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Invited Commentary
June 10, 2013

Creative Arts Therapies Defined: Comment on “Effects of Creative Arts Therapies on Psychological Symptoms and Quality of Life in Patients with Cancer”

Author Affiliations

Author Affiliations: Department of Creative Arts Therapies, College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania.

JAMA Intern Med. 2013;173(11):969. doi:10.1001/jamainternmed.2013.6145

A diagnosis of cancer and subsequent treatments may result in significant emotional, physical, and social suffering, placing cancer survivors at greater risk for mental health issues.1,2 Therefore, the care of cancer patients should incorporate services that help meet patients' psychological, social, and spiritual needs. Creative arts therapies (CATs), such as dance/movement, music, art, poetry, drama, and psychodrama, are increasingly used to aid in the care of cancer patients and in their recovery. The results of several systematic reviews, as referenced in the study by Puetz et al3 have reported small to moderate effects of music, art, and dance/movement therapies on a variety of psychological outcomes in cancer patients. The systematic review by Puetz and colleagues aims to expand the existing evidence base by identifying potential moderators of the efficacy of CATs during and after cancer treatment.

The review included 27 randomized clinical trials (RCTs) that examined the effects of arts interventions (music, art, dance, and expressive writing) on psychological outcomes in 1576 cancer patients. The pooled estimates indicate that arts interventions significantly reduced anxiety, depression, and pain and improved the quality of life in cancer patients. The results indicate no evidence of an effect on fatigue. Moderator analyses suggest greater pain reductions during inpatient treatment and for homogeneous cancer groups. In addition, the authors report that anxiety reduction was greater for those studies “in which the arts intervention was administered by a non-CAT therapist compared with those delivered by a CAT therapist.”3

The continuum of care in arts in health care practices ranges from performances for patients by artists to focused individualized psychotherapeutic CAT interventions. We value and applaud the use of the arts and creative processes across this continuum because they enhance patient care and well-being. Research on the efficacy of these interventions, however, requires clarity about the nature of the interventions themselves. Unfortunately, the analysis by Puetz et al3 offers no operational definition of CATs. Instead, the authors use“creative arts therapies” as a generic term to reference true CATs and also arts interventions administered by non-CAT health care professionals or artist volunteers. This limitation compromises the analysis at its foundation: the understanding of the independent variable in the included studies.

We offer the following definition of CATs, drawing on a number of authoritative sources.4-9 Creative arts therapies involve the implementation of an arts intervention by a trained, credentialed creative arts therapist; the presence of a systematic psychotherapeutic process; and the use of individualized treatment interventions. Thus, CATs use a wide range of arts experiences to address specific therapeutic issues identified individually for patients and always include patient assessment, treatment, and evaluation. Specialties include art therapy, music therapy, dance/movement therapy, drama therapy, psychodrama, poetry therapy, and expressive therapy. In contrast, arts interventions administered by volunteers or professionals in other health care disciplines typically follow a universally applied program of arts activities and, in the case of music interventions, are often limited to passive listening to music. Many studies in the review by Puetz et al3 indeed investigated the effects of listening to prerecorded music.

In their moderator analysis, the authors distinguish studies that involved a monitoring therapist from those that did not. However, the definitions provided in Table 2 for the 2 levels of therapeutic monitoring (ie, therapist present vs no therapist present) are not congruent with the study's conclusion, namely, that greater anxiety benefits were found when the arts intervention was administered by a non-CAT therapist compared with those studies that used a CAT therapist. This conclusion suggests that a therapist (CAT or non-CAT) was present during the intervention session for all studies in this review. However, the authors elsewhere identify 18 of the 25 trials that included anxiety as an outcome as “no therapist” trials. This contradiction leaves the reader somewhat confused. Regardless of the authors' intended meaning, relying on the distinction of therapist present vs no therapist remains problematic when no definition of therapist is provided. The absence of such a definition further complicates the matter in that a provider may have been present but the report does not say if that provider was a certified creative arts therapist, another health care professional, or an artist volunteer. Furthermore, the authors did not provide information on which of the included studies were categorized as “therapist present” or “no therapist present.” This lack of transparency, in combination with the apparent definitional contradictions within the review, renders the findings based on that categorization potentially meaningless.

We are excited to see yet another systematic review confirm the health benefits of arts interventions in cancer patients. We hope that this rapidly expanding evidence will inspire cancer patients to include the arts and/or CATs in their treatment regimen so that their psychosocial well-being can be safeguarded during the challenging treatment and recovery period. We recommend that future research teams conducting systematic reviews of CATs include a CAT specialist to improve construct validity and ensure that included studies have proper adherence to professional standards for the provision of CAT services. When systematic reviews include CATs and arts interventions delivered by non-CAT providers, the 2 forms of intervention must be clearly defined and categorized. This step will yield meaningful results that can better inform programming in health care environments.

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Article Information

Correspondence: Dr Bradt, Department of Creative Arts Therapies, College of Nursing and Health Professions, Drexel University, Bellet Bldg, Room 1041, 1505 Race St, Philadelphia, PA 19102 (jbradt@drexel.edu).

Published Online: May 13, 2013. doi:10.1001/jamainternmed.2013.6145

Conflict of Interest Disclosures: None reported.

References
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Massie MJ. Prevalence of depression in patients with cancer.  J Natl Cancer Inst Monogr. 2004;32(32):57-7115263042PubMedGoogle ScholarCrossref
3.
Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer [published online May 13, 2013].  JAMA Intern Med. 2013;173(11):960-969Google Scholar
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American Art Therapy Association.  American Art Therapy Association home page. http://www.arttherapy.org/. Accessed February 18, 2013
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American Dance Therapy Association.  American Dance Therapy Association home page. http://www.adta.org/. Accessed February 18, 2013
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American Music Therapy Association.  American Music Therapy Association home page. http://www.musictherapy.org. Accessed February 18, 2013
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American Society of Group Psychotherapy and Psychodrama.  American Society of Group Psychotherapy and Psychodrama home page. http://www.asgpp.org/. Accessed February 18, 2013
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National Association for Poetry Therapy.  National Association for Poetry Therapy home page. http://www.poetrytherapy.org/. Accessed February 18, 2013
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North American Drama Therapy Association.  North American Drama Therapy Association. http://www.nadt.org/. Accessed February 18, 2013
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