The Arts in Psychotherapy 34 (2007) 1–10

Contribution of visual art-making to the subjective well-being of

women living with cancer: A qualitative study
Frances Reynolds, PhD ∗ , Kee Hean Lim, MSc
School of Health Sciences and Social Care, Mary Seacole Building, Brunel University, Uxbridge, Middlesex UB8 3PH, United Kingdom

Abstract
This qualitative study examined accounts of women diagnosed with cancer who engaged regularly in art as a leisure activity.
The purpose of the study was to explore participants’ views about the contribution of art-making to their subjective well-being
in the context of living with cancer. The study was based on the principles of interpretative phenomenological analysis (IPA). A
convenience sample of 12 women aged between 23 and 74 years participated in semi-structured interviews, and their accounts
were analysed thematically. Participants described a range of ongoing difficulties associated with cancer such as fear for the future,
pain, sleeplessness, role loss, activity restriction, reduced self-confidence and altered social relationships. They described art-
making as supporting subjective well-being in four major ways. Creative activities helped participants to focus outwards on positive
life experiences relieving debilitating preoccupation with illness. Art-making enhanced self-worth and identity through providing
opportunities to demonstrate continuity, challenge and achievement. It also enabled participants to maintain a social identity that
resisted definition by cancer. For a minority, art enabled symbolic expression of feelings, especially during chemotherapy. The
findings supplement previous case studies and suggest that meaningful creative activity may provide psychosocial resources for
living with cancer.
© 2006 Elsevier Inc. All rights reserved.

Keywords: Cancer; Well-being; Identity; Art; Creativity; Leisure

Introduction

This study explored the meanings of leisure-based art-making for women who were living with cancer. It is increas-
ingly recognised that many people with cancer need to draw upon psychosocial resources such as positive attitudes,
spiritual beliefs, information and support in order to cope with their condition (Dunn, Steginga, Rosoman, & Millichap,
2003; Jenkins & Pargament, 1995). Creative art-making during leisure time may offer another resource. Some people
identify their diagnosis of cancer as a “wake-up call” to be self-expressive, and turn to art and other creative activities
(Predeger, 1996). Most studies of cancer patients undertaking art therapy have focused upon those who are in the
relatively early stages after diagnosis, when fear and grief may be particularly intense. Participants at this stage of the
cancer trajectory seem to use art to communicate feelings of anxiety, anger and body estrangement, which are difficult
to put into words (Borgmann, 2002; Lynn, 1994). Sibbett (2005) has argued that the creative process may also help
those who live with cancer to tolerate the discomforting experience of inhabiting a liminal or threshold space between
life and death. Art therapists, particularly those who adopt a psychodynamic perspective, have interpreted the artwork

∗ Corresponding author. Tel.: +44 1895 268826.

E-mail addresses: frances.reynolds@brunel.ac.uk (F. Reynolds), kee.kean.lim@bruel.ac.uk (K.H. Lim).

0197-4556/$ – see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2006.09.005
2 F. Reynolds, K.H. Lim / The Arts in Psychotherapy 34 (2007) 1–10

of individuals with cancer as rich in symbolism (Minar, 1999). Imagery of the damaged body has frequently been
expressed in the artwork of people living with cancer, as have themes of hope and reintegration (Borgmann, 2002;
Lynn, 1994). Whether art-making has these themes when engaged in as a leisure occupation rather than as therapy is
uncertain.
Cancer affects many people every year, and few, it seems, have access to art therapy. With better medical treatments,
more survive and face the task of coping with the legacy of their diagnosis for many years (Bower et al., 2005). It can
be argued therefore that a better understanding of the role of leisure-based art-making in promoting well-being may
also help to inform professional interventions and people’s own strategies for coping with cancer.
Cancer can be profoundly disruptive of personal and social identity (Carpenter, Brockopp, & Andrykowski, 1999;
Mathieson & Stam, 1995). Stressful features of cancer such as pain, potentially arduous and disfiguring treatments,
and a future perceived as highly uncertain all tend to challenge the previously taken-for-granted relationship with
the self. Many describe cancer as bringing about a profound loss of subjective control. In addition to imposing a
cognitive and emotional burden, cancer poses threats to subjective well-being through undermining everyday lifestyle
and social relationships. About 40% of people report losing their job or taking early retirement after cancer diagnosis
and treatment (Spelten, Spranger, & Verbeek, 2002). Cancer still carries a stigma, and from a sociological view imposes
an all-defining “master status” upon the person (Charmaz, 1991; Mathieson & Stam, 1995). The person may yearn to
establish a sense of normality and an identity that is not totally defined by cancer (Lam & Fielding, 2003; Landmark
& Wahl, 2002; Shannon & Shaw, 2005).
Some people respond to cancer by placing more emphasis on personally enriching activities (Arman & Rehnsfeldt,
2002). Shannon and Shaw (2005) found that participants re-appraised their leisure habits, wanting “to be actively
living and making the most of life” (p. 207). Such re-appraisal may occur soon after a cancer diagnosis. Landmark
and Wahl (2002) interviewed women recently diagnosed with breast cancer who reflected on their need to engage with
meaningful activities, to provide evidence of their mental and physical strength, to stay actively engaged in daily life,
and to distract their thoughts away from cancer. Similar themes were found in the study of women who took up a sport
after breast cancer (Tocher, 2002).
Link, Robbins, Mancuso, and Charlson (2004) found that 11% of participants who tried to control the psychological
impact of their cancer in daily life turned to creative activities such as painting and writing. However, they did not
examine in depth how such activities enhanced participants’ subjective well-being. Reynolds and Prior (2003) offered
some insights into this issue, albeit from interviews with women who were living with both malignant and non-malignant
illnesses. They explored the meanings of art-making guided by the principles of interpretative phenomenological
analysis (IPA) as described by Smith, Osborn, and Jarman (1999). Participants’ accounts suggested that art-making
offered a way of managing many aspects of long-term illness ranging from unpleasant physical symptoms to loss
of roles. Immersion in artistic activities helped to ward off cognitive preoccupation with illness. The participants’
accounts did not focus solely upon coping with the restrictions of illness. They also revealed a more positive project of
re-engaging with “normal” life. As one participant with cancer explained: “Art blocks out sad thoughts or frightening
thoughts and scary bits. . . but it also moves you on” (Reynolds & Prior, 2003, p. 792). Art-making provided some
participants with new relationships and generally restored feelings of competence and self-esteem. Present-moment
awareness was enhanced, enriching perceptual experiences. Some appreciated that their illness had catalysed a more
positive lifestyle. Of the 35 women participating in the study, six were living with cancer. A more detailed examination
of the role of art-making in coping with life-threatening illness was recommended.
This study sought to understand how visual art-making as a leisure activity contributed to the subjective well-
being of women who were living with cancer. An inclusive definition of “art-making” was used, to encompass the
practice of any form of visual art or craft resulting in a visible end-product, whether at an amateur or advanced level of
expertise.

Methods

Methodology

This research aimed to gather rich “insider” descriptions of the meanings of art-making, and was guided by the
principles of interpretative phenomenological analysis (IPA), as outlined by Smith et al. (1999). Ethical approval was
given by the Research Ethics Committee of the host institution.
 F. Reynolds, K.H. Lim / The Arts in Psychotherapy 34 (2007) 1–10 3

Participants

Participants were recruited through invitations placed in national UK arts magazines. Those expressing interest
were given full information including the main interview questions prior to giving consent. They were assured of
confidentiality and their right to withdraw from the study at any time. In the quotations below, participants are identified
by pseudonyms, and their occupations, where distinctive, are slightly masked.
Twelve women participated. The age range was 23–74 years, with the majority aged in their late 40’s to 50’s. They
resided in many areas of England. All were White. Nine had a professional work background but had discontinued
regular paid work since becoming ill. The others had mainly been homemakers. Ten disclosed that they were married
or living with partners and most of these had adult children living away from home. Participants had all lived with
cancer for at least a year, therefore gaining some emotional distance from the initial trauma of diagnosis. Six had
been diagnosed with breast cancer and the remaining participants reported other types of cancer. Seven were currently
receiving treatment for cancer. Participants varied in time since diagnosis. Five considered that they were facing terminal
illness, five expressed varying degrees of uncertainty and two were optimistic about their longer-term health. It was
considered acceptable to include women living at different stages of the cancer trajectory in this exploratory study.
This is because the stress of cancer is not confined to those engaged in medical treatment. Long after treatment has
ended, people report remaining vigilant and fearful about recurrence or metastasis (Bower et al., 2005).

Procedure

Semi-structured interviews lasted between 1 and 2 h. All were carried out by the first author, audiotaped and fully
transcribed. Ten interviews were carried out in participants’ homes, and two were conducted by telephone according to
participants’ preferences. Participants reflected on their experience of cancer, initial reasons for taking up art-making,
and the ways in which visual art-making as a leisure occupation contributed to their subjective well-being. In relation
to the last topic, questions included:

1. Can you describe what is satisfying about creative activity?

2. Do you think that your artwork has helped you to express your feelings about your illness—or not?
3. In what ways has your artistic work helped you to manage/live with your health problems?

These questions were not asked in a rigid way but were modified and probed, as needed, to guide a flowing conversation.

Data analysis

Data analysis was carried out jointly with the second author, focusing on the verbal meanings of engaging in the
process of art-making (rather than interpreting the content or imagery of the artwork). The authors spent a considerable
period of immersion in the transcripts. Based on the guidelines for IPA (Smith et al., 1999), one lengthy interview
transcript was initially coded for micro-themes. This list expanded as subsequent transcripts were analysed. Gradually,
the “micro-themes” initially identified were clustered into larger meaningful themes as the process of analysis unfolded,
aided by concepts recorded in a memo book and discussion between the authors. The focus of this paper is on the major
recurring themes in participants’ accounts. An audit trail supported the confirmability, and hence rigour, of the analysis.

Findings

Summarising the stressful aspects of cancer

Before examining the contribution of art-making to subjective well-being, it is important to acknowledge that
participants had faced many cancer-related problems. Indeed, they referred to most of the stressful experiences that
have been reported in previous qualitative research (such as those presented by Mathieson & Stam, 1995). There
is insufficient space to give details but their descriptions included the initial shock of diagnosis, the discomforts of
treatment, feeling out of control, fears for the future, negative changes in some of their social relationships, early
retirement from work, and loss of self or identity. One participant (Jean, aged 50) summed up her difficulties after
4 F. Reynolds, K.H. Lim / The Arts in Psychotherapy 34 (2007) 1–10

diagnosis of breast cancer: “That was a horrendous year. Mastectomy, chemotherapy, radiotherapy. . . that was months
of treatment. At that stage I was feeling really battered.”

Patterns of art-making: brief outline

Most participants had engaged in considerable lifestyle change since the beginnings of their illness. Half of the
sample had taken up art after their cancer diagnosis, generally during the crisis of initial treatment; five of the others
had substantially intensified their involvement after their diagnosis. Only the youngest participant, a student aged 23
years, had enjoyed art as a leisure activity quite steadily throughout her life. Participants engaged in many different
types of visual art, including textile art, card-making, collage, pottery, watercolour and acrylic painting. Some of the
artwork was freely self-expressive (for example, creating exploratory images in paints, or constructing fragile textile
hangings); much was created to be aesthetically pleasing to self and others (including samplers, tapestry cushion covers,
hand-made cards, and paintings of floral arrangements, animals and landscapes).

Art and subjective well-being: themes within the interview data

Whilst the rich interview data provided testament to a wide variety of subjective benefits of engaging in art after
diagnosis of cancer, these were clustered into four distinct themes, reported in Table 1. One theme (symbolic self-
expression) was only seen in the interview data of five participants. However, because of its subjective importance for
this group it is included here. The remaining three major themes were present in all of the interview data.
Although presented in linear fashion, it is important to emphasise that the subjective benefits of art-making were
highly interconnected in participants’ accounts. For example, with the achievement of better self-worth, participants
described feeling more confident in their social relationships. Reciprocating care (through hand-made gifts, for example)
had individual and social benefits, in building self-esteem, and helping to ward off others’ pity. When participants
focused attention upon planning or creating artwork rather than dwelling on their worries about cancer, they re-
connected with a familiar self-image as an effective, capable person. Participants also felt that their social interactions
were normalised rather than dominated by the stigma of cancer and “cancer talk.” There did not seem to be any clear
differences between the accounts of those who intensified their involvement in art-making and those who took up new
artistic pursuits following their diagnosis.

Art symbolised the cancer experience

Five of the 12 participants described some of their art-making as enabling symbolic self-expression. However,
only one or two pieces of their artwork had this function. Four of the five referred to a “chemotherapy piece,” which

Table 1
How did art-making enhance participants’ subjective well-being after a cancer diagnosis?
1. Art symbolised the cancer experience
Fear and grief
Hope and strength
2. Art-making focused attention on life experiences other than cancer
Encouraged an outwards focus
Relieved worry, pain, sleeplessness
Provided a future hopeful orientation
3. Art-making maintained personal identity and self-worth
Provided experiences of challenge and achievement
Promoted learning and self-development
Enabled expression of self-defining interests
Increased subjective control
4. Art-making preserved an “able” social identity
Offered a mutual social interest unrelated to cancer
Provided a non-cancer source of social identity
Relieved family from concerns about well-being
Enabled reciprocal care through hand-made gifts
Provided a legacy or memorial
 F. Reynolds, K.H. Lim / The Arts in Psychotherapy 34 (2007) 1–10 5

generally had a symbolism that was perceived only at a later stage. Some of these pieces were emotionally disturbing.
One participant (Carol, aged 57, with breast cancer) recollected her first piece of art: “I did a sort of collage. . . a deep
dark ravine, all greens and dark colours. . . the dark ravine was obviously where I was. . . that was the only one that
seemed to be symbolic. And I threw it away.”
Symbolic expression was not confined to fear or grief. Another participant, Jean, interpreted some of her early
artwork as a permanent witness to her psychological strength during treatment for breast cancer: “[The art] was
something I could manage, I was sure to get it right, right enough to say ‘I’ve done that, that’s fine, I’ll frame it.’ It
stands for something in my life now. . . I keep it somewhere and I think it says ‘that’s a stage in my life that I went
through.”’
Although infrequently constructed, symbolic pieces appeared to have great psychological significance, enabling
participants to express feelings about the cancer, including hopes and vulnerability, that were almost out of reach of
conscious awareness at that particular time.

Art-making focused attention on life experiences other than cancer

Art-making was highly valued by all participants for providing a strong cognitive and emotional involvement with
aspects of life other than cancer, thereby relieving some of the stress associated with the condition. Deep immersion
in art-making was described as reducing perceptions of pain, alleviating worry and preoccupations with cancer. For
two participants whose pain was difficult to control, art-making helped participants to cope with long sleepless nights.
Many participants considered that their time-consuming projects had a wider benefit, in helping them to retain positive
plans and hope for the future, even within the context of life-limiting disease. The length of experience with the
visual medium, or level of skill, did not seem relevant to these self-reports. These different sub-themes will be further
illustrated with quotations.
Many participants spent a substantial part of the interview reflecting on their inspirations for artwork, including the
work of recognised artists, and the natural and man-made environment. This emphasised their outwards focus. For
example, Marie (aged 55, with a life-limiting blood condition) constructed fragile textiles out of silk thread that she
dyed herself. She explained how was one piece was developed “from a combination of inspirations. I went to Venice
and was totally struck by the verdigris on the bellies of the horses in St. Mark’s Square. . . the fabulous, fabulous
greeny gold rivulets going down the belly of the horse. . . The other thing that struck me was all sorts of old doors
around the fish market. They were kind of really beaten up. . . it was so textural.” With this degree of attention to her
surroundings, Marie felt able to give less attention to her life-limiting illness. She explained: “I suppose my whole
approach to the whole problem with my health is put it on one side and do the best I can with it. Otherwise, it can
consume you. And it will.” This strategy of re-focusing did not seem to reflect denial or other defensive strategies, as
she was quite open about her poor health prospects. Rather, re-focusing outwards enhanced the quality of subjective
experience, maintained engagement in a world of “health,” and reduced unproductive and emotionally debilitating
rumination upon illness.
Many other participants referred to their outward focus on art-making and the benefits of this strategy for living
with cancer. One participant (Carol, 57 with breast cancer and lung disease) explained: “Four or five hours can go
by without your realising. It’s wonderful. You thought of nothing else. I mean that’s the beauty of it”. Such complete
mental absorption was seen as helpful for managing worry as well as the discomforts of treatment and illness, and was
reported by both experienced and novice practitioners.
As well as reducing preoccupation with illness, art (including the focus on outside inspirations, design, texture,
colour and the process of making) offered a coping strategy for pain, nausea and sleeplessness. Several had discovered
that the more they focused upon their bodies, the more unpleasant their symptoms became. They had learned to break
what they regarded as a vicious circle. One participant described coping with pain during sleepless nights: “It might
sound strange, but it [art] is a way of. . . not thinking of the pain. Or at least you’re thinking of something to take the
pain away, rather than the pain itself. So you’re not getting into a vicious circle of saying, ‘I’ve got pain, I must be
getting worse’ and then the next minute it is worse.”
In most cases, participants’ outward focus also included planning many future art projects. This strategy helped to
ward off negative preoccupations with mortality, and maintained hope. Jessica (47, with breast cancer) was perhaps the
most articulate about this strategy: “I’ve got notebooks of things that I want to do. If I lived until I was 107, I wouldn’t
finish everything and I think that’s a good thing. I mean especially when you’re looking at a shorter life span, rather
6 F. Reynolds, K.H. Lim / The Arts in Psychotherapy 34 (2007) 1–10

than concentrate on that, you think, I’ve got to get this finished, I’ve got to do this and that, I think that helps a lot.”
Louise, aged 66 and currently receiving treatment for breast cancer, was also adamant about the subjective importance
of having future goals: “While you’re doing something, you’re not dying. Literally.”

Art-making maintained personal identity and self-worth

Physical and functional losses have deleterious effects on self-worth and identity, and so do social role changes.
Participants described many ways in which art-making was helping them to maintain or restore a positive sense
of identity, and to resist being overly defined by cancer. Feelings of accomplishment through meeting the challenges
involved, ongoing learning and personal growth, experiencing continuity through involvement in long-standing interests
and enhanced choice and control were all important benefits derived from creative activity that helped to sustain identity
and thereby helped participants to live more positively with cancer.
Most participants used the word “challenge” at least once during the interview. One participant (Dorothy, aged 74),
who was paraplegic from a spinal tumour, welcomed the challenges inherent in her art-making, explaining: “I haven’t
got many challenges, so doing a difficult piece of [art] work is helpful.” Another (Marie) enrolled on a City and Guilds
textile art course after her early retirement. “It was a massive learning curve, but very challenging, which was just
great. . . You know, unless you shift your comfort zone, you just carry on being what you are.” She considered that her
new-found lifestyle helped to provide the level of challenge and on-going development that she used to enjoy in her
former academic work.
Participants did not necessarily require the challenge of an advanced course to feel achievement. For example, Louise
(aged 66, with breast cancer) enjoyed making hand-made cards. “It’s a sense of achievement, you know. It beats anything.
For me, anyway.” That this could be helpful for living with cancer became very clear later in her interview: “I don’t see
the sense of sort of going to bed and waiting to die, or sitting in a chair and waiting. I would rather be doing something
that I enjoyed and have something at the end to show for it. . . It’s the sense of achievement more than anything.”
During interviews, many participants focused at length upon their inspirations, courses, internet contacts and other
sources of learning and skill development. Participants emphasised the enjoyment and personal growth associated with
gaining new skills. They referred to themselves as “blossoming” and “having something to knock me off course.” As
well as developing new skills, art during leisure time also afforded opportunities for participants to express some of
their pre-cancer interests, even within a context of diminishing physical function. This outcome also can be interpreted
as helping to maintain personal, or biographical, continuity. For example, Eve (48, with metastasised breast cancer)
emphasised how continuity of creative interests contributed to “normality” within her life, and hence subjective well-
being: “Well, I think really it’s [important] doing normal things. . . Obviously with all these sort of toxic drugs some
days are less normal than others and some days are more normal than others. . . I think really that by doing these
things [arts and crafts], I’m doing the things that I always did do, so those always were my hobbies and I suppose I’ve
just added a new interest or, like, taken the interest into a different dimension.”
In many ways, participants had suffered a profound loss of control over their lives. Some recounted difficulties in
gaining a correct diagnosis, and their sense of vulnerability in entrusting their lives to medical practitioners. Treatments
sometimes had unexpected side-effects, and the progress of the illness continued, for many, to be uncertain. As disabled
people, some faced barriers to accessing taken-for-granted resources such as transport and so on. Whilst many difficulties
remained in relation to cancer treatment and prognosis, art-making was experienced as a haven of choice and control
in everyday life. Marie made this point clearly: “It is quite hard to discover that you’re not going to live forever and
your body’s gone a bit cranky. . . Having a disorder of some sort makes you very aware of your own vulnerability, you
know. You used to be immortal and now you’re not, and if you do creative things, they’re entirely within your control
and it gives you a sense of something that you can do something about. Because it’s coming from within you and then
you’re expressing it outwardly and you know, you’re not vulnerable. You’re growing a little bit.”
Another participant (Jill, aged 50, who had finished treatment for a pituitary tumour) agreed that art-making gave
her more power in relation to her cancer: “I don’t feel I’ve been defeated. . . if I can do things like this.”

Art-making preserved an ‘able’ social identity

As discussed in introduction, cancer tends to have a powerful “master status” that can radically re-shape social
relationships and interactions. Several participants had suffered social difficulties as a result of their illness. Louise
 F. Reynolds, K.H. Lim / The Arts in Psychotherapy 34 (2007) 1–10 7

recounted: “That’s the saddest part about it. I had a friend, a really close friend, we worked together for years. . . I
tried to meet up with her but as soon as I mentioned the word that I’d got cancer, I haven’t heard from her anymore.
I’ve not heard from her since that day.”
Jessica’s experience was similar: “I’ve known people hide. . . because they don’t know what to say to you and you
get comments. Someone came up to me and said, ‘Oh, if I had to have a mastectomy, I’d kill myself.’ Very helpful! And
what I actually said is, ‘Oh, it’s a good job I don’t feel like that, isn’t it?’ But people are ridiculous about what they
say and I think that’s another reason for doing something that they can talk to you about, that’s not cancer, because
people are scared of cancer, aren’t they?”
Art-making provided a shared interest with others that had nothing to do with cancer. With the cancer rendered less
dominant, a better quality of social life was achieved, and stigma was resisted. Participants felt able to retain active
roles in their social circles rather than feeling totally defined by the cancer diagnosis or pitied as a “tragic victim.”
Art-making also provided a shared focus of social activity for many participants. Those who joined courses or set
up arts and crafts groups of their own (e.g. for painting, cross-stitch, patchwork, or charity fund-raising) belonged on
their own terms, rather than being defined by their illness. Jessica said: “I think one of the biggest factors in that is that
your disability or your ill health, or whatever, isn’t the most important thing in your life. I don’t think about it when
I’m out and about at all. I keep that for family. I think it’s boring listening to someone else’s health problems and I
think by having the art and the craft and everything, it gives you that interest that you can talk about. I mean what do
people talk about? They talk about their work, their family, their hobbies, their health.”
Some participants regarded their art-making as helping family and friends to feel less concern about their well-being.
For example, Jean described wishing to protect her young adult children from distress by having a positive focus in
her life during treatment for breast cancer: “I’d still got three kids at home, early 20’s, old enough to be helpful but in
other ways I needed to protect them a bit. I wanted something so they’d feel their mum was riding above this. . . so I
joined the Embroiders’ Guild.”
Eve described sometimes sparing her friends details about her breast cancer treatment. With her hand-made cards,
she took care to avoid focusing on her illness or treatment: “If you sometimes include nice photos or you send a [pink]
ribbon or whatever and maybe that’s not so depressing for the people receiving. Better than saying ‘Oh, this week I’ve
been to the hospital again and I’ve had another scan’. . . Because people have been very good and they do want to
know what’s going on, but I don’t always want to be the bearer of bad tidings. It’s nice sometimes to send something
just a bit more cheerful.” She not only exercised control over disclosure of her illness; she also maintained her status
as an equal partner in her social relationships, giving as well as receiving emotional care.
Making hand-made gifts was popular among the participants. As well as spending enjoyable time in making the
gift, the act of giving also contributed to maintaining or restoring the status of the person with cancer. Gifts helped to
reciprocate care. The youngest participant (Susie, aged 23, who was receiving treatment for a brain tumour) explained: “I
like to make things for people who have done stuff for me or looked after me or been kind to me.” Participants appreciated
that hand-made gifts also encouraged others focus on their positive talents, not simply their cancer diagnosis. Gifts
were sometimes given as a strategy to ward off pity and to emphasise personhood instead of cancer. For example, one
participant (Carol) returned to work after weeks of chemotherapy with a set of embroidered waistcoats that she had
made for all of her colleagues. Talk in the office then centred on the embroidery rather than illness.
For some participants with life-limiting illness, gifts were viewed as a legacy, helping to preserve their memory.
Louise thought that she was unlikely to live long enough to see her young grand-daughters marry, yet she described
embroidering wedding presents, “something to remember me by.”

Discussion

None of the participants ascribed any “mystical” healing powers to their creative activities. Nor did much of the art
have a symbolic function, according to their accounts. Although art therapists (such as Borgmann, 2002; Minar, 1999)
have explored the symbolism within the art of clients with cancer, art as a leisure activity generally did not have this
purpose, according to participants. With the exception of a few “chemotherapy pieces,” art was rarely experienced as
creating or expressing any negative emotion. Instead, it provided important sources of subjective well-being. Participants
emphasised that they gained a sense of vitality from ongoing engagement with the beauty and creative inspirations of
the physical environment; participation in active planning and problem-solving; and from observing development of
their own artistic skills. Art-making also offered opportunities to re-focus attention away from distressing symptoms.
8 F. Reynolds, K.H. Lim / The Arts in Psychotherapy 34 (2007) 1–10

Through their art, participants could retain aspects of their familiar personal and social identities, maintaining personal
continuity, control and reciprocal relationships, in face of the physically and social disruptive nature of cancer.
The themes that emerged were broadly consistent with the themes derived from a sample of people living with
chronic illnesses of different types (Reynolds & Prior, 2003). However, the intensity of emotional turmoil, awareness
of limited time, and degree of physical pain among participants with cancer may have been responsible for the greater
emphasis reported here on the value of art-making for actively managing the negative aspects of illness. Compared with
the previous study, this sample of participants with cancer made fewer references to art as a catalyst for other positive
lifestyle choices (such as travel, exhibitions, or courses). Art-making provided opportunities to experience continuity,
agency and self-esteem, all recognised as defining features of identity which are readily threatened by cancer (Gillies
& Johnston, 2004). Art-making also helped participants to move beyond preoccupations with cancer and mortality. It
offered a re-vitalising experience, preserving a healthy and vigorous engagement with life. For at least short periods,
participants were able to escape from the liminal zone between life and death that has been described by Sibbett (2005).
Participants’ length of artistic experience and level of skill were not clearly related to the benefits that they identified in
their art-making, although it must be acknowledged that even those who had taken up art since diagnosis had enjoyed
sufficient time to acquire valued skills, and to produce work that they found pleasing.
Previous research (such as Gall & Cornblat, 2002) has found that social support and spiritual beliefs provide
resources for living with cancer. This study provides fresh insights by revealing how a personally meaningful leisure
activity such as art-making helps to preserve a familiar, “normal” and positive identity during cancer and a sense of
re-engagement with life. Findings are consistent with previously reviewed evidence about people’s needs to protect
their identities from the labelling that is so readily imposed by cancer.
The findings support previous qualitative research studies (Luker, Beaver, Leinster, & Owens, 1996; Luoma &
Hakamies-Blomqvist, 2004) that have documented how some people cope with cancer by getting on with their lives
(“living well”) rather than dwelling on their illness. However, Luoma and Hakamies-Blomqvist (2004) interpreted
participants’ desire to focus on experiences other than cancer as a form of conscious denial or reality distortion. They
used this term to describe participants’ strategy of trying not to think about their illness, instead seeking absorbing
pastimes such as watching films. Yet denial occurs when people reduce their anxieties by refusing, consciously or
unconsciously, to accept or believe a threatening event. In the current study, there was little evidence of denial, as
participants were quite open about their fears for the future and they talked quite explicitly about their harrowing
experiences of diagnosis and treatment. Yet when engaged in creative activity, they experienced an opportunity to
withdraw attention from their cancer. Such a strategy can be understood as emotion-focused in relieving participants
from worry and stress at least temporarily during creative activity, or as problem-focused in managing the intrusive
cognitive burden of cancer. This strategy of deliberate immersion in activity may be a form of self-distraction, a strategy
that was noted by Kershaw, Northouse, Kritpracha, Schafenacker, and Mood (2004) to be unrelated either to avoidant
or active coping. Its relationship with subjective well-being requires further examination.
Previous research (by Tocher, 2002) has focused on the meanings of a physically active leisure pursuit for breast
cancer survivors. In this study, participants’ accounts of art-making emphasised certain similar psychological and
social benefits. These included enhanced control, the experience of living more intensely in the present moment, a
commitment to future projects and making use of precious time, as well as social relationships built upon shared
interests other than cancer.
Participants, through their art-making, appeared to be practising a form of resistance to the all-defining power
of cancer. Narratives have been understood as a means of resistance to the life disruption that cancer brings about
(Dreifuss-Kattan, 1990; Mathieson & Stam, 1995). This study seems to demonstrate many ways in which visual
art-making confers psychological resistance to the potentially overwhelming psychological and social power of this
condition. Other studies have emphasised that cancer disrupts identity (Gillies & Johnston, 2004; Mathieson & Stam,
1995). This study has revealed that leisure-based art-making can offer a powerful means of maintaining identity and
subjective well-being during and after cancer treatment.
From a critical perspective, this qualitative study has a number of limitations. In interview-based research, one
may take a “realist” view that participants are offering transparent windows on to their thoughts and feelings, and this
assumption tends to be made by those conducting IPA studies (Smith et al., 1999). A more critical position is that par-
ticipants may be providing “heroic” narratives to enhance their self-presentation, a strategy that is understandable given
that people with cancer are bombarded with exhortations to be “positive” (Wilkinson & Kitzinger, 2000). Nevertheless,
we argue that the interviewees, in describing the meanings of art-making, were not engaged in exaggeratedly positive
 F. Reynolds, K.H. Lim / The Arts in Psychotherapy 34 (2007) 1–10 9

self-presentation. They clearly engaged in art-making outside of the interview, as demonstrated by their artwork in the
home, and had certain reasons for choosing creative activity, even if they could not fully articulate their motives in
the interview. Also, they were quite open about their difficulties in relation to cancer and did not seem to be in denial.
Interviews embraced both negative and positive experiences; participants’ narratives were not therefore artificially
“heroic.”
The sample size was small though typical for a phenomenological study using IPA, but the generalisability of the
findings cannot be assumed, as the sample was restricted in social and economic terms. Most had professional careers
prior to their illnesses and seemed to be well supported by partners and families. These psychosocial resources may
have promoted positive attitudes to living with cancer, and assisted their immersion in artistic pursuits. The sample
was diverse in terms of diagnosis. A few regarded themselves as cancer “survivors”; some were uncertain about future
health, and some regarded themselves as terminally ill. For an exploratory study this was considered helpful, but further
research should compare and contrast the meanings of leisure art-making for participants in various stages of the cancer
trajectory.

Conclusions

This phenomenological study sought to understand how visual art-making, as a leisure pursuit rather than as formal
psychotherapy, contributed to the subjective well-being of people living with cancer. Participants described many
stressful experiences associated with cancer and its treatment, which prompted a search for meaningful activity to
help relieve stress. Emotional turmoil and/or early retirement from work prompted most participants to initiate or
intensify an interest in art-making after diagnosis. For a minority, a few pieces of artwork enabled expression of
feelings about cancer in symbolic or implicit terms, especially in the early stages after initial diagnosis or recurrence,
and this was thought to be an emotionally fraught yet valuable experience. Art-making was also valued by participants
for encouraging a positive outwards focus, and for limiting their preoccupation with cancer-related fears and physical
discomfort. Art-making helped to support continuity of personal identity, an “able” self-image and equality within
social relationships, thereby counteracting the ‘master status’ that cancer tends to confer.
There are several implications for art therapists. Firstly, cancer creates long-term stress, and art-making later in
the cancer trajectory may assist some people to reconnect with aspects of their former identity, to resist the ‘master
status’ that cancer can exert, and to experience “vital engagement” with life (Nakamura & Csikszentmihalyi, 2002).
However, it must be acknowledged that personal interests and wider psychosocial resources will inevitably influence
which leisure occupations are meaningful to individuals. Another implication from this study is that not all of the
therapeutic potential of art resides in its symbolic function (although some individuals do need to engage in symbolic
self-expression atleast in the early stages of cancer). It is possible, of course, that individuals cannot readily use art to
explore deeper feelings symbolically, without the support and containment of a therapist. Yet participants suggested
that art-making as a leisure activity promotes subjective well-being in many other ways. Although published studies of
artwork by cancer patients emphasise the exploration of darker themes, the sense of re-integration that can be achieved
from creating aesthetically pleasing artwork should not be discounted.
Participants continued to face distressing experiences in relation to their illness, yet art-making during leisure time
offered an important resource for regaining subjective well-being. Helen (50 years old, who had completed treatment
for non-Hodgkins lymphoma), explained: “You eventually carry on but in a way, the living afterwards is more of a
challenge than actually just getting through your treatment—although you don’t realise it at the time. And actually to
live it positively.”

Acknowledgements

The authors would like to thank participants for sharing their experiences and the Arts & Humanities Research
Council (UK) for its financial support.

References

Arman, M., & Rehnsfeldt, A. (2002). Living with breast cancer: A challenge to expansive and creative forces. European Journal of Cancer Care,
11, 290–296.
10 F. Reynolds, K.H. Lim / The Arts in Psychotherapy 34 (2007) 1–10

Borgmann, E. (2002). Art therapy with three women diagnosed with cancer. The Arts in Psychotherapy, 29, 245–251.
Bower, J., Meyerowitz, B., Desmond, K., Bernaards, C., Rowland, J., & Gantz, P. (2005). Perceptions of positive meaning and vulnerability following
breast cancer: Predictors and outcomes among long-term breast cancer survivors. Annals of Behavioral Medicine, 29, 236–245.
Carpenter, J., Brockopp, D., & Andrykowski, M. (1999). Self-transformation as a factor in the self-esteem and well-being of breast cancer survivors.
Journal of Advanced Nursing, 29, 1402–1411.
Charmaz, K. (1991). Good days, bad days: The self in chronic illness and time. New Brunswick, NJ: Rutgers University Press.
Dreifuss-Kattan, E. (1990). Cancer stories: Creativity and self-repair. Hove: Analytic Press.
Dunn, J., Steginga, S., Rosoman, N., & Millichap, D. (2003). A review of peer support in the context of cancer. Journal of Psychosocial Oncology,
21, 55–67.
Gall, T., & Cornblat, M. (2002). Breast cancer survivors give voice: A qualitative analysis of spiritual factors in long-term adjustment. Psycho-
Oncology, 11, 524–535.
Gillies, B., & Johnston, G. (2004). Identity loss and maintenance: Commonality of experience in cancer and dementia. European Journal of Cancer
Care, 13, 436–442.
Jenkins, R., & Pargament, K. (1995). Religion and spirituality as resources for coping with cancer. Journal of Psychosocial Oncology, 13, 51–74.
Kershaw, T., Northouse, L., Kritpracha, C., Schafenacker, A., & Mood, D. (2004). Coping strategies and quality of life in women with advanced
breast cancer and their family caregivers. Psychology and Health, 19, 139–155.
Lam, W., & Fielding, R. (2003). The evolving experience of illness for Chinese women with breast cancer: A qualitative study. Psycho-Oncology,
12, 127–140.
Landmark, B., & Wahl, A. (2002). Living with newly diagnosed breast cancer: A qualitative study of 10 women with newly diagnosed breast cancer.
Journal of Advanced Nursing, 40, 112–121.
Link, L., Robbins, L., Mancuso, C., & Charlson, M. (2004). How do cancer patients who try to take control of their disease differ from those who
do not? European Journal of Cancer Care, 13, 219–226.
Luker, K., Beaver, K., Leinster, S., & Owens, R. (1996). Meaning of illness for women with breast cancer. Journal of Advanced Nursing, 23,
1194–1201.
Luoma, M., & Hakamies-Blomqvist, L. (2004). The meaning of quality of life in patients being treated for advanced breast cancer: A qualitative
study. Psycho-Oncology, 13, 729–739.
Lynn, D. (1994). Myself resolved: An artist’s experience with lymphoma. Philadelphia: Meniscus Health Care Communications.
Mathieson, C., & Stam, H. (1995). Renegotiating identity: Cancer narratives. Sociology of Health and Illness, 17, 283–306.
Minar, V. (1999). Art therapy and cancer: Images of the hurter and healer. In C. Malchiodi (Ed.), Medical art therapy with adults (pp. 227–242).
London: Jessica Kingsley Publishers.
Nakamura, J., & Csikszentmihalyi, M. (2002). The construction of meaning through vital engagement. In C. L. M. Keyes, & J. Haidt (Eds.),
Flourishing: Positive psychology and the life well-lived (pp. 83–104). Washington: American Psychological Association.
Predeger, E. (1996). Womanspirit: A journey into healing through art in breast cancer. Advances in Nursing Science, 18, 48–58.
Reynolds, F., & Prior, S. (2003). ‘A lifestyle coat-hanger’: A phenomenological study of the meanings of artwork for women coping with chronic
illness and disability. Disability and Rehabilitation, 25, 785–794.
Shannon, C., & Shaw, S. (2005). ‘If the dishes don’t get done today, they’ll get done tomorrow’: A breast cancer experience as a catalyst for changes
to women’s leisure. Journal of Leisure Research, 37, 195–215.
Sibbett, C. (2005). An art therapist’s experience of having cancer: Living and dying with the tiger. In D. Waller, & C. Sibbett (Eds.), Art therapy
and cancer care (pp. 223–247). Maidenhead: Open University Press.
Smith, J. A., Osborn, M., & Jarman, M. (1999). Doing interpretative phenomenological analysis. In M. Murray, & K. Chamberlain (Eds.), Qualitative
health psychology: Theories and methods (pp. 218–240). London: Sage Publications.
Spelten, E., Spranger, M., & Verbeek, J. (2002). Factors reported to influence the return to work of cancer survivors: A literature review. Psycho-
Oncology, 11, 124–131.
Tocher, M. (2002). How to ride a dragon: Women with breast cancer tell their stories. Toronto, Ont.: Key Porter Books.
Wilkinson, S., & Kitzinger, C. (2000). Thinking differently about thinking positive: A discursive approach to cancer patients’ talk. Social Science
and Medicine, 50, 797–811.