Effect of Mindfulness-Based Art Therapy (MBAT) on Psychological Distress and Spiritual Wellbeing in Breast Cancer Patients Undergoing Chemotherapy

Estimation of the sample size

Sample size calculation tool on https://sample-size.net/sample-size-study-paired-t-test/ was used.

N = Sample size/Group size

Z ^α_/2 is the standard normal z-value for a significance level α = 0.05, which is 1.96.

^β is the standard normal z-value for the power of 80%, which is 0.84.

Based on the reference study, the pre-test and post-test mean difference of psychological domain scores was 2.82.^[15]

Effect size (E) = 2.82, S^Δ is the standard deviation of the change in outcome= 5.5

B = (Z ^α_/2+ Z^β)²=7.8489.

C = (E/S^Δ)²=0.2629.

N = B/C =29.8562 = 30

The required sample size was estimated as 30. By assuming 5% lost to follow-up, the updated sample size was 32 [Figure 1].

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Figure 1:

Methodology.

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The total number of patients screened was 53. Of these, 32 were included in the study, eight patients did not consent to participate in the study, while 13 patients did not meet the inclusion criteria [Figure 1]. The reasons for not consenting to participate in the study were time constraints (n = 3), presence of lymphedema with associated pain in the arm (n = 2), not interested in art (n = 2), and vision-related problems (n = 1). Out of the 32 enrolled patients, 30 completed the 1-week MBAT intervention while two patients dropped out. The reason for dropout was the deterioration of health because of chemotherapy and associated side effects (n = 2).

The inclusion and exclusion criteria for patient recruitment are shown in [Table 1]. A detailed evaluation of patients’ condition before enrolling them in the study was made by the medical oncologist, who was a part of the research team. The presence of any cognitive impairment or neurological disease was evaluated through detailed case history, required investigations, and mentioned in the medical records of the patient. As a regular standard protocol, all patients are assessed and evaluated by the psycho-oncologist while noting down past and present history of any psychological/ psychiatric illness.

Data collection tools

The following questionnaires were used for collecting the data before starting the chemotherapy treatment, after ^1st supervised MBAT session, and after 1 week of daily home practice. The patients’ responses were recorded by the interview technique by a clinical psychologist.

The MBAT intervention

MBAT intervention consisted of the first in-person supervised session conducted by the facilitators, followed by 1 week of daily guided home practice. The sessions were conducted by experts having training and experience in art therapy and mindfulness. The mindfulness sessions were conducted by the first author of this paper, a medical doctor, qualified yoga therapist with certification in Mindfulness-Based Stress Reduction program. She has 21 years of meditation practice experience and has been teaching yoga and meditation for 15 years. The psycho-oncologist and the co-author of this paper received training in “Expressive Arts Therapy Interventions for relieving emotional and physical suffering in cancer patients” in Banff, Canada, in 2019. It was a Pre-Congress workshop during the 21^st World Congress of Psycho-Oncology, organized by the International Psycho-Oncology Society and Psycho-social academy. However, regarding art therapy intervention, the focus of our study was to add an element of mindfulness to the art activity.

The session was designed to suit the specific health conditions of the patients. Patients’ medical oncologist was consulted regarding the safety concerns and health conditions to participate in the study. Care was taken to protect vulnerable patients from potential risk factors. The following potential risk factors were considered while giving MBAT intervention.

Potential risk factors related to patient’s health

The medical oncologist was an integral part of the research team. Toxicity, chemotherapy-induced neutropenia, and side effects of chemotherapy such as nausea and vomiting were monitored and supervised. The participants enrolled in our study did not report any severe adverse effects of chemotherapy during the entire duration of MBAT intervention.

Since this study was carried out from December 2020 to February 2021 while COVID-19 pandemic was still going on, patients’ safety was given a priority. The COVID protocol was strictly adhered to. Group sessions were avoided and individual patient’s MBAT sessions were conducted.

Potential risk factors related to MBAT intervention

Although a growing body of research has documented the benefits of mindfulness-based practices, its potential adverse effects cannot be ruled out. A few studies have suggested that mindfulness may increase the awareness of difficult feelings, exacerbate psychological problems and can even lead to psychotic episodes.^[18] It is believed that the occurrence of adverse effects can reflect pre-existing problems and/or unbalanced approaches to practice.^[19]

Therefore, care was taken to exclude the vulnerable patients during the patient recruitment process. Clear instructions on how to practice the intervention were given to the patients. The intervention was simple, easy to understand and follow at home with the help of guided meditation audio in the local language.

Since no participants in the study had previous experience of mindfulness practice, the first session was supervised to monitor the patients’ responses to the mindfulness practice and to clear any doubts. Before the session, the details of the study were explained to the patients and their informed consent was obtained in writing. The responses of the patients were recorded on the questionnaires.

MBAT session

The intervention included didactic and experiential components of mindfulness meditation and mindful art.

Statistical analysis

Data analysis was done using R i386 4.0.3. Non-normal continuous data represented using median (1^st Quartile, 3^rd Quartile). Paired continuous data were compared using Quade test followed by Paired Wilcoxon test with “Bonferroni” adjustment as post-hoc. P < 0.05 was considered significant. A total of 30 patients were considered for the analysis. [Table 2] shows the demographic characteristics of the study population with reference to age, gender, diagnosis, co-morbidities and previous mindfulness practice. [Table 3] provides the summary of the data analysis.

Psychological distress

We observed a significant reduction in distress scores immediately after the first supervised session and after 1 week of daily home practice of MBAT intervention. The results of this study are in agreement with a study that has shown decreased distress levels and improved QoL in women with breast cancer after the MBAT intervention.^[15] Another randomized, controlled investigation of MBAT reported a reduction in symptoms of distress and improvements in key aspects of QoL in women with cancer.^[20]

Our results are consistent with a study that evaluated the impact of a coloring intervention on female adults’ psychological experiences. The participants experienced lower levels of depressive symptoms and anxiety following the intervention.^[21,22]

In our study, we used mindful coloring as a form of art therapy. The therapeutic value of coloring was demonstrated in a study^[22] that reported significantly lower levels of depressive symptoms and anxiety. It was suggested that daily coloring can improve some negative psychological outcomes and may provide an effective, inexpensive, and highly accessible self-help tool.^[22] Mandala coloring paired with focused breathing was suggested as an effective technique for reducing self-reported negative affect and state anxiety.^[23] A study^[24] supported the hypothesis that coloring a mandala for 20 min was more effective at reducing anxiety than free-form coloring for 20 min. Another study^[25] also concluded that coloring structured mandalas were associated with greater anxiety reduction than unstructured coloring.

SWB

In our study, significant improvements in peace, faith, and meaning sub-scales scores, as well as total SWB score, were observed. These results are consistent with a study^[14] where 8 weeks of MBAT intervention was found to have significant improvement in peace, faith, and meaning sub-scales of SWB and improvement in emotional well-being in cancer patients. SWB is being considered an important component of a comprehensive care program that influences other aspects of health. A strong association between spirituality and QoL among patients undergoing cancer chemotherapy has been identified.^[26] It has been suggested that the treatment of breast cancer patients should address SWB along with physical health.^[27] Breast cancer patients with higher scores of SWB were reported to have lower levels of stress, anxiety, and depression.^[27]

It has been observed that higher SWB is associated with reduced death anxiety in cancer patients.^[28]

Duration of intervention

Different duration of art therapies, MBAT intervention and mindfulness meditations have been investigated in studies and found to be effective in improving various aspects of psychological wellbeing. Reduction in distress levels and anxiety has been reported after a single session of art therapy^[24,25,29] and 7 days of art therapy.^[22]

While in a few studies on MBAT intervention, the duration was 12 sessions,^[21] 8 weeks^[20] and 12 weeks,^[15] short duration of MBAT interventions have also been reported to be effective. A Japanese study^[30] on advanced cancer patients suggested that a single session of Mindfulness Art Therapy Short version might activate physiologically, alleviate tension, and increase energy.

Regarding the duration of mindfulness meditation, significant results have been reported with varying duration of practice. In a study,^[31] a single 20-min session of mindfulness meditation resulted in a greater sense of religious SWB and more positive religious-spiritual coping resources. It also increased positive feelings such as optimism, hope, security, contentment, peace, and compassion. It was also observed that physiological measures of novice meditators were similar to those of the experienced group following a single session of meditation training.^[32] A brief mindfulness meditation training program (25 min each day for 3 days) has been shown to alter psychological and neuroendocrine responses to stress and buffers self-reported psychological stress reactivity.^[33]

In our study, 7 days duration of intervention was selected to improve patients’ compliance, retain their participation, and reduce the number of drop-outs.

Mechanism of MBAT intervention

The probable mechanism for the effects of MBAT intervention can be attributed to different components of mindfulness as well as expression through mindful art [Table 4]. In mindfulness meditation, we used body scan (moving attention systematically from toes to head), non-judgmental awareness of the physical sensations, breathing, thoughts, and emotions. How these elements of mindfulness meditation can help alleviate the pain and emotional suffering in oncology patients has been explained by a few researchers. The body scan helps to develop an awareness of subtle changes happening moment to moment which makes unpleasant sensations more tolerable. It reduces pain-related distress and helps in relaxation.^[34]

Awareness of breathing helps to breathe more easily and often elicitates a relaxation response.^[35] It can enhance the parasympathetic nervous system that is associated with calm, rest, and repair.^[36] Mindfulness aims for non-striving and acceptance of reality as it is. This prevents worry about the future and ruminating thoughts of past events, allows to live more fully in the present moment, regardless of what lies ahead.^[37] It helps to alleviate the suffering that is often accompanied by pain or emotional discomfort.^[35] Seeing things from a different perspective helps to observe habitual reactions and gives more control and choice to act in a more adaptive way.^[38] MBAT is also referred to as “focusing-oriented art therapy”, as it involves an emphasis on shifting focus as part of the experience. Mindful art is believed to facilitate a sense of immersion, flow, focus, calm, and being in the present-moment experience.^[39]

It is often suggested that coloring induces a mindful or meditative state,^[23,24] reduced activity in the amygdala,^[40] or changes in brain waves activity.^[41] Coloring is also referred to as mindfulness or meditative-like activity.^[23] Coloring complex geometric forms help the participants to suspend the “inner dialogue” and deeply engage in the activity that removes them from the negative thought patterns and emotions that can sometimes dominate their lives.^[24] The complexity and structure of these designs draw the participants into a meditative-like state that helps reduce anxiety.^[24]

Limitations and recommendations for future research

The sample size was small hence study findings may have limited generalizability to those patients seeking care at study settings like ours. To substantiate the findings, there is a need for studies with larger samples that are more elaborate. The possibility of bias cannot be ruled out as we relied on self-report measures of psychological distress and SWB. Non-compliance by some patients in regards to inconsistency in daily home practice may have affected the outcome. We have studied the effectiveness of MBAT in breast cancer patients. It would be interesting to explore its potential role in other oncology populations. SWB may have different implications specific to gender, age, and cross-cultural issues. These variables can be explored in future research.