Art Therapy

Journal of the American Art Therapy Association

ISSN: 0742-1656 (Print) 2159-9394 (Online) Journal homepage: http://www.tandfonline.com/loi/uart20

Art Therapy with Pediatric Cancer Patients:

Helping Normal Children Cope with Abnormal
Circumstances

Tracy Councill MA, A.T.R.

To cite this article: Tracy Councill MA, A.T.R. (1993) Art Therapy with Pediatric Cancer Patients:
Helping Normal Children Cope with Abnormal Circumstances, Art Therapy, 10:2, 78-87, DOI:
10.1080/07421656.1993.10758986

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 Art Therapy: Journal of the American Art Therapy Association, lO(2) pp. 78-87 0 A A T 4 Inc. 1993
Art Therapy with Pediatric Cancer Patients:
Helping Normal Children Cope with
Abnormal Circumstances
Tracy Councill, MA, A.T.R., Washington, DC
Abstract
Art therapy with pediatric cancer patients ad-
dresses the emotional and developmental needs of an
essentially normal population under extreme stress.
Assessment and intervention must be made in re-
sponse to the unique emotional impact of cancer and
its treatment on young patients. This paper reviews
the literature on the problems likely to be encoun-
tered by the pediatric cancer patient and presents
case examples to illustrate the emergence of these
issues and their management in art therapy.
Introduction
Art therapy with pediatric cancer patients pre-
sents a set of diagnostic and theoretical challenges
distinct from those encountered in working with psy-
chiatric populations. Traditionally, art therapists
have used artwork to identlfy psychopathology and
to resolve internal conflicts. The medical patient, in
contrast, may not only need to resolve internal con-
flicts, but also to negotiate physical illness and/or
disability so that she or he can continue to grow and
develop as a person.
In the medical setting, art therapy may be con-
sidered as an adjunctive treatment, since patients
come to the hospital primarily for medical treat-
ment. However, when the art therapist is part of the
overall treatment team, she or he can provide a
uniquely humanizing influence in the midst of an ex-
perience that threatens the childs sense of self and
trust in the world (Rollins, 1990). Also, the art thera-
78
pists evaluative skills can help the medical team
identify psychiatric and behavioral problems that can
affect a childs response to diagnosis and medical in-
tervention.
Literature Review
Psychosocial intervention with pediatric cancer
patients is predicated on the notion that the diag-
nosis of cancer and the treatment that follows repre-
sent stressors that warrant intervention. Even with-
out expressions of distress, such as noncompliance
with treatment, school refusal, or self-destructive be-
havior that typically result in requests for psycholog-
ical or psychiatric intervention (Tovian, 1991), pedi-
a t r i c c a n c e r p a t i e n t s may b e n e f i t from early
psychosocial support. Sanger, Copeland, and David-
son (1991) suggest that screening pediatric cancer
patients for adjustment problems is worthwhile,
given that psychological sequelae of illness and treat-
ment may extend well beyond the treatment period.
Glazer (1991) and others have suggested that bone
marrow transplant patients may experience symp-
toms of post-traumatic stress disorder, and thus ex-
tensive psychosocial support for such patients and
their families is in order.
Many authors have described the following
problems likely to be encountered by chronically ill
children: (a) separation anxiety (especially in pre-
school children), (b) the belief that illness and/or
treatment is a punishment for some misdeed or bad
thought (in school-age children), and (c) conflicts
over dependency versus autonomy (Pfefferbaum,
1989; Schowalter, 1970). Depression, anxiety (both
 COUNCILL
situational and generalized), and disturbances of
body image and self-esteem are reported to occur
widely in cancer patients (Lesko, Massie, & Hol-
land, 1987; Pfefferbaum, 1989; Sanger, 1991). Bull
and Drotar (1991), in a study of coping mechanisms
used by pediatric cancer patients, report that chil-
dren use different coping mechanisms when encoun-
tering cancer-related stressors than they do for other
life stressors. Rather than problem-solving strategies
they describe more intrapsychic, emotion-manage-
ment coping devices for cancer-related stressors. In
general, much of the literature suggests that chil-
dren who were preschoolers at the age of diagnosis
are most successful in adapting, while children who
were adolescents at diagnosis have the most diffi-
culty (Koocher & OMalley, 1981).
Art therapists have identified several potential
applications of art therapy intervention with medi-
cally ill patients. Jeppson (1982) describes how to
use art therapy to reduce symptoms of depression
and anxiety, increase patients sense of control and
autonomy, and facilitate communication with family
and the health care team. She also notes that art
therapy can promote effective coping strategies out-
side the hospital and therapeutic session, including
relief of pain through distraction. Crow1 (1980) de-
scribes how art therapy can be used to help a child
master his or her anxiety regarding impending sur-
gery. Cotton (1985)presents a case analysis based on
the work of Perkins (1977) that highlights the value
of nonverbal communication through artwork and
suggests methods of interpreting pictures specific to
life-threatened children. Bach (1990) emphasizes the
interpretation of artwork as a preconscious ex-
pression of a patients physical condition while
Jessee (1992) measures body-image in burn patients
through art assessment. Themes of helplessness,
anxiety, isolation, a n d body-image e m e r g e in
Geraghtys (1985)work with a hospitalized Alaskan
girl. Numerous authors have written about their
work with the terminally ill: Kern-Pilch (1980) em-
phasizes the value of choice and control, Rudloff
(1985) describes the therapeutic process, and
Fenster (1989) explores the search for meaning.
Overview of the Art Therapy Program with
Pediatric Cancer Patients
The author works as an art therapist and mem-
ber of the Pediatric Oncology treatment team at a
medium-sized cancer treatment and research center
where art therapy is available to all patients, from
toddlers through young adults. Since much of the
79
childrens chemotherapy is given on an outpatient
basis, they spend many hours in the waiting room.
Thus, art activities are provided in the waiting room
on clinic days. In this very public setting, the tradi-
tional boundaries of therapy-a separate room, a
closed door, an uninterrupted hour-are unavail-
able. Parents, siblings, and friends sit close by and
sometimes participate. During therapy, patients are
called to exam rooms to undergo medical procedures
and often return hooked u p to IV poles; nausea,
aches and pains, o r fatigue often disrupt participa-
tion. Even when sessions take place in the relative
privacy of an inpatient hospital room, the primacy of
medical procedures and the childs physical limita-
tions supersede the therapeutic process.
Though all patients are encouraged to partici-
pate, as both in- and outpatients, the child decides
whether he or she is able or willing to participate on
a given day. I t is believed that this measure of
choice, given the innumerable procedures over
which the patient has no choice, is essential to build-
ing a therapeutic alliance in this setting. Hans Peter
Weber, the clinical artist who collected many pic-
tures for Susan Bachs study of the artwork of medi-
cally ill children, emphasizes the element of choice
in working with the medically ill. Children under
medical treatment have few opportunities to choose
what they do, so I find it not only important but also
necessary to allow the child to choose if, when, and
what he will draw for me (Bach, 1990, p. 13). A
childs choice not to do artwork may represent a gen-
eral sense of isolation and social withdrawal that
often accompanies cancer treatment, or it may be
the result of anxiety over an upcoming procedure,
lack of interest, or simply a chance to exert control
by saying no. Thus, every attempt is made to
assess the childs behavior in the clinic to help par-
ents and staff support the child effectively.
Case Material
The case material presented reflects work ac-
complished during the first year and a half of the art
therapy program. I n the examples that follow,
themes of separation anxiety, alienation, anger, ag-
gression and fear, and body-image and self-concept,
beliefs about disease and treatment, and images that
may represent concepts of death itself are observed.
The use of art therapy in the beginning phase of di-
agnosis and treatment, during middle or mainte-
nance phase of therapy, and following relapse or in
advanced stages of disease with poor prognosis are
grouped together in order to pinpoint interventions
 ART T H E W WITH PEDIATRIC CANCER PATIENTS
that may be particularly useful at these stages of
treatment.
Diagnosis and Early Treatment
The earliest phase of cancer treatment assaults
childrens body image, identity, and self-esteem.
Embarrassment, anger, and social withdrawal may
accompany the childs sudden loss of self. Children
may try internally based coping strategies, resulting
in depression, withdrawal, self-blame, and aliena-
tion. A supportive, client-centered, and at times
nonverbal approach can help the patient both ex-
press troubling feelings and regain some sense of
bodily integrity and self-worth. The active presence
of the art therapist in both inpatient and outpatient
encounters and the relative safety of art materials for
displaced expression can afford valuable psychosocial
support.
Bonnie
Bonnie, a five-year-old diagnosed with an ex-
tremely large abdominal tumor, was immediately
hospitalized for evaluation and possible resection of
the tumor. I was urged by medical staff to visit her
as soon as possible and to begin preparing her for
surgery that might be both disfiguring and disabling
due to the size and location of the mass. It was ex-
pected that the surgery would take place within the
next few days.
At our first session I offered play-doh, and she
chose to make Easter eggs which we took turns hid-
ing and finding. The hiding and finding game may
have expressed Bonnies efforts to find her own hid-
den tumor. Though invisible without x-rays and spe-
cial scans, this mysterious thing had brought Bonnie
into the baffling new world of the hospital. Bonnie
was so delighted with our game that she used it to
begin every subsequent session while she was an in-
patient. In our daily sessions, she also created pre-
schematic representations of Barbie and used glit-
ter with enthusiasm.
Although I could see the trust-building value of
these early sessions, I felt compelled to raise the
issue of Bonnies tumor because of the potentially
imminent surgery. I asked Bonnie to make a picture
about herself in the hospital. She frowned at first,
but proceeded to draw two tadpole figures, a small
one with a frowning expression to represent herself
and a larger one with what appears to be two smiling
mouths to represent her mother (Figure 1). The self-
figure is interesting in that the area below the neck
is suggested only by a series of dots, which Bonnie
80
Figure 1.
indicated represented her tumor. No body outline is
used, and a strong horizontal line suggesting bed-
covers separates the head from the rest of the figure.
Bonnie commented that she felt better when her
mommy was with her in the hospital. She abruptly
concluded our discussion of her tumor by saying she
did not like to talk about it, that it made her feel like
she had glitter on [her] head, and she wanted to
hunt Easter eggs again. When I wondered aloud
what it felt like to have glitter on your head, Bonnie
giggled, then looked sad, and said that people
would look at you funny.
Bonnie seemed to express a mix of curiosity,
anxiety, and embarrassment about her tumor. Her
early work with me seemed to encapsulate the strug-
gle with body image and self-esteem that a cancer
diagnosis can bring. Faced with being looked at and
monitored by many new people and strange ma-
chines, Bonnie used indirect play (hiding and finding
eggs) to search metaphorically for her tumor. She
drew Barbie repeatedly, rehearsing her premorbid
identification with an ego-ideal that seemed to re-
present a fantasy of grown-up femininity. Also, Bon-
nie used drawings to work out her ideas about her
tumor, its appearance, and location within her body.
Bonnies surgery was subsequently delayed in
favor of a period of chemotherapy. As a new surgery
date approached some months later, Bonnie again
drew her tumor. In the second figure, there is a
boundary around the dot-filled tumor; the figure has
two-dimensional arms with fingers, a smiling head,
and indications of two internal organs, the lungs and
the heart. Bonnie made this picture, again at my
suggestion, to illustrate the ultrasound findings on
a doll during a medical play session. Bonnie ex-
pressed pride in her drawing, saying that at first she
wasnt sure how to draw it, but she thought she did
 COUNCILL
pretty well. Medical st& commented that her depic-
tion placed her tumor rather accurately within her
abdomen.
A client-centered approach was employed to
sensitively follow Bonnies lead and allow her feel-
ings to emerge without overwhelming her fragile de-
fenses. Bonnie did not ask many questions or at-
tempt to assign blame. Rather, she sought to work
things out within herself, using metaphoric play and
representations of her own body and an ideal female
form in artwork.
Benjie
Benjie was a quiet boy who sometimes mysti-
fied me. Although he liked art and seemed to con-
nect well with me during his initial inpatient stay,
his participation in art activities in the clinic was in-
frequent. Many days he sat in the hallway with a
family member, far away from the art table, declin-
ing invitations to participate. One day Benjie came
into the clinic, smiling, and presented me with an il-
lustrated story (Figure 2). The story tells of a boy
who went to a boat, which was painted red by
some men and then looked as good as new. The
illustration shows the newly painted boat on a calm
sea, with a jumping dolphin beside it and a wealth of
marine life under the water. A large half sun is at-
tached to the left edge of the page. This picture was
followed by many pencil drawings of dolphins, boats,
and marine life of many kinds.
Figure 2.
81
Although Benjies initial phase of treatment was
completed without further hospitalizations, he did
experience hair loss from chemotherapy and tempo-
rary weight gain due to steroids. His burst of marine
pictures and renewed communication with me came
during a time when his hair had grown back and his
weight had returned to normal. The content of his
story suggests hope that the doctors would make him
as good as new. His use of the color red for the
boat is interesting in the light of Bachs work, which
suggests that in leukemic children the absence of red
may represent the profusion of white cells within
their blood (Bach, 1990, p. 45). Within Bachs frame-
work, his red boat may relate his own perception
that his health is being restored by his treatment.
In this early phase of cancer treatment, Benjie
withdrew from an activity and an expressive outlet
he enjoyed. The work of Koocher and OMalIey, in
reporting the insights of childhood cancer survivors,
makes a case for the adaptive value of denial and
suppression of feelings during active cancer treat-
ment (1981). It may be that such denial and with-
drawal, rather than representing pathological de-
pression, allow t h e child to conserve his or her
emotional resources for the concrete hurdles ahead.
It was only when Benjie felt better physically that he
rejoined the art therapy group. The constant avail-
ability of art therapy in the waiting room seems to
have significant value for children like Benjie, who
may withdraw as the cancer and its treatment attack
their bodies and change their outward appearance
and rejoin when they are physically able.
Arthur
Arthur, a 12-year-old boy, had surgery to re-
move a tumor immediately upon diagnosis and hos-
pitalization. Though I visited him during inpatient
treatment, his initial artwork was created at his first
outpatient clinic visit. H e used clay to create a
human head with a gaping mouth, upturned eyes,
exaggerated ears, and a large scar on the side of his
face (Figure 3). After creating this head, Arthur
pointed out his own scar, at the back of his head,
from removal of his tumor.
After he was hospitalized for a course of chemo-
therapy, Arthur began a series of clay heads, which
he described as space aliens. Each of the figures
has a gaping mouth a n d some combination of
human, animal, and insect-type features. In one no-
table session, Arthur said he wanted to make an
alien that was really scary. After several attempts,
he made two creatures, the first a bell-shaped head
 ART THERAW WITH PEDIATRIC CANCER PATIENTS
Figure 3.
with round eyes and an open, round mouth (Figure
4). Next, he completed a dinosaur-like creature with
one sharp horn, a scar on his face, and a wide-open
mouth. Expressing frustration with his work, Arthur
finally blurted out, I think they look more scared
than scary. During this time, Arthur was experienc-
ing many painful side effects of chemotherapy and
was having difficulty complying with treatment, es-
pecially swallowing pills and adhering to daily rou-
tines. Arthur stated that he just wanted to sleep and
kept his drapes closed and the lights off most of the
day. He often would not acknowledge the presence
of staff members in his room, pretending to be
asleep. I offered clay, a material Arthur enjoyed, and
a chance to interact without talking unless he chose
to. Participation in art therapy was one of the few av-
enues of communication with hospital staff that
Arthur kept open.
Arthur seemed overwhelmed by the disfiguring
and disabling aspects of his treatment. Hair loss,
scars, pain, fear, and social isolation may have left
him feeling like an alien creature. His forced regres-
sion to dependence on his parents and staff for daily
care and the fear of death caused Arthur to become
depressed. Arthurs work in art therapy allowed
medical staff to better appreciate the roots of his
withdrawal and to regard him as a young man with
complex e m o t i o n s r a t h e r t h a n s i m p l y a n u n -
cooperative and unappreciative adolescent. The clay
figures also gave Arthur a way to express his feelings
in the safe displacement of artmaking.
Middle Phase of Treatment
In the middle phase of treatment, intervention
is aimed at supporting the patient through the long-
term stress of treatment. Denial may be an impor-
82
Figure 4.
tant ingredient of the patients defenses. During this
phase, careful attention must be given to helping re-
store the patients sense of self. Often, the cancer
treatment team becomes a primary social support.
Art therapy can provide a valuable outlet for reflec-
tion of feelings about loss and self within a suppor-
tive environment.
Jason
Five-year-old Jason was forced to undergo a se-
ries of scans requiring ingestion of a thick, chalky
barium liquid prior to the test. Jason had great diffi-
culty swallowing enough of the substance to suffice,
and several times had to have tubes placed to force-
feed him t h e substance. Jason and his m o t h e r
worked closely together to devise strategies that
might help him drink the liquid, but these visits
most often ended in trauma and humiliation as he
was forced to have tubes placed. Before and during
much of this period in his treatment, Jason had
drawn a figure on nearly every clinic visit. His
schema included a squarish yellow head (Jason had
blond hair), smiling face, a rectangular body, and
two-dimensional arms and legs, and was generally
placed in the center of the page. Sometimes Jason
placed himself beside another similar figure repre-
senting his brother or his dad. His repetitive schema
appeared to be a self-image. As the frequency of in-
vasive procedures increased, Jason began to come to
the clinic armed with various toy weapons such as
armor, a knife, a bow and arrow, and a water pistol.
Once, when Jason had been through the ordeal
of tubes and completed the scan, he insisted on re-
turning to the clinic to see the art therapist before
going home. Upon entering the room, he requested
materials and created Figure 5. H e said this image
 COUNCILL

Figure 5. Figure 6.

represented himself, and he left it in the clinic for the hospital. Frank reported that art therapy helped
display. His strong need to create this image seemed him feel less anxious about upsetting treatment pro-
to represent his efforts to maintain bodily integrity cedures, especially blood drawing. Despite his ap-
and a concept of himself in the face of necessary but parent adjustment to the treatment setting, Frank
traumatic violation of his body boundaries. one day drew a very messy, smeared, and layered
As Jason neared the end of his treatment pro- picture of the clinic (Figure 7). He labeled it Hospi-
tocol, with the invasive procedures limited to pe- tal Map, and marked several exits along the bot-
riodic but comparatively infrequent monitoring, a tom of the page; Frank included no entrances to the
greater expressiveness evolved in his self-representa- hospital. In commenting on his picture he laughingly
tions. After a family fishing trip, Jason depicted him- said that if he owned the hospital none of the kids
self rowing a boat (Figure 6). H e also began to draw would ever have to get shots, and they would all get
deer and other animals, places, and vehicles he had well. Frank adamantly did not draw himself in the
encountered in his life outside the clinic, suggesting clinic picture, and he never pursued themes of
both renewed energy and an appropriate focus on feelings about his illness when they arose, saying it
life events. made him feel too sad to think about his cancer.
Frank seems a salient example of the adaptive use of
denial in coping with cancer diagnosis and treatment
Frank
during a middle phase, when the outcome is uncer-
Frank was a nine-year-old boy who had suffered tain.
many impairments as a result of his treatment. In
addition to temporary side effects, he was left with
visual impairment, motor difficulties, and premature
signs of puberty. H e had visited many doctors at
various hospitals, and his approach to the clinic staff
was that of an old hand. H e was outgoing and
cheerfully demanding in eliciting support from care
givers, sometimes resembling a little old man in his
sophisticated banter, and other times behaving like a
demanding two-year-old. H e had an articulate, en-
gaging, and supportive family.
Frank was always willing to relate to a new pa-
tient how frightened he himself had been upon first
coming to the clinic. Franks family had moved to
America from another country to obtain treatment
for Frank, and he did not know English on arrival at Figure 7.

83
 ART THERAPY WITH PEDIATRIC CANCER PATIENTS

Eugene painting, Eugene appeared to gain some confidence

and questioned the therapist about artists whose
Eugene was diagnosed with cancer during col-
work he had seen in museums. Then he produced a
lege. Because of his age and the type of cancer, h e
sketch (Figure 10) showing a hermaphroditic figure
was classified a pediatric patient though he was in
dominating the page, with a bald, bespectacled fig-
his early twenties. An introspective and artistically
ure behind him on one side and a tall palm tree on
talented young man, Eugene resisted participating
the other. A small, multicolored sun is placed above.
in t h e art therapy program, perhaps because t h e
Eugene laughed and made self-effacing remarks
predominant clinic population were young children.
about this drawing. His artwork alludes to late-ado-
Eugene became more engaged in the art process
lescent identity concerns, with an overlay of rather
when invited to prepare a canvas for a patient art ex-
brooding and perhaps death-related imagery. I t is
hibition. Following that event, which brought him in
impossible to know whether Eugenes artwork ex-
contact with other older patients, Eugene occasion-
presses concerns related to an individuation process,
ally ventured some artistic expression.
but he certainly expresses significant worries about
Figure 8 represents a tiny painting of a parade
himself, his potency, and his capacity for relatedness
of assorted characters and animals making their way
discussed in the literature on cancer survivorship.
along a narrow, serpentine precipice surrounded by
a black void. By applying Bachs quadrant method of
analyzing artwork, the path along the precipice leads
into what she terms the minus-minus quadrant,
described as the place of darkness and the unknown
(Bach, 1990). According to Bachs method, this as-
pect of the painting and its overarching darkness
may be a poor prognostic sign. Eugene explained
that the inspiration for his painting came from a song
by the Doors, but he did not explain what the song
meant to him.
Some months later, Eugene again produced a
tiny painting (Figure 9); this one shows an aerial
view of a streetcorner in a deserted cityscape domi-
nated by red and grey. Though this second painting
is more firmly grounded than the first, the mood of Figure 9.
isolation and danger is profound. After a st& mem-
ber expressed an interest in purchasing t h e first

Figure 8. Figure 10.

84
 COUNCILL
Relapse and Palliative Care
During relapse or palliative care, heightened
uncertainty replaces the now-familiar routines of
treatment. Anger and isolation may resurface, and
communication with family members and staff may
break down (Kubler-Ross, 1969). Art therapy may be
especially helpful in facilitating communication at
this difficult time. Parents and staff members may
feel their decisions about treatment are responsible
for the patients imminent death; e.g., if only some
different route had been chosen, perhaps it would
not have come to this.
The transition from working to save the pa-
tients life to allowing him or her to die is extremely
difficult for care givers. Often, it is the patient who
first senses that death is imminent, and that isolation
becomes painful if it cannot be expressed somehow.
The power of art to give expression to profound
existential themes and the relationship with the art
therapist can be a strong support to the patient when
words are too difficult either to say or to hear.
Paul
Six-year-old Paul was considered in remission
and then suddenly relapsed. Following the recur-
rence of his disease he did many paintings and draw-
ings directly focusing on issues of loss and death.
When first hospitalized after relapse, Pauls play
often related to hearses, and he drew pictures about
burglars and a 16-year-old boy who had died of
AIDS. Shortly after his relapse was diagnosed, Paul
asked the doctor straightforwardly, Am I going to
die? Paul displayed none of the denial associated
with other cases, but rather a disarming awareness of
his own mortality.
Figure 11.
85
Pauls best hope was a bone marrow transplant
at another center after several rounds of chemother-
apy. H e was hospitalized several times during a
three-month period. His parents were unable to be
with him for long stretches of his inpatient stays,
though they kept in close touch by phone. On one
occasion, when Paul was particularly lonely and
angry with his parents and acting out with staff and
other patients, he was asked to draw a picture to
show how he felt. Paul painted a simple schematic
figure in red watercolor, surrounded by slash-marks
in green. He called the figure Freddy Krueger
(Figure 11)and explained that Freddy was angry be-
cause people keep bothering him.
Hoping to help Paul accept his own intense
feelings while conveying that I accepted them, I
asked Paul to draw another picture, this time show-
ing Freddy with someone who understands him.
Paul then produced Figure 12, a representation of a
smiling Freddy alongside a larger female figure.
Both figures are shown with upraised arms. Paul re-
lated that Freddys friend was a girl, older than he,
who understood how he felt. After producing this
picture, Paul said he would like to just rest, and
he busied himself in bed with a favorite toy. Pauls
work in art therapy seemed to relieve his anxiety at
being separated from his loved ones, and to give him
a vehicle for expressing both anger and trust of adult
care givers.
Paul sailed through his bone marrow transplant
with flying colors, only to relapse again. This time
his cancer progressed rapidly despite aggressive
chemotherapy. Around the time of his second re-
lapse, Paul created a picture of a person picking an
apple from a tree. It shows a tree that is completely
overtaken in red, possibly the tumor red identified
by Bach (1990)which symbolizes the burning, pain-
Figure 12.
 ART THERAPY WITH PEDIATRIC CANCER PATIENTS

ful force of disease. The tree holds five large apples,

the sixth about to fall, a poignant suggestion that
Pauls sixth year might be his last.

Wanda
Wanda was a young woman in her early twen-
ties first diagnosed and treated at age 12. Failure to
achieve remission had resulted in prolonged treat-
ment and eventual failure of her immune system;
eventually she chose a course of palliative care over
prolonged chemotherapy with no likelihood of cure.
Wandas youth had been disrupted by her illness
and treatment. She was in some ways immature and
had made few moves toward individuation. Wanda
strongly resisted talking about her feelings and had
difficulty trusting anyone outside her family, but she
was engaging toward staff members and quite tal-
ented in art. She related to me, asking my advice on
materials, techniques, and subject matter, but pre-
ferred to work at home and bring her artwork in to
discuss it.
Her first major work in this context was t h e
large painting she created for the patient art show.
This image (no photograph is available) is of a light
blue mask-like face floating in a watery green atmos-
phere, with long, vertical tendrils of seaweed in the Figure 13.
background. Within the mask, several goldfish swim.
Following this image, Wanda began to do many ing for her death was not to talk about her life and
more creative projects at home and to sell her hand- her leaving, but rather to allow images to arise from
crafted jewelry and items of painted clothing to staff within. When she began the Firebird image, she
members. told me it was something she had always wanted to
Several months later, she produced the Fire- paint. My role as her art therapist was to provide
bird image (Figure 13). In this dramatic, crisply ar- technical advice, materials, and encouragement, so
ticulated image, the firebird rises over a moonlit lake that in the context of our relationship her innermost
hidden within a grove of trees. It is surrounded by experience could find expression.
iridescent paint, giving the bird an ethereal pres-
ence. The patient clearly articulated the meaning of
the Firebird story as having risen up from the ashes. Conclusion
She did not, however, relate the image to herself. It The preceding discussion and case material il-
is my opinion that Wanda used artwork effectively to lustrate psychological characteristics, issues, and
sublimate her concerns about the meaning of her coping mechanisms of pediatric cancer patients. The
own impending death. The bird, placed centrally efficacy of art therapy intervention with medically ill
and ascending in the landscape, unmistakably an- children is demonstrated, especially through the fol-
nounces that Wanda will soon leave this world, lowing therapeutic benefits:
though she was not to speak of her death in words 1. Patients control their own choices of art mate-
until the very end. She visited our clinic for the last rials, subject, and verbalization regarding their
time only a few days before her death, but she did artwork, enabling them to experience themselves
not say goodbye until she asked her mother to tele- as active creators as opposed to victims of a dis-
phone us just hours before she died. ease or helpless recipients of treatment.
Bertman (1991), Kubler-Ross (1969), and many 2. Patients maintain communication with the treat-
others have written of the existential aloneness that ment team through art expression at times when
surrounds the time of death. Wandas way of prepar- relationships are strained by anger, withdrawal,

86
 COUNCILL
fatigue, and feelings that a r e too emotionally
charged to be said with words.
3. Patients continue the process of development
through visual communication, supporting social
and mental growth and mitigating the isolation of
the hospital experience.
4. Patients rehearse troubling events and work out
concepts of self in art expression, supporting a
sense of mastery over feelings about illness and
treatment.
As art therapists, we are well acquainted with
the value of artistic expression in communicating
what is not spoken and in marshalling psychic ener-
gy to support the work of life. In medical centers,
where science and technology bring about the mira-
cles of modern medicine, the image making along
with careful listening can support the work of heal-
ing. Familiarity with the emotional consequences of
diagnosis and treatment, sensitivity to patients
graphic messages, and trust in the value of open-
ended creativity allow the art therapist to be a valu-
able support to physically ill children.
Editors note: This research was funded by a grant from the Can-
cer Research Foundation of America, Alexandria, Virginia.
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