oxenberg, a TV writer who tried art therapy after she was involved in a shooting during a civilian ride-along with the LAPD.

While making art activates the right brain, talking about it and constructing a coherent story about the traumatic experience activates the left hemisphere as well. Integrating the two leads to healing. “What is expanded is the interconnectivity of the brain,” Schore said.

Interest in art therapy for trauma has skyrocketed in recent years because of world events such as the Sept. 11 attacks, the Asian tsunami, Hurricane Katrina and the Iraq war. According to Malchiodi at the American Art Therapy Assn., membership has grown from 4,000 to 4,500 since Sept. 11, and many art therapy programs are having to turn away applicants.

San Francisco art therapist Linda Chapman, creator of a model for treating pediatric trauma patients, conducted a 2001 UC San Francisco study of 85 hospitalized children and adolescents suffering from trauma after violence, abuse, accidents and chronic illnesses. Results were published in the Journal of the American Art Therapy Assn.

Chapman found that art therapy significantly reduced some of the acute symptoms of post-traumatic stress disorder one week and one month after discharge from the hospital.

However, it did not reduce the symptoms of PTSD compared with control groups at a six-month follow-up. Chapman said it was impossible to control whether participants had suffered additional traumatic experiences and that more research is needed.

In fact, a large study of art therapy for veterans with PTSD is in the planning stages. Stanford art therapy researcher Kate Collie and a committee of the American Art Therapy Assn. are designing the study, which may include recent Iraq War veterans, one of eight of whom exhibit signs of PTSD, according to an Army survey. The long-term goal is a clinical trial.

A small 1997 study of in-patient Vietnam veterans with PTSD published in the Journal of Traumatic Stress compared the effectiveness of a single session of 15 different treatment methods administered to 25 veterans over 16 weeks. Art therapy was the only treatment method that reduced PTSD symptoms in the most severe patients. Researchers theorized that it not only provided a distraction, but it helped vets deal with traumatic memories at their own pace.

Pacing is also crucial for young trauma victims, who can get overwhelmed recounting frightening experiences. By choosing specific art materials, therapists can help children experience their emotions in small, manageable doses. Chapman often starts with No. 2 pencils and tiny pieces of paper. The familiar tools and their manageable size give kids a sense of mastery and control -- over the art and over their feelings, she said.

In fact, when young trauma victims are given a choice of No. 2 pencils, colored pencils and markers, they often pick plain pencils. That’s because color evokes emotion, Chapman said.

Used correctly, however, color can be a powerful tool. When Chapman worked with kids in pain, she would ask them to paint the color of pain onto a drawing of the part of the body that hurt. Most kids would choose red or black. Next she would have them pick a color to take away their pain, usually blue or white. Chapman found the simple act of painting over the problem area would soothe them.

Revelations and renewal

Art therapy can be an especially useful diagnostic tool with kids and others who have a hard time talking about feelings.

Art therapist Esther Dreifuss-Kattan, who leads the art therapy group at UCLA’s Ted Mann center, also works with the university’s Pediatric Pain Program. She recalls one teenager whose drug addiction was revealed in a single session.

Although he said he “had pain all over,” doctors could find no cause. But then he created a collage of a monkey with a skeleton on its lap. He told Dreifuss-Kattan, “When you take drugs you feel like a skeleton.”

“Millions of things come up with one picture that would take three months when you just talk,” she said. “You go to a level of depth so fast.”

Art therapist Delaine Due, who works in a youth correctional facility in Oregon, has found that combining art therapy with journaling helps inmates reveal incidents and feelings they might normally find too uncomfortable to share with others.

One boy in her group recently created a drawing with the word “Failure” in red on a black piece of paper. In his journal, he wrote about falling short of his mother’s expectations. “If you just ask questions, you would not get that type of information,” she said. “But with 15 minutes to sit with it and get the whole brain and body involved, it’s a better intervention.”

Involvement of the body is a main difference between art and traditional psychotherapy. Physical activity -- particularly the act of creation -- can combat depression, said Noah Hass-Cohen, director of Phillips Graduate Institute, one of two art therapy schools in the Los Angeles area. “When we’re depressed, we tend to be able to do less,” she said. Making art is a safe way for people to jump-start their brains and bodies after a period of lethargy and inaction.

Toni Morley and Angel Duncan, codirectors of the Memories in the Making Program at the Alzheimer’s Assn. of Northern California and Northern Nevada, have documented positive effects of fine arts on men and women with dementia.

Patients had a limited ability to verbalize their feelings, so observers recorded signs of emotion and compared the effect of attending two separate activity groups. Those in a watercolor painting group displayed more positive emotions and little sadness, anger and agitation compared with a group that discussed current events.

One African American man from Louisiana, who was depressed when he joined the art group, painted his childhood farm home entirely in black. Within a month, he was painting in color and saying how much he looked forward to it.

The art also helped some patients recall long-forgotten memories. One generally nonverbal woman with Alzheimer’s painted a pale pink flower. When Morley asked if she’d seen the flower before, she put her hands on her hips and said, “Well, my dear, for my 30th anniversary, I booked a trip to the Hawaiian Islands. The flower grows everywhere on the Hawaiian Islands.”

If not for the painting, such memories probably “would not have come back,” Morley said.

A growing support group

The benefits of making art extend to people who aren’t suffering from emotional or physical problems, and a therapist is not necessarily required either. Older adults, for example, have been shown to improve their general health, mental health and social functioning through community-based art programs.

In a 2001 study of 300 people ages 65 and older, Gene Cohen, director of the Center on Aging, Health and Humanities at George Washington University in Washington, D.C., found that art gave study participants a sense of accomplishment, boosted the immune system and decreased loneliness.

Those who participated in art groups also had fewer doctor visits and used less medication than those in control groups.

“Art is like chocolate to the brain,” Cohen said. “It taps into both sides. It has benefited the soul of the species since the time of cavemen or before.”

Of course, that raises a fundamental question about art therapy: How much of the benefit derives from the art and how much from therapy?

“There’s always a dynamic tension between the two,” said Paula Howie, president of the American Art Therapy Assn. Some programs emphasize one more than the other, and no one knows for certain which methods work best.

At UCLA’s art therapy cancer support group, the time is split evenly between making art and discussing emotional issues. After St. Jon disclosed that she might not seek treatment, art therapist Dreifuss-Kattan urged her to reconsider.

She also offered a less fatalistic interpretation of the tunnel-like center of her sketch. “For me, the space here gives an opening, a possibility for a way through the jungle,” she said. “It’s a protected, quiet, contained area, but not enough to stay here because the lion might creep up.”

Group member Desacoff chimed in to add support. “I see a bridge,” she said. “I see hope. I think there’s brightness in your future.”

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Creative therapy resources

* For more information about art therapy, contact the American Art Therapy Assn. at (888) 290-0878 or www.arttherapy.org.

* To find a licensed art therapist near you, go to www.arttherapistlocator.org.

* For more information on UCLA’s cancer support group, contact the Ted Mann Family Resource Center at (310) 794-6644 or www.cancerresources.mednet.ucla.edu.