International Conference: Re-creating the World. The Transformative Power of Arts and Play in Psychotherapy
Varna, Bulgaria, September 4-7, 2003
Title: The use of Art in Psychological Assistance for patients with Cancer
Joel Salles Giglio
Erika Antunes Vasconcellos
Department of Psychological Medicine and Psychiatry
The present study was designed to study the use of techniques from the area of art therapy in the psychological treatment of cancer patients. It is based on a review of research using this therapy in the area of psychoncology, as well as clinical observation. The literature in the field points out that the creative experience is an expression of the internal world, thus providing a channel for the elaboration of internal conflicts, whether or not these are related to the illness and its treatment, as well as an option for the rehabilitation of cancer patients. These affirmations are confirmed by our clinical observations. There are basically three lines of research which link art therapy to psychoncology. The first investigates the curative nature of the intra-psychic creative process; the second studies the therapeutic exploration of interpersonal relationships as expressed by the artistic process; and the third involves an interpretative analysis of artistic production within the framework of one or more psychodynamic theories, here that of Jung. Our clinical experience has linked the use of such techniques to an increasing awareness of the disease, with different techniques being effective for different therapeutic aims, since the situation of each patient can be used to trigger the selection of the most adequate techniques and materials for that specific case. Art therapy in the hospital context, however, is a relatively unexplored practice in Brazil, although it can contribute important orientations for therapy designed to reintegrate the cancer patient psychologically into society.
- Key words: art therapy, artistic techniques, cancer
The utilization of art in the psychological treatment of cancer patients can help the therapist understand these patients by means of an analysis of their artistic production. This knowledge can then facilitate obtaining concrete results in clinical practice. The present study, which is based in part on the doctoral research of one of the authors, has used the qualitative clinical method to gain insights into the subjective world of a young cancer patient who participated in art therapy sessions. The data obtained are then discussed from the point of view of Jungian Analytic Psychology.
1. Artistic expression and the subjective world
The pioneer studies relating artistic activity to the expression of the subjective world were conducted at the end of the nineteenth century, although this idea became more popular at the beginning of the twentieth, with the progressive interest of various authors in a more detailed comprehension of the processes involved. However, the studies which outline the role of artistic expression as a therapeutic instrument are more recent.
The recognition of the subjective aspects inherent in artistic expression and the utilization of this expression in the therapeutic process increased in scale during the 1920’s and 30’s. Prior to this period, Freud had used art to analyze the intrapsychic process in his attempt to analyze culture and understand the work of certain famous artists. Jung had also delved deeply into the archetypes of the collective unconscious, investigating and analyzing symbols, dreams, and the language of images, and already included the use of art as part of his psychotherapeutic treatments. The contemporaries of these men also contributed widely to the area in their investigation of the use of correlations between subjective experience and art. Two of these individuals receive special attention. The first of these is Mohr (1906), whose work influenced the elaboration of psychological tests such as the Rorschach and TAT; the second is Prinzhorn (1910; 1922, apud Andrade, 1993), who studied both psychopathological and normal processes of artistic expression.
But it was only in the 1940’s, after these initial studies, that art therapy was truly defined as a definite area of work. This was basically due to the efforts of Margareth Naumberg, working in New York, who was largely influenced by the Freudian approach. Naumberg worked with the spontaneous production of art in the psychotherapeutic process and suggested that the spontaneous production of images, whether two- or three-dimensional, provided the liberation of the unconscious.
“The process of art therapy is based on the recognition that man´s fundamental thoughts and feelings, derived from the unconscious, reach expression in images rather than in words (…) The techniques of art therapy are based on the knowledge that every individual, whether trained or untrained in art, has a latent capacity to project his inner conflicts into visual form. As patients picture such inner experiences, it frequently happens that they become more verbally articulate.” (Naumberg, 1958, p.g 511).
Various professionals in the 1970’s also explored the clinical use of art therapy in general, including Françoise Dolto, Janie Rhyne, and Natalie Rogers, whose contributions were concentrated on work with children, the introduction of the concept of Gestalt therapy to art, and the application of Carl Roger’s person-centered theory, respectively (Andrade, 1993).
The first to use art therapy in the treatment of somatic illnesses was the British artist Adrian Hill. In the 1940’s, he worked with art with his tuberculosis patients in a sanitarium; he was the first to use the term ‘art therapy’ to refer to the utilization of art with such patients. Hill had therapeutic objectives, as he hoped to develop resources which would help this special group of individuals to overcome their symptoms of depression (Luzzatto & Gabriel, 1998; Wood, 1998; Malchiodi, 1999). This work had important repercussions in England, and little by little, his ideas were adopted by other professionals. In 1993, Creative Response, which is devoted to the development of art therapy, especially in attempts to mitigate suffering (Wood, 1998), became a sub-area within the British Association of Art Therapists (BAAT). Art therapy has come into its own in the USA and Europe, and at present the expression Medical Art Therapy has been coined to designate the utilization of artistic expression and images with patients with somatic illnesses in order to improve the quality of their lives by the integration of somatic, psychological and existential aspects (Luzzatto & Gabriel, 1998; Malchhiodi, 1999).
Art Therapy has thus come to be known as a single therapeutic modality, yet it involves two distinct approaches: art as therapy and art psychotherapy. The first of these, Art as Therapy, focuses on the artistic process itself and its curative properties. The second, Art Psychotherapy, utilizes artistic resources to facilitate the psychotherapeutic process, using pictures and other images to enhance the communication between patients and the therapist. In this second approach, the production of art occurs within a specific psychotherapeutic framework, using specific principles and techniques with a specific theoretical basis and objectives designed to promote the development of certain aspects of the individual’s personality (Andrade, 2000).
No clear conceptual distinction is yet made between these two approaches in Brazil. Here professionals trained in the use of the techniques and theories of psychotherapy, both psychologists and psychiatrists, tend to utilize those techniques and theories which are their professional instruments in clinical practice, merely adding their knowledge about various art forms to their arsenal of techniques. The professionals in other areas with training in art therapy also tend to utilize the theoretical and technical framework of self expression in art education, adding some knowledge about clinical and educational psychology to their therapeutic arsenal, which already included artistic production.
There is one important difference between art therapy and expressive therapies in general. The former uses manual production of art as a therapeutic resource, whereas the latter includes other forms of language as well, such as dance, music, dramatization and poetry. The two are based on the theoretical frameworks of different authors, but both can be used in the same contexts, including clinical practice, the school and the hospital, or institution. In each case, the specific therapy should reflect the specific needs of the group.
In general, art therapy was designed to improve the therapeutic experience through the use of the language of art, including both verbal and non-verbal expression, as well as the development of physical, cognitive and emotional resources, and that of skills and potentials. It can also facilitate the utilization of internal resources in the solution of conflicts, and stimulate free expression by offering space for the externalization of various aspects of the subjective world, even when the subject is unaware of them.
The artistic process in itself may involve therapeutic elements. For example, there is the possibility of accessing the subjective world, as well as the role of artistic expression as mediation between the internal and external worlds. From the point of view of subjective expression and the elaboration of intra-psychic conflicts, the value of artistic production is not based on the final product, but rather on the process involved to achieve this product (Luz, 1990; Giglio, 1992). This process involves discoveries, the freedom to create, the development of self-knowledge, and the expression of internal experiences in which symbols, shapes, outlines, colors, textures, and other elements are not necessarily perceived in terms of language, but rather in terms of images.
In Brazil, art as a therapeutic option was introduced by Osório César, and his work has greatly influenced the present approach to the use of art as part of therapy. Osório César worked with patients in the Psychiatric Hospital in Juqueri, using a Freudian perspective; he published his first article (Primitive Art of the Alienate) on the topic in 1925 (Ferraz, 1998). More important was the work of Nise da Silveira, a psychiatrist working from a Jungian perspective. She developed and coordinated systematic workshops in art with psychiatric patients in the hospital where she worked; two of the books reporting her work are classics in the field: “Imagens do Inconsciente” – Images of the Unconscious (1981) and “O Mundo das Imagens” – The World of Images (1992).
The work of these two individuals has had national, and even international, repercussions, and other foci have arisen, increasing, little by little, the use of art therapy for other segments of health care services, and for groups with different problems and pathologies.
2. Development of psychoncology and art therapy in the treatment of cancer patients
As seen above, modern psychology and psychiatry have gradually increased the use of these new therapeutic resources, especially the use of languages other than the traditional verbal one, as they progressively recognize the importance of images and body expression. This expansion is part of the penetration of psychology into other areas; instead of being limited to a general ‘Medical Psychology’ we now speak of ‘Health Psychology’, with various sub-specialities such as Hospital Psychology and Psychoncology. All of these branches of psychology assume a strong correlation between psychic and somatic processes, and have been strongly influenced by the psychosomatic approach emphasizing the need for the intergration of the professional practices from various areas.
Patients with cancer desperately need such professional help. Authors such as Simonton (Simonton et al., 1987) and LeShan (1992; 1994) were pioneers in the development of psychosocial support practices for cancer patients in the 1970’s, and they made various studies of the psychological processes involved in becoming ill with cancer. Interest in this new area of psychoncology continued to grow and was officially delineated by Holland (1990: 11) as a subspeciality of oncology involving the two psychological dimensions present in a diagnosis of cancer: 1) the impact of the cancer on the emotional functioning of the patient, his/her family and the health-care professionals involved in treatment, and 2) the role of psychological and behavioral variables in the occurrence of and survival from cancer. She also was the main founder of the International Psychoncology Society.
Psychoncology also attracted the attention of Brazilian practioners, and the first scientific meeting of Psychoncology was held in Brazil in 1989. Increasing interest led to the foundation of the Brazilian Psychoncology Society in 1994. This organization has outlined the following areas of work within the Brazilian reality:
“Psychoncology represents an interface between psychology and oncology, utilizing educational, professional and methodological knowledge from Health Psychology in the following areas: 1) the treatment of cancer patients, their families and the health-care professionals involved in the prevention and treatment of the disease, as well as the rehabilitation of recuperating patients and support provided during the terminal phase of the disease; 2) the study of psychological and social variables relevant in to an understanding of the occurrence of, recuperation from, and survival after the diagnosis of cancer, 3) the organization of cancer services designed to provide treatment for the patient as a whole, emphasizing especially the formation and optimization of health-care professionals involved in the various steps of the treatment.” (Gimenes, 1994: 46).
At present, the large cancer centers have been gradually introducing the concept of interdisciplinarity to their assistance programs. The present tendencies in the treatment of the patient with cancer are moving towards the rupture of the traditional paradigm considering the treatment of the disease in isolation from the patient as a whole.
The quality of life and the mental health of cancer patients have been the focus of many scientific studies, which have shown that the objective of therapy for such patients should not by concentrated on a single objective such as the reduction of the tumor, an increase in survival time, relief from pain, or a cure, but should rather include an improvement in the quality of life and the restoration of personal dignity and a desire to live.
In the area of Psychoncology, Art Therapy can play an important role, as it takes advantage of the creative experience expressing the subjective world for the patient. In this field, Art Therapy occurs at the intersection between psychology, oncology and art, an area which is part of Medical Art Therapy, although this concept is not yet utilized in Brazil. Clinical practice in Brazil, however, has shown that the exploration of artistic processes can facilitate a revival of meaning of life itself for the cancer patient, at least insofar as it facilitates coping with the difficulties faced during the development of the disease and its treatment.
There are three dimensions of the approach of Art Therapy (Luzzatto & Gabriel, 1998):
Expressive-Creative Dimension: This emphasizes the relationship between the patient and the image, with the therapist facilitating the expressive process.
- Cognitive-Symbolic Dimension: This emphasizes the relationship between the therapist and the patient, but this is developed from the stimulus of an image, with therapist facilitating the expressive process.
- Cognitive-Symbolic Dimension: This emphasizes the relationship between the therapist and the patient, but this is developed from the stimulus of an image.
- Interactive-Analytical Dimension: This utilizes both communication via images and direct communication between the therapist and patient, emphasizing relations of transference and countertransference.
These authors have developed specific work in Art Therapy for cancer patients and suggest that these three dimensions furnish greater flexibility for the art therapist, since they suggest how such therapy can be used to obtain various goals, depending on psychological support, cognitive work, and psychodynamic process.
In general, art therapy is used in the palliative care of patients with minimal chances for cure, helping the patient understand his/her true situation, cope with changes related to the body image, and reduce the emotional pain involved, as well as increasing autonomy and confidence, strengthening skills for coping with the disease, facilitating the expression of feelings, and strengthening the relationship with the health-care team (Wood, 1998). However, unconscious processes may also come to conscious awareness during the practice of art therapy, according to authors who work within a psychodynamic framework (Dreifuss-Kattan, 1990).
The consideration of art as an eminently subjective process and, later, as a therapeutic resource, have constituted the basis for the introduction of such knowledge into other areas of health care. Further studies are, however, necessary for the elaboration of more effective intervention with those groups where psychology and psychiatry are already practiced. This interface between the artistic process and cancer has as yet received little attention in the academic area in Brazil, although it is in a state of unbridled expansion in international circles, with numerous papers exploring the field, generally consisting of case studies (Kern-Pilch, 1980; Rubloff, 1985; Mango, 1992) or descriptions of specific art programs in a hospital context (Lane & Graham-Pole, 1994; Luzzato, 1998).
3.1 Data Collection
The present study was designed within the framework of the qualitative clinical approach, thus providing a combination of observation and intervention, as will be seen in the present discussion of the clinical practice of psychological treatment in the oncology section of the public university hospital of the State University of Campinas, in the state of São Paulo, in Brazil, where the sessions for both interviews and art therapy were conducted in the out-patient oncology clinic. Although four adult patients dagnosed with malignant neoplasia were originally included in the study, what will be reported here is the case study of only one of them.
An initial semi-structured interview was used to obtain data about patient lives, family relationships, medical history, social situation and psychological feelings in relation to the disease and its treatment. For ethical reasons, the participants were also asked to sign a form indicating informed consent. After the initial interview, the art therapy was initiated.
3.2 Data Analysis
The analysis considered not only the data obtained during the art therapy sessions, but also that obtained during the initial interview, as well as information from the medical records and that furnished by the doctors. This data is organized as follows: life story, clinical history, and observations made during the sessions involving the expressive process.
The artwork produced was saved as a record of the psychological development of the patient; this was later photographed in digital form as an image file. It was analyzed using criteria for the psychological evaluation of graphic expression (Hammer, 1991; Campos, 1994). The analysis involved basically the Jungian Analytical Approach for the understanding of images and symbolic language, although eventual relevant contributions from related theoretical schools are occasionally mentioned.
4. Synthesis of clinical case
4.1 Summary of life story
Renato (not his true name) was a 23-year-old bachelor living with his parents. He was the youngest of the eight children of the couple, although all of his brothers and one of his four sisters had already passed away. His three living sisters were married and lived with their families. Renato talked about not have had “much of a childhood”, complaining that he had never received toys from his father (possibly blaming him for a lack of interest and the attention which might have given him a happy childhood), although he had received toys from one of his sisters. Renato’s happiest memories were from pre-school years. He remembered his friends and his happiness at starting school. He dropped out of school after failing the fifth grade, however, and started working at a bakery at age 13. He later returned to school, but again dropped out in the seventh grade when he decided that he preferred to work than to be unable to buy the things that he wanted. He used the money that he earned to pay his every-day expenses. He played a lot of soccer, and even became a member of the local team. He had his first girlfriend at 16, and his sexual life began about that time; over the years he reported having had numerous girlfriends, with the longest relationship lasting two years. During adolescence, he started smoking marihuana and later used cocaine with his friends, although he no longer consumed these drugs when he initiated treatment for cancer.
His father was a very demanding person, severe and difficult to live with, who never wanted to spend money on the family. He was heard to say that only those who worked could eat. None of the brothers had gotten along with their father, and [all of the brothers and sisters had] wanted their mother to leave their father. Renato revealed hostility to the father figure in general, and referred to his mother as a calm and simple stay-at-home who suffered helplessly. Despite his mother’s presence in the home, he reported having communicated very little with her, although he reported communicating with his sister, who had helped him out financially and provided a certain affection. He also mentioned that he had difficulty in revealing his true feelings for the family.
One of his brothers had died at the age of 28 in an automobile accident when Renato was till a young child; the second disappeared when Renato was 13, and the third drowned some two years prior to the onset of Renato’s illness; that same year he also lost one of his sisters. The loss of the third brother affected him greatly, as they had been very close.
Renato’s comment about personal relationships was ‘I am a person who always tries to show that he is OK, never show people my problems. I think that there are lot of people who like me. A person easy to become friends with … But, on the other hand, I often feel lonely, and don’t know how to tell anyone what I am feeling, what’s happening, but easy to make friends.’ He reported having fewer friendships since he had become ill, although he thought he was probably more demanding in his choice of friends.
4.2 Summary of Clinical History
At 18, Renato started feeling pain in his lower body, a symptom which persisted for about a year; at that time he was the diagnosed as having Ewings’s sarcoma. He underwent chemotherapy, surgery, and further chemotherapy, after which time he showed no further signs of the disease for seven months, but the disease soon returned and he again had to drop out of school to re-initiate treatment. With the spinal column affected, radiotherapy was used, but nine months later, the cancer had metathesized in the lungs, and experimental palliative chemotherapy was initiated. This was interrupted when the disease worsened, and only eleven days before his 24th birthday, he passed away.
During the sessions of therapy, the subject revealed feelings of solitude, abandonment, sorrow, anxiety, affective deprivation and insecurity. He complained about not being able to sleep at night and about concern with the instability of his medical situation, which made it impossible to make plans for his life. He was concerned by his lack of activity and unemployed state. He expressed hope, however, that he could be cured, as he was putting his faith on the treatment and his religion. He was aware of the diagnosis and the seriousness of the illness, and recognized the limitations of medicine for his case, but he still believed in the possibility of recovery.
During therapy, he commented on his feelings about cancer: “I think, in my opinion, this disease doesn’t choose… both rich and poor. I think if it happens to somebody, they have to be aware of the fact that they have to get treatment, they are getting treatment and a lot of hope that they will overcome it … Now, I think that it has something to do with nervousness, anger, resentment.” But in relation to himself, he said, “It’s not because of this that I got sick. But I think it may have helped.”
4.3 Art Therapy sessions
Renato was included in art therapy sessions after the disease had reappeared in the spinal column. His participation in the project was accompanied for ten months, until his death in 2002. However, he had also participated in Art Therapy, both individual and group, during earlier treatment, and we have therefore included some of his artistic productions from this previous period. The comments made here will focus principally on the pictures actually produced, although it must be remembered that during certain sessions the subject chose not to produce anything.
Session 1 (group)
In this session, the patients were asked to make a painting representing some personal characteristic. Renato’s drawing (Fig. 1) shows a house without doors or windows, painted in strong contrasting colors, mainly red, which is the color of the roof. On the front of the house he wrote the word ‘closed’. This picture is suggestive of his attitude towards affection. The roof is over-large for the house, which may, according to Homer (1991) suggest his feelings of being threatened by the loss of control of his imagination, causing him to close himself off from the expression of affection. These emotions may be related to his fear of death and the progression of the disease.
Session 2 (group)
The image produced during this group session (Fig. 2) was a joint effort of Renato and another cancer patient. It showed the stump of a tree with an ax embedded in the horizontal surface. This image seems to be an allusion to the destructive nature of the disease, which cuts off lives. This picture was entitled “Hope is the last to die”. The picture is iconic, with the ax symbolizing destruction, but also representing life since a single leaf is growing from its handle. This is symbolically reminiscent of the ritual of chemotherapy, in which the medication actually destroys the healthy cells (along with the diseased ones), so that later life can be restored.
Session 3 (individual)
In this session, Renato remembered a place in the mountains where had gone with his friends to camp and climb. This reminded him of the time when he was healthy and could freely participate in outdoor sports and activities. On the other hand, the picture (Fig. 3) represents him as hanging by a rope, swinging in a void. The mountain (which also seems to be an arch of rocks) can be seen to consist of two halves: the left half represents life in the form of a tree replete with leaves, with a spring gushing forth at its base, while the right half pictures drought and destruction — a bare-branched tree, with a fire at its base. Renato has drawn himself hanging dangerously in the left half, near the healthy tree and facing the water, with his back to the fire, which may represent his attempts to live. This picture clearly shows the perils of the disease, but also his heroic fight against it. It should be remembered that in the adolescent sub-culture, sports such as rappeling involve the challenge of confronting danger (in this case, the disease).
Session 4 (indivudual)
In this session, the patient pictured the day and night in the two halves of a single scene (Fig. 4). On the left is a palm tree, covered with fruit, and another flowering plant. Above this, to the left, is a sun with four tongues of flame in the shape of a cross. On the right side are two “old trees, without leaves and without strength”. Along their trunks, stubs of branches may indicate earlier traumatic situations, also linked to helplessness, a lack of virility, and impotence in the widest sense (Hammer, 1991). These stubs may represent the conflicts with his father, the loss of his brothers under traumatic circumstances, and/or his own illness. Also on the right is a black moon, with six black stars around it. The patient himself commented on the contrast between day and night as being related to oscillations in his emotional state — fluctuating from depression and low vitality to a highly keyed up state as he contemplated a possible cure. One can infer these oscillations from the variation in the landscape, as areas covered with trees alternate with others devoid of any vegetation.
The resemblance of the sun to a cross represents a synthesis of opposites, with the sun being the symbol of life and the cross that of death. In reality, the cross in itself can also be understood in the Christian tradition as a synthesis of the opposites of death and resurrection, which would suggest dreams of cure or immortality.
The black moon on the right reminds us of the horrors of the night, indicating terrifying fears which are also represented in his first painting of the house without doors and windows and the exaggerated roof. The awareness of these feelings may generate disruptive actions as he loses control of his own emotions.
Session 5 (individual)
The picture produced during this session (Fig. 5) was made after a long interruption in psychotherapy (the patient was absent because he got a partial physical recovering). This picture portrays a heart, obviously linked to affection, which seems to be an attempt to reestablish affective ties with the therapist by offering his injured heart. The picture reveals his fear of expressing his feelings and emotions, since the concept of affection is made obvious by the use of the symbolism of the heart. In this picture, it seems to be scarred or injured. The marks represent the dimension of the traumas which injured him so badly and have reached this extremely vital organ.
The figure of the heart is surrounded by a fence, which suggests his need to protect his affective or emotional life, an interpretation which would jibe with that of the other images he produced during other art therapy sessions.
After drawing the heart, a symbol of both affection and love, he spoke about his present feelings and about how he had felt during various traumatic episodes, as well as about the conflicts throughout his life. These episodes are represented by the three “spots”, which also provide, unconsciously, a concrete record of the physical pain originating in the tumors in his pelvic region, the spinal column and the lungs.
Renato explained that he had drawn his own heart, showing his feelings and his internal life. He spoke about his “good heart”, but added that it has some “spots” that represent the ‘dissention’ involving his illness, his daily problems, his conflicts with his father, and the circumstances which had brought such pain and sorrow into his life. He said that he hoped that his heart would some day become all red, which suggests his intense desire for a cure. As a symbol of the Self, it may represent the integrated capacities of the patient in his search for a cure, despite the precariousness of his health.
Session 6 (individual)
In this session, the activity involved the preparation of a collage, which Renato completed by drawing a picture. Renato initially selected two pictures, one the illustration of the hold of a slave ship and the other a picture of a family living in abject poverty (Fig. 6) He tried to find other pictures in magazines which could contrast with the ideas of slavery and misery, but couldn’t find what he was looking for. In the end, he glued the pictures he had chosen to the page and completed the collage with sketches. For the elements with a negative connotation, Renato had found pictures, but for those with a positive connotation he had had to create his own images to symbolize what was missing. He thus drew a dove, representing freedom, and a lot of food, representing wealth or abundance. The shape of the dove also reminds us of a fish, which may reflect the depth of his desire for freedom (fish are representative of the unconscious). The negative images reveal his lack of freedom at the time, as well as his financial difficulties. Moreover, in relation to hunger, he also showed his affective need to “feed the soul”. Once again, that which was the representation of human suffering on a collective level became the reflection of personal suffering as well.
Session 7 (individual)
In the painting produced during this session, the patient drew a road disappearing into the mountains (Fig. 7). In the distance is the sun. On the two sides of the road are two large trees, with a smaller one right below the one on the left. It was originally drawn after a drop of paint had accidentally splattered on the page while he was painting the large tree. One can think of the two large trees as representing his parents, while the smaller one is he himself. It is interesting to notice that this smaller tree is on the left-hand side of the picture — the maternal side (Zimmermann, 1992).
The road stretching into the mountains may be interpreted in two ways. One interpretation would be that it represents the road of his life on earth coming to an end. In spiritual terms, it could also be interpreted as a road leading to the sun, and hence to heaven, with the sun representing God (the Self) (Jung, 1976; Edinger, 1972; Chevalier, 1988). The reader should remember that this was the next-to-last picture made by the patient, possibly presaging his death and resurrection. With this interpretation, it is interesting to notice that the three trees, mentioned above, may also be related to the number ‘three’, a symbolic reference to the holy trinity (Chevalier, 1988).
Although our interpretation implies rather profound thoughts on the part of the patient in relation to physical death and eventual rebirth on the spiritual level, the patient at this time continued to express his desire for a cure, as can be seen in a story that he told to the therapist during a session of relaxation and visualization in which Renato, hospitalized and quite weak, imagined himself getting up, walking and leaving the hospital.
Session 8 (individual)
In this session, the last of Art Therapy (Fig. 8), Renato drew a picture of his sick lungs, replete with metathesis, on the left-hand side of paper, while on the right, he drew two healthy lungs, representing his high hopes for cure. After dividing the page with a line down the middle, he wrote: “before” and “after” above the two images that he had drawn. The black spots on the sick lungs represent the disease, but they have disappeared from the healthy lungs, colored orange. Orange is the color of health and equilibrium (Chevalier, 1988). It is interesting to notice, however, that orange is more closely related to fantasies than to actions (Campos, 1994). This picture clearly represents the patient’s hopes for a cure, even though this would contradict the medical prognosis, which was not at all promising. Despite this, some of the doctors who were working with him commented shortly after his death that he had survived much longer than had been expected.
The clinical prognosis was very discouraging, and Renato showed a great need to verbally share his experience of physical pain and his difficulty in coping with the situation of dependence. In all of his sessions of Art Therapy, he revealed his rejection of the limits imposed by the disease, as well as a reaffirmation of the possibility of a cure, denying the imminence of death.
We have seen that Renato used archetypical images of the Hero, as he waged a true battle against the cancer, following the arduous path and challenging both internal and external dangers: the disease itself and the aggressive treatment attempted. He came to be admired by the other patients and by the medical team. All projected heroic aspects on Renato. But in the end, the disease was even more resistant, and it finally sapped all his reserves, leading to his death.
5. Final reflections on the use of Art Therapy
5.1) In this study we have seen that the process of art therapy seems to facilitate the expression of subjective experiences and conflicts related to being sick, thus making it possible to enhance the consciousness of the patient, as in the case cited above. During the expressive process, patients tend to project elements from their internal world on their artistic production, making associations between the work of art and their personal lives. The free associations resulting from the artistic process facilitate verbal communication and help patients understand better the meaning of their lives.
5.2) The production of art has been shown to develop attitudes of free choice, independence, and autonomy in patients who, in general, have become dependent as a function of their illness. This contribution of art provides a reaction to the passivity often felt in the hospital, where all patients are submitted to daily treatment.
5.3) The possibility of psychic integration and the organization of the internal world, as well as the channeling of psychic energy into a constructive activity and the strengthening of the relationship with the therapist were also observed with the use of Art Therapy.
5.4) The patients who feel pain or are facing the collateral effects of chemotherapy seem to be resistant to the effects of art therapy. At these times, there seems to be a greater need for verbal expression, as well as for the use of techniques of relaxation and visualization.
5.5) For the psychotherapist, the pictures produced by patients who have passed away after a long period of illness serve as a valuable reminder, symbolically perpetuating the therapeutic ties. This can be reverted into new energy to invest in the initiation of work with new patients who are at the beginning of their struggle with cancer. One might ask what the patient contributes to the sessions of art therapy and what he gains. This question helps one understand the interpersonal dynamics between patient and therapist. In his projection of internal images and the elaboration and transformation of artistic material during the process of producing art, the patient symbolically leaves a part of himself with his therapist but, in exchange, he can take a better understanding of his own feelings with him, now decodified and re-interpreted. Moreover, the material left behind during psychotherapy may represent permanence and immortality by means of the images produced.
5.6) The construction and reconstruction of collective and personal symbols results from the elaboration during the artistic process. The construction of a work of art is subjective and favors the search for symbols in the collective universe, both familiar and personal. Certain images representing collective symbols are frequently found: a heart; a path; a crossing; opposites such as day and night, slavery and freedom, hunger and abundance; the polarity between health and disease, the contrast of a flourishing tree and a dead one, storms, the sun and the moon, eclipses, stones, islands, a sea of tears, fire, springs, and old age.
5.7) Artistic expression during psychotherapy introduces a language of images, which can pave the way to the communication between the patient and the therapist, especially since various feelings and conflicts are explicitly identified and verbalized. Depending on the strength of the ties with the therapist, communication on an unconscious level can be initiated, first using the pre-verbal language of images, but the therapist can then decipher these images, especially if they reappear time and again in the sessions. This unconscious communication also seems to influence the choice of techniques of art therapists, as well as the selection of the material to be offered to the patient. This shows that a therapist must recognize and correspond to the needs of a patient while simultaneously respecting his limits.
5.8) Artistic products are different in relation to the degree of conscious intention involved. Some pictures clearly reveal the intention of communicating a given experience, whereas others provide subjacent symbolic communication which can be interpreted, even when it is not consciously elaborated. These variations occur not only from one patient to another, but also from one production to another in the work of a single patient. It is probable that this is due to the fact that an artistic production presents both an explicit message and a latent one. The explicit content is subjected to the interference of conscious and egoic processes, while the latent content is codified by the symbolism of images and transmitted through unconscious communication between patient and psychotherapist.
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 Associate Professor and Coordinator of Mental Health Post Graduate Program of the Medical Psychology and Psychiatry Department of the Medical School – State University of Campinas (Unicamp), Brazil
 Doctorate Student at the same Department. Clinical Psychologist – Service of Clinical Oncology of the School Hospital, at Unicamp, Campinas.