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

Background

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.

Methods

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 ].

Study eligibility

Inclusion criteria

(1) Participant type: this review considered all peer-reviewed published studies, including all cancer patients who received DT, regardless of age, category, or stage. (2) Concept: this review considered all studies that addressed the application of DT in cancer patients. (3) Context: this review considered all studies conducted in hospital units such as outpatient clinics, chemotherapy centers, and counseling centers. Studies conducted in home settings and community settings were also considered. (4) Types of studies: We considered peer-reviewed research articles that explored the methods and effects of DT as applied to cancer patients. (5) Duration and language: We included all articles published in English or Chinese from the time the database was created until October 31, 2023.

Exclusion criteria

studies in which the participant was the primary caregiver of cancer patients, studies without full text, and articles published in languages other than Chinese or English.

Search methods

With consultation from an academic librarian, two authors (JH and JQ) employed a three-step search strategy for relevant articles. Throughout the process, disagreements were resolved through discussion with the fourth author (CG) until a mutual agreement was met.

Firstly, we performed a pilot search. Embase and MEDLINE databases were searched with keywords. From this pilot search, we scanned selected papers’ titles, abstracts, and index terms for relevancy. A pilot screening was conducted with five articles to discuss and clarify any difficulties in the screening process. A full screen was commenced immediately after the pilot screening.

Secondly, we combined keywords and indexed terms in a unique search strategy according to the specifics of each database (PubMed, Web of Science, Cochrane, CNKI (China National Knowledge Infrastructure), Wan Fang (Wan Fang Database in China), VIP (China Science and Technology Journal Database)和CBM (China Biology Medicine). Taking PubMed as an example, the search strategy is shown in Fig. 1 .

Thirdly, we scanned the reference list of relevant papers from the first two steps and contacted the corresponding authors whenever further information was needed.

Retrieved articles were uploaded into EndnoteX9, a software application allowing researchers to manage and analyze large volumes of scientific literature efficiently. After duplicates were removed, articles were screened for eligibility according to the inclusion and exclusion criteria. During the eligibility assessment phase, disagreements between the two authors (JH and JQ) were resolved through discussions with the fourth author (CG) until a mutual agreement was met. Based on this process, 30 articles were eligible for inclusion in this review.

Data compilation and charting

Two researchers independently extracted information from the 30 studies included in this review. The following were summaries of each article that included the first author, publication year, country, sample size, study design, study participants, implementers, intervention time, intervention methods, and outcomes. The data extraction method was tested with one of the included articles. Neither researcher reported any differences or problems regarding data extraction. The method was repeated for the rest of the studies. A third experienced researcher checked the extracted data for accuracy and integrity. Synthesis of results and presentation.

We performed frequency counts for some data, such as sample size, country, and type of cancer. In addition, the data collected was also presented in a narrative format, which may include tables and figures to map the evidence available in the DT literature on cancer patients. In this way, gaps in the existing knowledge can be identified, and the form, duration of intervention, and patient outcomes of DT can be analyzed.

Results

Literature search

Initially, 3318 papers were retrieved from nine databases, resulting in 2926 references after eliminating duplicates. Then, 2812 articles were excluded from the literature after browsing the titles and abstracts. In the eligibility phase, two researchers from the research team independently assessed 114 full-text articles and conducted an additional search through their references. No new eligible articles were found, and 84 records were discarded for failing to meet the eligibility criteria. Thirty articles were ultimately included. Figure 2 shows the PRISMA flowchart diagram used for eligible studies.

Article characteristics

Key characteristics of the included studies were presented in Table 1 . The results of the calculations for the characteristics listed in Table 1 were shown in Table 2 . Of the 30 studies reviewed, there were significant variations in the aims and designs of the studies. All studies reviewed were quantitatively described and contained 14 randomized controlled trials.

These studies were conducted in 9 countries: United States ( n = 6), China ( n = 11), Turkey ( n = 5), Iran ( n = 2), Japan ( n = 1), Israel ( n = 1), Italy ( n = 1), Spain ( n = 1), and Sweden ( n = 2).

These studies had different study populations: seven of them were specific to breast cancer patients ( n = 7), pediatric cancer patients ( n = 2), hematological and bone marrow tumor patients ( n = 4), and gynecological tumor patients ( n = 3).

The overall sample sizes of the included studies were relatively small, with a maximum sample size of 230 cases and a minimum of 7 cases.

Intervention characteristics

The specific interventions were summarized in Table 3 , including the implementer, intervention duration, post-intervention assessment time, assessment tools, and outcome indicators.

This study defined a DT implementer as a person responsible for facilitating DT. Implementers were mentioned in 26 out of 30 studies in the literature included in this study. The implementers conducting DT included nurses ( n = 9), art therapists ( n = 12), psychotherapists ( n = 2), volunteers ( n = 1), clinical psychologists ( n = 1), and postgraduate students ( n = 1).

The forms of DT for cancer patients could be summarized as free drawing, thematic drawing, and mandala drawing. Free drawing referred to the participants’ free creativity, giving full play to their imagination (e.g., scribbling) and expressing their inner emotions and feelings to the maximum extent possible. After the drawing, the researchers encouraged the patients to elaborate on the content and meaning of the drawing. Thematic painting referred to the patients’ creation of paintings according to a limited context or form (e.g., family painting, room-tree-human quiz, etc.). The researchers discovered the patients’ inner feelings, emotions, and needs by analyzing the specific details of the paintings. Mandala drawing involved participants filling in and coloring within a given mandala template (e.g., The Secret Garden picture book by Johanna Beresford). After the painting was completed, patients were guided to appreciate their work from different perspectives and were encouraged to express their emotional experiences during the painting process.

Twenty-six of 30 studies described the DT intervention duration in detail, which included the length of the entire intervention (40 min to 12 weeks), the number of interventions (1 to 21), and the length of a single intervention (25 min to 4 h).

The majority of studies ( n = 21) assessed the effects of the DT intervention immediately after the intervention. A small number of studies ( n = 8) assessed the effect 24 h after the intervention, and 4 studies assessed the effect at specific nodes (e.g., 1 week after intervention, 1 month after intervention, 2 months after intervention). Only 1 of the 26 studies assessed the DT effect in a 4-month follow-up.

Twelve studies reported physical indicators including pain (the Universal Pain Assessment Tool), cancer-caused fatigue (BFI), nausea and vomiting (MAT, nausea and vomiting grading scale), stress (VAS, CRI, salivary cortisol levels), sleep (PSQI), somatic symptoms of malignancy (SCL 90), and incisional discomfort. Psychological indicators were reported in 25 studies, including anxiety (SAS, HAMA-14, SATI, SAI), depression (SDS, CDI, SASB), self-efficacy (Standardized Psychosocial Measurement Questionnaire), psychological distress (The distress thermometer), hope (HHI, SHS), negative emotions (PANAS, POMS, MSAS), and mental health (FACIT-Sp). Three studies reported social functioning, including social competence (KIDSCREEN-10) and social adjustment (Quality of Life Questionnaire, FACIT-Sp). Nine studies reported other indicators, including quality of survival (QLQ-C30, FLIE), self-satisfaction, and medication correctness (Quality of Life Questionnaire for Cancer Patients). Most studies reported positive effects of DT on physical, psychological, social functioning, and quality of life in cancer patients. However, some studies ( n = 3) showed that DT has almost negligible effects on patients’ fatigue and anxiety.

Discussion

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.

Limitations

This study has several limitations. Only full-text articles published in Chinese or English were included in the study, which led to the exclusion of some DT studies. Additionally, the limitations of the existing study design may have contributed to biased results.

Implications for practice

We found that some DT interventions could be optimized. To begin with, the duration of DT interventions should be set according to the actual situation of cancer patients. Then interdisciplinary collaboration is strongly recommended to facilitate the effective implementation of DT. Finally, it is recommended to consider the use of objective indicators such as salivary cortisol in combination with subjective indicators for a comprehensive assessment.

Conclusion

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.

Acknowledgements

We acknowledge the technical review by the editorial board.

Author contributions

CJH conceived the entire paper framework and was responsible for writing the paper. SJQ and HCG were responsible for data extraction and paper screening. WLP was responsible for the revision, editing and approval of manuscripts. All authors have rigorously revised and edited successive drafts of the manuscript. All authors read and approved the final version of the manuscript.

Funding

Not applicable.

Data availability

Data is provided within the manuscript.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

1. World Health Organization. https://www.who.int/health-topics/cancer/

2. Siegel R, Miller K, Wagle N, Jemal A. Cancer statistics, 2023. Ca-a Cancer J Clin. 2023;73(1):17–48.

3. Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Cancer. 2021;71(3):209–49.

4. Chen Z, Zhang P, Xu Y, et al. Surgical stress and cancer progression: the twisted tango. Mol Cancer. 2019;18(1):132.

5. Wolyniec K, Sharp J, Fisher K, et al. Psychological distress, understanding of cancer and illness uncertainty in patients with Cancer of unknown primary. Psychoncology. 2022;31(11):1869–76.

6. Amano K, Hopkinson J, Baracos V. Psychological symptoms of illness and emotional distress in advanced cancer cachexia. Curr Opin Clin Nutr Metab Care. 2022;25(3):167–72.

7. National Institutes of Health,National Centre for Complementary. and Alternative Medicine(NCCAM).Complementary,alternative,or integrative health [EB/OL].(2021-04-17).

8. Kim O, Heo N. Self-management support with yoga on psychological health and quality of life for breast cancer survivors. Int J Environ Res Public Health. 2022;19(7):4183.

9. Ghesquiere A, Wyka K, Smith M, Kutner JS. Associations between psychological symptoms and treatment outcomes of a massage therapy intervention: secondary analyses of a randomized controlled trial. Complement Ther Med. 2019;46:116–22.

10. Zhao C, Lai L, Zhang L, et al. The effects of acceptance and commitment therapy on the psychological and physical outcomes among cancer patients: a meta-analysis with trial sequential analysis. Journals Psychosom. 2021;140:110304.

11. Cai J, Wang C. Effects of drawing therapy on chemotherapy-related nausea, vomiting and anxiety in breast cancer patients. Nurs Res. 2022;36(21):3890–6.

12. Sun L, Zang Y, Dun X, Ming J, Wei Y, Leng M. Effects of mandala painting therapy on negative emotions of tumor patients. People’s Liberation Army Nurs J. 2021;38(09):71–4.

13. Sun Y, Du K, Li Q, Zhang X. Application of painting art therapy in postoperative rehabilitation of breast cancer patients. Hebei Med. 2017;39(11):1743–5.

14. Liu H. Research on the application of drawing therapy in psychological counseling. Educ Modernization. 2017;4(46):377–8.

15. Qiu H, Liang R, Chen L, Yi C. Research progress on the role of drawing therapy in psychological rehabilitation. Chin J Health Psychol. 2015;23(05):788–92.

16. Dolan W, Dilkes B, Stout J, Bonawitz N, Chapple C. Mediator complex subunits MED2, MED5, MED16, and MED23 genetically interact in the regulation of phenylpropanoid biosynthesis. Plant Cell. 2017;29(12):3269–85.

17. Deshmukh SR, Holmes J, Cardno A. Art therapy for people with dementia. Cochrane Database Syst Rev. 2018;9(9):CD011073.

18. Zou L. A study on the application of drawing therapy to the enhancement of college students’ self-awareness. Jinan: Shandong College of Arts; 2012.

19. Peters MDJ. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synthesis. 2020;18(10):2119–26.

20. Tricco A. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med. 2018;169(7):467–73.

21. Li Y, Chen H, Ma L, Gao W. Psychological intervention of mandala painting psychotherapy for advanced cancer patients. Qinghai Med J. 2017;47(08):33–5.

22. Liu X, Zhang M, Jiang S, et al. Study on the application of drawing therapy in the perioperative care of gynecological cancer patients. Gen Pract Nurs. 2022;20(25):3527–30.

23. Su L, Xing Y, Li H. Application of mandala painting therapy in primary liver cancer patients treated with radiofrequency ablation. Henan Med Res. 2022;31(17):3227–31.

24. Yang L, Su L. Effects of drawing therapy on mood and quality of life of postoperative chemotherapy patients with breast cancer. Mod Clin Nurs. 2022;21(09):55–61.

25. Peng X, Chen J, Huang L, Wen Q, Yan Qi, Du L. Study on the effect of drawing therapy on breast cancer chemotherapy patients. Chin J Nurs. 2017;52(10):1200–3.

26. Zhang W. Effects of painting art therapy on nausea and vomiting, life functioning and anxiety in tumor chemotherapy patients. Med Theory Pract. 2022;35(16):2852–4.

27. Zhao S, Yu X, Bi L, Yang H, Zhang Y. Effects of mandala painting therapy on depression status and quality of life of esophageal cancer patients. J Community Med. 2019;17(24):1597–600.

28. Zhou C, Wang C, Ren S, Wu E. Effects of drawing therapy on chemotherapy-associated nausea and vomiting and quality of life in female lung cancer patients. Nurs Res. 2020;34(15):2788–92.

29. Abdulah D, Abdulla B. Effectiveness of group art therapy on quality of life in pediatric patients with cancer: a randomized controlled trial. Complement Ther Med. 2018;41:180–5.

30. Akbulak F, Can G. Effectiveness of mandala coloring in reducing anxiety in women with early-stage breast cancer receiving chemotherapy for the first time. Explore. 2023;19(1):42–7.

31. Ando M, Imamura Y, Kira H, Nagasaka T. Feasibility and efficacy of art therapy for Japanese cancer patients: a pilot study. Arts Psychother. 2013;40(1):130–3.

32. Bar-Sela G, Atid L, Danos S, Gabay N, Epelbaum R. Art therapy improved depression and influenced fatigue levels in cancer patients on chemotherapy. Psycho-oncology. 2007;16(11):980–4.

33. Brondfield S, Bochatay N, Perlis C. Developing a community for patients with Cancer through longer-term art therapy. JCO Oncol Pract. 2021;17(4):e506–16.

34. Bell J, McHale J, Elliott J, Heaton W. The impact of art therapy on anxiety and hope in patients with gynecologic cancer undergoing chemotherapy. Arts Psychother 2022, 80.

35. Bozcuk H, Ozcan K, Erdogan C, Mutlu H, Demir M, Coskun S. Comparative study of art therapy in cancer patients receiving chemotherapy and improvement in quality of life by watercolor painting. Complement Ther Med. 2017;30:67–72.

36. Feudis R, Graziano G, Lanciano T, Garofoli M, Lisi A, Marzano N. An art therapy group intervention for cancer patients to counter distress before chemotherapy. Arts Health. 2021;13(1):35–48.

37. Elimimian E, Elson L, Stone E, et al. A pilot study of improved psychological distress with art therapy in patients with cancer undergoing chemotherapy. BMC Cancer. 2020;20(1):899.

38. Gurcan M, Turan S. The effectiveness of mandala drawing in reducing psychological symptoms, anxiety and depression in hospitalized adolescents with cancer: a randomized controlled trial. Eur J Cancer Care 2021, 30(6).

39. Kaimal G, Carroll K, Mensinger J, Dieterich R, Biondo J, Levin W. Outcomes of therapeutic artmaking in patients undergoing radiation oncology treatment: a mixed-methods pilot study. Integr Cancer Ther. 2020;19:1534735420912835.

40. Lawson L, Glennon C, Fiscus V, et al. Effects of making art and listening to music on symptoms related to blood and marrow transplantation. Oncol Nurs Forum. 2016;43(2):E56–63.

41. Lawson L, Williams P, Glennon C, Carithers K, Andrejack A, Wright N. Effect of art making on cancer-related symptoms of blood and marrow transplantation recipients. Oncol Nurs Forum. 2012;39(4):407–407.

42. Öster, I, Magnusson, E, Thyme, K. E, Lindh, J.,Åström, S. Art therapy for women with breast cancer:: The therapeutic consequences of boundary strengthening. Arts in Psychotherapy 2007, 34(3): 277–288.

43. Sertbaş G, Ok E, Unver V. Effects of creative arts intervention on anxiety, depression and sleep quality among bone marrow transplantation patients during protective isolation. Cancer Nursing 2023, 46(1): E1-E10.

44. Tahmasebi Z, Maghsoudi J, Talakoub S. The effect of painting on depression in children with cancer undergoing chemotherapy. Iran J Nurs Midwifery Res. 2017;22(2):102–5.

45. Thyme K, Sundin E, Wiberg B, Oster I, Aström S, Lindh J. Individual brief art therapy can be helpful for women with breast cancer: a randomized controlled clinical study. Palliat Support Care. 2009;7(1):87–95.

46. Wiswell S, Bell J, McHale J, Elliott J, Rath K, Clements A. The effect of art therapy on the quality of life in patients with a gynecologic cancer receiving chemotherapy. Gynecol Oncol. 2019;152(2):334–8.

47. Yakar H, Yilmaz B, Ozkol O, Gevher F, Celik E. Effects of art-based mandala intervention on distress and anxiety in cancer patients. Complement Ther Clin Pract. 2021;43:101331.

48. Lane M. Creativity and spirituality in nursing: implementing art in healing. Holist Nurs Pract. 2005;19:122–5.

49. American Art Therapy Association. About art therapy [EB/OL]. (2017-06-01) [2021-04-24]. https://arttherapy.org/about-art-therapy/

50. Sonke J, Pesata V, Lee J, Graham J. Nurse perceptions of artists as collaborators in interprofessional care teams. Healthc (Basel). 2017;5(3):50.

51. Vallortigara G. The evolutionary psychology of left and right: costs and benefits of lateralization. Dev Psychobiol. 2006;48(6):418–27.

52. Stahl J, Dossett M, LaJoie A, et al. Relaxation response and resiliency training and its effect on healthcare resource utilization. PLoS ONE. 2015;10(10):e0140212.

53. Zhou L. An overview of the unique role of painting psychotherapy. Jiangsu Social Sci. 2006;S1:61–3.

Associated Data

Data Availability Statement

Data is provided within the manuscript.