The Role of the Creative Arts Therapies in the Treatment of Pediatric ...

CASE REPORT
Primary Psychiatry. 2008;15(7):56-58,61-62
The Role of the Creative Arts Therapies in
the Treatment of Pediatric Hematology and
Oncology Patients
Laura Letchworth Nesbitt, MT-BC, MPH, and Kim Tabatt-Haussmann, MA, ATR-BC
ABSTRACT
The positive effects of art and music therapies for distraction
during medical visits and procedures have been well studied.
These interventions can reduce anxiety, promote relaxation, and
minimize the perception of pain. This article describes combined
art and music therapy interventions in the pediatric oncology/
hematology environment and discusses various goals addressed
during out-patient visits. Patient experiences are described as
they relate to engagement in procedural accompaniments, cre-
ative arts therapy groups, individual therapy sessions, and group
music therapy sessions. Interventions discussed include art mak-
ing, active music listening, progressive muscle relaxation, music
technology, active participation in music making, songwriting,
and lyric analysis. The patients’ social, emotional, cognitive, and
physical outcomes are discussed as they relate to treatment. In
addition, the significance of the interventions for creative arts
therapy practiced and researched is explored.
INTRODUCTION
For over 50 years, creative arts therapists have been used
in hospital environments to facilitate relaxation, decrease
anxiety, and provide distraction. During this time, extensive
research documented in medical journals has proven that
Primary Psychiatry
56
FOCUS POINTS
• The use of the creative arts therapies in pain management
is a successful non-pharmacologic intervention.
• The presence of music and art therapy provide a context of
normalization for a child in a medical environment.
Ms. Nesbitt is music therapist and Ms. Tabatt-Haussmann is art therapist in the Pediatrics Department at New York University Langone Medical Center in New York City..
Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Kim Tabatt-Haussmann, MA, ATR-BC, Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, 160 E 32nd St, Second Floor, New York, NY 10016; Tel: 212-263-9923;
Fax: 212-263-8410; E-mail: kim.tabatt@nyumc.org.
© MBL Communications
non-pharmacologic interventions such as art and music therapy
have a positive impact on the patient’s quality of life. 1-5
The following description offers insight into the interventions
provided by the art and music therapists at an outpatient
pediatric hematology/oncology clinic at New York
University Langone Medical Center. Both therapists worked
individually with patients and families and exercised their
specific skills to achieve various goals, including facilitating
relaxation, providing social and peer interaction, decreasing
anxiety, and providing an environment to normalize the
patient within the medical environment. In the past year both
disciplines collaborated so that patients and their families
could have more opportunities to actively participate in the
creative arts. The outcome was extremely positive.
THE CREATIVE ARTS DEFINED
Music therapy is the art of using music to address a nonmusical
goal. In pediatric medical settings, the music therapist
particularly focuses on decreasing a patient’s anxiety and normalizing
the hospital or clinical environment through music
activities. 1-5 A variety of interventions can be used to bring
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The Role of the Creative Arts Therapies in the Treatment of Pediatric Hematology and Oncology Patients
about relaxation, promote normalization, and provide distraction,
including progressive muscle relaxation with music,
music and imagery, hypnosis, procedural accompaniment,
songwriting, lyric analysis, and music and movement. 1-5
In a medical environment, the music therapist works with
patients, families, and medical staff in the treatment room.
During various procedures, the therapist engages the patient
in live music and introduces relaxation skills, including selfhypnosis,
progressive muscle relaxation, and music-assisted
imagery, to distract the patient from pain and decrease
anxiety. Music therapy establishes a “therapeutic environment
that enhances the effects of medication and involves patients
in activities that direct attention away from the stresses of
illness.” 3 Once patients focus less on the stress and anxiety
of an illness, their perception of pain often abates. West 4
relates that relaxation, a goal in music-therapy interventions,
decreases muscle tension and anxiety and results in a “positive
influence on pain perception, nausea, and other symptoms.”
Art therapy, with the creative process of art making, improves
and enhances the physical, mental, and emotional well being
of individuals of all ages. It is based on the belief that clinical
intervention with the act of art making can heal patients and
enhance their quality of life while helping to reduce stress,
increase self awareness, and cope with difficult experiences. 6-11
Medical art therapy is a term applied to “the use of art expression
and imagery with individuals who are physically ill, experiencing
trauma to the body, or who are undergoing aggressive
medical treatment such as surgery or chemotherapy.” 7 A study of
the innovative use of art therapy in relieving symptoms in cancer
provides beginning evidence for the efficacy of art therapy in
reducing a broad spectrum of symptoms in cancer patients. 8
“When art therapy is partnered with medical treatment, children can meet the
challenges of serious illness. For instance, when children create art in the medical
setting, they have a sense of the familiar that produces pleasurable and positive
associations. The child artist gains control by mastering art materials and developing
personal imagery in a situation that is often out of his/her control.” 9
A study of art therapy as a support for children during
painful procedures was shown to be a useful intervention
that can prevent permanent trauma and support children and
parents during intrusive interventions. 10
In medical settings, when children are not well enough or
are unable to visit the playroom for an art therapy group,
individual art therapy sessions can be provided in the treatment
room so as to normalize their clinic environment and
provide opportunities for socialization and expression.
“One of the contributions of art therapy to cancer treatment is the possibility of
helping young people emerge from their illness as emotionally whole and healthy
as possible. Encouraging growth and development through art activities can help
the ill child preserve many areas of normal functioning.” 12
A COLLABORATIVE APPROACH: ART
AND MUSIC GROUP AT THE STEPHEN
D. HASSENFELD CHILDREN’S CENTER
FOR CANCER AND BLOOD DISORDERS
Art therapy and music therapy used collaboratively in a
group provides the children and families with an outlet for
stress management. In such an environment, they can sustain
social and peer interactions as well as normalization. In addition,
they have an opportunity to develop effective coping
skills. Furthermore, art and music “therapists can address the
functional skills of individual patients and encourage improved
social skills, while providing the emotional outlet that is necessary
for patients and families involved” in treatment for cancer
and blood disorders. 5 The art and music group takes place 1–2
times a week during clinic hours. Patients are invited to the
Wellness Room, which is a large, open, non-threatening space
with ceiling tiles designed as night-time stars. A large sheet of
blank mural paper lies in the center of the room, and plush
pillows and blankets are placed around the art area for the
patients’ comfort. Children, parents, and siblings are assisted
into the room, and markers, crayons, colored pencils, foam
cutouts, and a variety of other art mediums are available. The
music therapist sitting on a bench near the art area begins
the session by introducing a theme, such as a trip to the zoo,
life under the sea, space exploration, future dreams, or the
patient’s view of him- or herself. The music therapist chooses
appropriate music for the theme, and the art therapist asks the
patients to close their eyes or focus on the song lyrics. After
the music therapist sings and plays the first verse of the song,
the art therapist invites the children to draw, color, or paint
what or how the music made them feel. As the group progresses,
different songs related to the theme are introduced. This
technique facilitates diverse imagery evident by the distinctive
pictures that appear on the mural paper. At the conclusion of
the group, patients are asked to draw a final image reflecting
the creative arts group theme. The result is a beautiful, unique
mural designed by the participants that reflects their self-concept
and emotions.
BENEFITS OF COMBINING ART AND
MUSIC THERAPY
Combining art and music therapy at the Stephen D.
Hassenfeld Children’s Center for Cancer and Blood Disorders
(SDHCC) of New York University Langone Medical Center
not only increases the participants’ creativity but also distracts
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L.L. Nesbitt, K. Tabatt-Haussmann
them from the clinic environment. The interventions offered
within the group “focus the attention away from the physical
sensation of pain to other aspects of the person.” 13 Pediatriconcology
patients are confronted with numerous challenging
situations, as most of them have to undergo chemotherapy,
radiation, and surgery. Because of their treatment, they are
unable to experience a carefree childhood. Since patients
often experience the side effects of treatment, including pain
and nausea, non-pharmacologic treatments are extremely
important in distracting them from the psychological aspects
of pain. Music and art therapies actively involve patients in
the creative process and, as a result, are able to draw attention
“toward the art and music.” 9 Therefore, “when an investment
in the art or music occurs, an exchange of energy results, and
energy is refocused [away] from the pain.” 13 When music and
art work together to enhance the creative process, the outcome
is positive because it reveals decreased anxiety, distraction
from pain, and increased relaxation response.
The music and art therapy group also provides children
and families with an opportunity to develop a positive social
support group. Not only do pediatric patients miss out on
classroom activities with their teachers and peers when they
are at a clinic, but they miss out on being with their friends
and participating in community activities as well. However,
with the combination of music and art in a social setting,
children are able to socialize with peers in similar circumstances
and not feel as isolated. In the creative arts group,
patients have the opportunity to feel normal, make friends,
work on art together, play and sing, learn, and, most importantly,
have fun in a safe creative environment.
THE MUSIC AND ART GROUP DEFINED
Patients visit the outpatient clinic with parents/guardians,
siblings, grandparents, other relatives and friends. Because
cancer affects the child’s family and network of support, the
therapists encourage and invite caregivers to actively participate
in the creative arts group. Focusing on family-centered
care, the group aims to reduce anxiety and educate participants
on effective coping skills and relaxation tools to increase
understanding and support. For each caregiver present, the
group work reinforces the idea that the child’s creativity,
imagination, development, and spirit are maintained and
validated throughout their treatment.
The Music and Art Group is a 45-minute session that takes
place in a controlled and comfortable space with minimal
design and distraction. The Wellness Room is separate from
the playroom and waiting room, which helps participants
focus on the music and art. Mural paper is placed in the
middle of the floor as well as markers, crayons, foam shapes,
and colored pencils. Pillows surround the paper, posing as
comfortable seats for the participants.
The therapists decide on a theme for the group (eg, animals,
beach activities, rainbows, water and outer space) that
has vivid imagery related to it. After the music therapist collects
appropriate song material, both therapists gather the
patients to begin the group. The art therapist provides various
materials and co-facilitates guiding participants in imagery
before the art creating begins.
The group is encouraged to sit comfortably and participate
in active listening, a music therapy intervention. As the
music therapist performs the song, participants are asked to
listen to the music, close their eyes, and imagine the pictures
that come to mind from the song lyrics. Songs performed in
the past to elicit vivid imagery include “Going to the Zoo,”
“Under the Sea,” “Rocketship Run,” and “Puff the Magic
Dragon” (Figures 1–4).
While the music therapist continues to perform a variety of
theme-related songs, the patients and families, who often sing
along, are encouraged by the art therapist to begin drawing
images on the mural paper. While they are listening and singing,
the art therapist helps the participants think about the
song and images that come to mind. Working on one piece
of mural paper, which is a metaphor for the group working
together, encourages therapeutic play through image making.
One initial image inspires another and gradually transforms
the mural into storytelling through music and art.
While the group is creating images and listening to the
music, individuals often talk about their drawings, and
others sing and dance to the music. As they observe the
FIGURE 1
GOING TO THE ZOO
Nesbitt LL, Tabatt-Haussmann K. Primary Psychiatry. Psychiatry Vol 15, No 7. 2008.
(cont. on pg. 61)
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(cont. from pg. 58)
The Role of the Creative Arts Therapies in the Treatment of Pediatric Hematology and Oncology Patients
dynamics of the group, the leaders reinforce the idea that
there is no right or wrong method.
As the session ends, the therapists review the journey
and discuss the images created on the mural paper, naming
the particular songs that guided the patients’ imagination.
Participants are encouraged to first discuss the images and
music then choose a title for the group mural. All participants
sign their names on the artwork, an act which increases their
self-esteem, produces self-actualization, and provides positive
reinforcement for their creative abilities. The group mural
is then displayed in the playroom for the SDHCC’s staff,
patients, and families. The participants take pride in their finished
product, and as a result, more patients are encouraged
to participate in the next creative arts group.
FIGURE 2
UNDER THE SEA
Nesbitt LL, Tabatt-Haussmann K. Primary Psychiatry. Psychiatry Vol 15, No 7. 2008.
FIGURE 3
ROCKETSHIP RUN
Nesbitt LL, Tabatt-Haussmann K. Primary Psychiatry. Psychiatry Vol 15, No 7. 2008.
CONCLUSION
Art and music therapy used together is extremely effective,
especially with pediatric oncology/hematology patients,
because it helps them address the physical issues of pain as
well as the emotional issues in a non-pharmacologic and
non-threatening way. The dynamics of sound and its impact
on physical symptoms should be understood. For example,
when sound travels through the “reticular activating system
of the brain stem [and] coordinates sensory input, it alerts the
cortex to incoming information.” 1 Therefore, when the brain
is activated, the sound “competes for cognitive awareness”
and causes pain and nausea to be ignored. 1
Music therapy and its effect on anxiety and relaxation
have been well documented in research and case studies
over the years. 2,5,13,14 Hanser 2 reports decreased scores on
the A-State Anxiety Inventory in the presence of induced
anxiety when music is playing, whereas Trauger-Querry
relates that music has a way to “engage, activate and alter
affective, cognitive and sensory processes through distraction,
alteration of mood, improved sense of control, the use
of prior skills and relaxation.” 2,13 Exercising these skills and
establishing a normal environment where pediatric patients
can play and have fun without thinking about their illness
is of paramount importance.
Imagery, facilitated by the art and music therapist, is
another layer that can be added to musical stimuli in diverting
pain perception. A study in which progressive muscle
relaxation and guided imagery was used to delay or prevent
“chemotherapy-induced nausea and vomiting” with HIV
patients was conducted, and the findings demonstrated that
24 hours after chemotherapy, the experimental group, hav-
FIGURE 4
PUFF THE MAGIC DRAGON
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L.L. Nesbitt, K. Tabatt-Haussmann
ing used guided imagery techniques, had decreased levels of
nausea for up to 60 hours after treatment. 15 As patients focus
positively and reach new levels of awareness through music
and art, their tension and anxiety decrease. PP
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