Intervention and application of drawing therapy in cancer patients: a scoping review

The World Health Organization reports a marked escalation in cancer incidence, with an estimated 19.5 million new malignant tumor cases identified globally in 2023 [1, 2]. Patients often endure significant physical and psychological distress due to the tumor and its treatment [3, 4], which encompasses pain, chemotherapy-induced nausea and vomiting (CINV), as well as anxiety, depression, and fear [5, 6]. These physical and psychological problems substantially degrade the quality of life of cancer patients. In response to these issues, healthcare providers have begun to focus on complementary and alternative medicine (CAM). CAM is an inclusive field encompassing many widely accepted treatments, from herbal remedies to art therapies [7]. Unlike traditional treatments, CAM not only effectively manages the physical and psychological symptoms of cancer patients but also has the advantages of being safe, non-toxic, and higher patient acceptance [8‐10]. Among them, drawing therapy (DT) is a representative CAM that is often used in conjunction with conventional treatments in clinical practice as a beneficial complement to traditional therapy to help cancer patients control their physical and psychological discomfort [11‐13]. DT is based on the psychological principles of projection and brain lateralization [14, 15]. In other words, drawing helps patients to divert their attention and express their inner feelings through creative activities, thus relieving physical and mental symptoms.

Although DT has demonstrated its unique value and potential in the cancer treatment field, there is currently no standardized concept of DT. The American Art Therapy Association defines it as a therapeutic modality that activates individuals’ free association mechanisms through drawing activities to regulate psychological states [16]. The British Association of Art Therapists describes DT as a process assisted by a therapist, where drawing serves as a conduit to externalize hidden thoughts and emotions [17]. Chinese scholars characterize it as a process in which suppressed emotions within the subconscious are released during drawing, thereby achieving therapeutic benefits [18]. These different definitions reflect the diversity and complexity of DT in different cultural and professional contexts. Despite varied descriptions across different countries, they all aim to express the inner meaning of emotions through the external creative form of drawing. With the help of non-verbal and verbal communication in the drawing process, the deeper emotions of patients can be explored, discovered, analyzed, and relieved, providing them with more strength. However, the lack of a unified definition may lead to a lack of uniformity in DT application in the clinic, as well as communication barriers between different practitioners, which ultimately creates specific difficulties in supervision.

Our review of the literature identified a lack of systematic literature reviews specifically focusing on DT in cancer patients to assess the effectiveness of DT in cancer patients. Therefore, this study aims to reveal the differences between DT practitioners and implementation methods in different practice contexts by integrating DT data from various countries; to explore in depth the impact of DT on cancer patients; and to make recommendations for future research based on the analysis of existing studies.

This review is based on the Joanna Briggs Institute (JBI) approach to scoping review. It is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews (PRISMA-ScR) [19, 20].

This scoping review of 30 studies examined the impact of DT on cancer patients. Interventions varied regarding implementer, intervention type, intervention duration, post-intervention assessment time, and outcome indicators. In China, predominantly DT interventions were nurses. This might be due to the nation’s current generally non-recognition of art therapy as a distinct professional discipline, resulting in a lack of professional art therapists. Nurses’ extensive ward experience promoted a profound understanding of patient needs [48], forming strong patient bonds and positioning them as suitable implementers of DT. However, it is important to note that although nurses effectively implemented DT, most lacked professional art therapy training. As our review results had shown, most forms of DT in China were limited to mandala forms that do not require much professional foundation. In countries outside of China, DT was conducted by certified professional art therapists. Through an in-depth understanding of art therapy knowledge, professional art therapists were able to design tailored DT programs according to the therapy goals [49], and they were also able to provide in-depth and professional guidance to patients during the DT process. Nevertheless, the interaction between art therapists and patients was typically concentrated within the therapeutic sessions. This might lead art therapists to lack a deep understanding of the patient’s situation, such as the patient’s needs and desires, as nurses do. Therefore, nurses and art therapists should develop an interdisciplinary collaboration to implement DT for cancer patients in the long run [50]. In this collaborative model, art therapists and nurses shoulder their respective professional responsibilities. Art therapists play a key role in the development, implementation, and assessment of DT. Nurses, on the other hand, play a supportive, communicative, and advocate role. Interdisciplinary collaboration not only ensures professionalism and comprehensiveness throughout the implementation process but also helps provide patient-centered care. This is because the art therapist’s expert interpretation of the patient’s creative work allows the nurses to gain deeper insight into the patient’s values and perspectives, personal experiences, and interests.

There was also variability in the form of intervention in DT. In China, DT particularly favored the form of mandala painting, which may be related to both the implementer and the patient of DT. Drawing education tended to be weak and, to some extent, even a neglected component of school education in China. This state of education left most graduates, including clinical nurses and patients, relatively lacking the complex knowledge and skills required for painting. Mandala painting, with its simple and easy-to-follow process, has become an accessible therapeutic tool for both nurses and patients who lack basic training in painting. In contrast, in other countries, such as the United States, DT favored more of a free drawing format. Freehand drawing allows patients to express their inner feelings and thoughts in a more uninhibited way, and it also requires implementers to have certain drawing skills and profound artistic interpretation abilities to effectively guide patients to express and interpret the deeper meanings in their drawings. This places higher demands on the implementer’s drawing ability and artistic interpretation than mandala painting, which are often difficult for ordinary nurses who lack an artistic educational background.

We found that the longest duration of DT intervention among the included studies was 12 weeks, and 3 of these studies [27, 28, 32] indicated that the lack of effectiveness of the DT intervention may be related to the short intervention period. Therefore, for cancer patients undergoing chemotherapy or radiotherapy, we strongly recommend extending the intervention period of DT to the entire period of chemotherapy or radiotherapy and determining the duration based on patient-specific symptoms at the end of the treatment. In addition, given the flexibility of DT implementation, we recommend DT be incorporated into primary health care so that patients can receive ongoing interventions even after discharge.

Our study also found that most of the current evaluation tools for DT in cancer patients are subjective scales. Our suggestion for this issue is to introduce more objective evaluation tools in future DT studies. Specifically, the use of biomarkers such as salivary cortisol levels could be explored to assess patients’ stress levels, or physiologic indicators such as heart rate variability (HRV), blood pressure, and respiratory rate could be used to monitor whether patients’ negative moods have improved. These objective indicators will not only provide more reliable data but will also be used in combination with subjective indicators to reveal the efficacy of DT more comprehensively. In addition, long-term follow-up assessments are essential to fully evaluate the long-term effects of DT. Thyme’s study [45] has provided us with solid evidence that DT has a long-term positive effect on depression and anxiety in cancer patients. In future studies, for short-term problems such as nausea and vomiting, follow-up visits within 24 h on Day 3 and Day 7 after DT are recommended to assess the immediate effects and whether the symptomatic improvement persists. For long-term negative moods, longer follow-up visits are recommended to fully assess the effects of DT, such as 1 week, 4 weeks, 3 months, 6 months, and 12 months (or longer) after the intervention. Such a long-term follow-up schedule helps DT implementers identify important points at which the patient’s thinking, feelings, or behavior change after DT.

This scoping review found DT has a positive impact on cancer patients. On the one hand, it relieves physical symptoms in cancer patients, which may be related to the theory of brain lateralization on which DT is based. This theory [51] clarifies that the left hemisphere of the brain is mainly responsible for logical thinking, language, analysis, and rational processing, while the right hemisphere is more involved in creative thinking, intuition, art, and spatial perception. As a creative activity, painting activates the right hemisphere of the brain and engages the patient’s attention, diverting it from pain and physical discomfort to the creation of art. When attention is shifted from physical discomfort to painting, patients can experience a state of physical relaxation and relief, which helps to reduce the body’s stress response and relieve symptoms of somatic discomfort [52]. On the other hand, the positive effects of DT on the mental health of cancer patients may be related to the projection theory. The theory mentions that projection is a form of psychological defense in which individuals transfer socially unacceptable and self-unacceptable impulses, attitudes, motives, or desires to something else [53]. Drawing offers a non-verbal means of expression for individuals to transform their negative emotions into visible works of art, thus achieving emotional release and purification. In addition, a possible reason for the social functioning improvement in DT is participants have more opportunities to interact and communicate with others during the process. The interactions during DT not only provide emotional support but also provide an opportunity to learn and practice various interpersonal skills which in turn improves the patients’ interpersonal confidence and competence. It may be due to the above-mentioned improvements in these physical, psychological, and social dimensions that DT ultimately has a positive impact on the quality of life of cancer patients.

It is important to note that there is a need to look more critically at the actual effects of DT in cancer patients. We note that the 30 studies included generally did not utilize a blinded design. This phenomenon is partly attributable to the inherent characteristics of DT. On the one hand, participants can easily identify whether or not they are engaging in DT, making subject blinding difficult. On the other hand, nurses or art therapists play a key role in DT, both as implementers and often as evaluators. This dual role complicates evaluator blinding. Our recommendations are firstly, to reduce bias by introducing an independent third-party evaluator on the outcome evaluation, and secondly, to consider objective indicators as the main indicator of the study to decrease the psychological influence.

As a relatively safe, easy-to-administer, and low-cost CAM, DT improved physical, psychological, and social dimensions in cancer patients and ultimately had a positive impact on the quality of life.

However, it was worth noting that the duration of DT and assessment criteria varied widely across studies. This inconsistency not only affected the validity of DT in clinical practice but also had the potential to lead to reduced comparability across studies. Therefore, in future studies, we strongly recommend strengthening the exploration and practice of DT standardization.