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PSYCHO-ONCOLOGY
Psycho-Oncology (in press)
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.988
A RANDOMIZED, CONTROLLED TRIAL OF
MINDFULNESS-BASED ART THERAPY (MBAT)
FOR WOMEN WITH CANCER
DANIEL A. MONTI*, CAROLINE PETERSON, ELISABETH J. SHAKIN KUNKEL, WALTER W. HAUCK,
EDWARD PEQUIGNOT, LORA RHODES and GEORGE C. BRAINARD
Thomas Jefferson University, Philadelphia, PA, USA
SUMMARY
The purpose of this study was to gather data on the efficacy of a newly developed psychosocial group intervention
for cancer patients, called mindfulness-based art therapy (MBAT). One hundred and eleven women with a variety of
cancer diagnoses were paired by age and randomized to either an eight-week MBAT intervention group or a wait-list
control group. Ninety-three participants (84%) completed both the pre- and post-study measurements. As compared
to the control group, the MBAT group demonstrated a significant decrease in symptoms of distress (as measured by
the Symptoms Checklist-90-Revised) and significant improvements in key aspects of health-related quality of life
(as measured by the Medical Outcomes Study Short-Form Health Survey). This investigation of MBAT provides
initial encouraging data that support a possible future role for the intervention as a psychosocial treatment option
for cancer patients. Copyright #2005 John Wiley & Sons, Ltd.
KEY WORDS: cancer; stress; mindfulness; art; oncology
INTRODUCTION
The overall prevalence rate of cancer in the United
States continues to increase, especially for some
cancers that commonly affect women (e.g. breast
cancer) (American Cancer Society, 2003). For
many women, the diagnosis of cancer means
coping with a chronic illness that will have a
variable course for an undetermined amount of
time. Receiving a cancer diagnosis can be a highly
distressing event and the illness experience for
cancer patients often presents numerous stressful
challenges. Cancer patients frequently report a
high level of unmet psychosocial needs, which
contributes to the stress inherent in the illness
experience (Sanson-Fisher et al., 2000). Stress
(Cohen et al., 1998; Heim, 1991), negative percep-
tions of the illness in relation to self and the
outside world (Mishel et al., 1991; Nelson, 1996),
poor coping strategies (Sanson-Fisher et al., 2000;
Jacobsen and Holland, 1991) and inadequate
social supports (Wortman and Lehman, 1985; Ell
et al., 1992) can all negatively impact health status.
Targeting these variables is a primary goal in
current cancer care (Hewitt and Rowland, 2002;
Sanson-Fisher et al., 2000).
Supportive group therapy is the most studied
psychosocial intervention for cancer patients;
researchers using group interventions have had
documented success at addressing psychosocial
needs and decreasing distress (Spiegel et al., 1981;
Fawzy et al., 1995; Helgeson et al., 2000). Such
interventions tend to be diagnosis specific (e.g.
breast cancer or prostate cancer), and they almost
exclusively rely on verbal exchanges (e.g. sharing
of experiences, educational lectures, etc.). An
estimated 20–40% of cancer patients have high
stress levels (McGarvey, 1998; Goodwin and
Leszcz, 2001); yet, only a fraction of them
participate in group interventions. There are
several possible explanations for this, including
limited access, negative perceptions about group
process, and stigma (Krizek et al., 1999). There-
fore, there is an apparent need to develop
innovative group formats for cancer patients that
Received 28 December 2004
Copyright #2005 John Wiley & Sons, Ltd. Accepted 15 August 2005
*Correspondence to: Jefferson Medical College, 1020 Sansom
Street - 1652 Thompson Bldg., Philadelphia, PA 19107, USA.
E-mail: monti1@pol.net
could potentially accommodate a broad range of
patients and provide alternative modes of infor-
mation processing.
The present study was designed to assess the
effectiveness of a recently developed psychosocial
group intervention for cancer patients, called
mindfulness-based art therapy (MBAT). MBAT
integrates mindfulness meditation skills and as-
pects of art therapy into an eight-week, gender-
segregated, supportive group therapy format. The
multi-modal design is intended to provide oppor-
tunities for both verbal and non-verbal expression,
enhanced support, and expanded coping strategies.
The overall goal is to decrease distress and improve
quality of life. The structure of MBAT also allows
for a different composition of participants than the
typically available psychosocial cancer group
programs. Since MBAT is designed with a focus
on health-promoting skills and behaviors applic-
able to a wide variety of cancer patients, the groups
are intended to accommodate a patient population
that is heterogeneous in regard to cancer type.
Theoretical framework: The MBAT intervention
is conceptually rooted in the principles of self-
regulation theory (Leventhal et al., 1984, 1992),
which provides a foundation for understanding
reactions to perceptions of physical and emotional
well-being. Self-regulation theory explains how
people cope with and adapt to, stressful situations
such as health problems or threats. The model
reflects two modes of information processing: (1)
objective representation of a (health) problem in
cognitive terms, such as the laboratory result or
tumor stage, and (2) subjective representation of
the problem in emotional terms, such as fear or
anger. An essential component to this theory is the
schema that is formed from the combined objec-
tive and subjective representations of the health
threat. Within the context of this model, there are
two main self-regulatory issues involved in coping
with health problems: the content of the represen-
tations and the process by which the representa-
tions are appraised and changed over time. The
ability to negotiate subjective and objective
representations directly affects stress levels (Folk-
man, 1984; Heim, 1991).
MBAT is designed to provide specific skills for
cultivating self-regulation in a format that is not
confined to verbal processing alone. For example,
one aspect of the MBAT intervention, mind-
fulness-based stress reduction (MBSR) (Kabat-
Zinn et al., 1987), provides standardized tools to
help participants observe, assess, and negotiate
their objective and subjective representations of
the illness experience. MBSR programs have had
documented success in reducing stress in cancer
populations (Speca et al., 2000; Carlson et al.,
2004). Mindfulness practices may foster self-
regulation through cultivation of focused attention
and acceptance of self in the present moment; this
may allow for conscious observation of both the
actual experience (objective representation) and
emotional responses to it (subjective representa-
tion), which may allow for more choices in regard
to stimulus reminders (Kabat-Zinn, 1990).
Another aspect of MBAT, art therapy, provides
concrete tasks for expressing representations in a
tangible and personally meaningful manner.
Research with cancer patients and with other
populations supports the use of tasks that allow
for focused expression of unpleasant emotions,
which can lead to a reduction in medical symp-
toms, such as pain, and an increased sense of
well-being (Shakin et al., 1989; Smyth, 1998;
Pennebaker et al., 1997; Stanton et al., 2001).
Although there are numerous published case and
qualitative studies from the field of art therapy,
including the widely reported and beneficial use of
art therapy with cancer populations in both
individual and group formats (Gabriel et al.,
2001; Deane et al., 2000; Luzzatto, 1998; Mal-
chiodi, 1999), few controlled studies exist. How-
ever, a recent clinical trial of an art therapy
intervention with hospitalized children with post-
traumatic stress disorder supports the way in
which MBAT utilizes specific art tasks. In that
study it was shown that art therapy tasks could be
designed in a way that may integrate brain
pathways related to distressing experiences, pro-
viding a mechanism for stress reduction (Chapman
et al., 2001).
Chapman’s neurodevelopmental approach to
art therapy posits that recollection of a blocked
pattern of memory (perceived experience stored as
images) due to stress trauma can be: (1) restored
from partial data, (2) tolerated affectively, and (3)
integrated into consciousness when art tasks are
designed to follow a neurodevelopmental course.
Specifically, the right hemisphere of the brain is
thought to be the predominate storage site for
traumatic memories (Schiffer et al., 1995). The
stimulation of art media used in art tasks may
activate the right hemisphere via kinesthetic and
sensory activity (Lusebrink, 2004), which leads to
greater awareness of different aspects of threaten-
ing events, including emotional responses. The
D.A. MONTI ET AL.
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
final stage is verbal articulation of the image and
what it represents (left hemisphere activity).
Representational integration, including the bilateral
integration of information processing between right
and left hemispheres, in particular, has been
proposed to be a core component of the resolution
of unresolved trauma (Siegel, 1999). It is interesting
that MBSR training also results in left-sided
activation (Davidson et al., 2003). Chapman’s
model supports the use of art therapy in distressed
cancer patients, especially given the very high
incidence of reported distressing cancer-related
experiences and recollections in this population.
In the MBAT intervention, art therapy tasks
also are designed to meaningfully complement the
MBSR curriculum, which may enhance the non-
verbal process of identifying and organizing
internal and external representations. The process
orientation in mindfulness practice and art making
in MBAT thus supports the potential transforma-
tion of threat schemas, thereby advancing more
adaptive coping. MBAT is conducted in a
supportive group milieu, which provides a verbal
mode of processing subjective representations that
emerge from group tasks, and allows for expres-
sion of related personal meanings and schemas
(a brief review of the eight-week intervention is
provided in Table 1). Hence, the MBAT format is
intended to integrate verbal and non-verbal modes
of information processing for the purpose of
facilitating healthful self-regulation.
Here we report our findings of a randomized,
controlled, clinical trial of women with hetero-
geneous cancer diagnoses, comparing the eight-
week MBAT intervention to a wait-list control
condition. There were two primary aims of the
study. The first aim was to test the hypothesis that
participants who receive an eight-week group of
MBAT along with usual medical care, will
demonstrate significantly greater reductions in
symptoms of distress, as measured by the Symp-
tom Checklist -90-Revised (SCL-90-R) anxiety
and depression subscales, than patients who
receive usual medical care alone. The second
aim was to test the hypothesis that partici-
pants, who receive the MBAT intervention
along with usual medical care, will demonstrate
significantly greater improvement in health-
related quality of life, as measured by the
Medical Outcomes Study Short-Form Health
Survey (SF-36) physical health composite
score, than patients who receive usual medical
care alone.
METHODS
Subjects
The protocol, research design and recruitment
plan for the MBAT study were reviewed and
approved by the Institutional Review Board of
Thomas Jefferson University. Female subjects were
recruited from a diversity of referral sources
throughout the Jefferson Cancer Network that
includes 16 hospitals within the Philadelphia region,
although the majority of subjects were directly
referred by Jefferson’s Kimmel Cancer Center. The
study population consisted of 111 adult women
who had a cancer diagnosis. Each subject was
beyond four months and within two years of an
original diagnosis of cancer (or cancer recurrence),
at the time of randomization. Patients were
excluded if they were terminal, or had a current
psychiatric diagnosis of a major mood disorder,
psychotic disorder, or significant cognitive deficits
as determined by their physicians. Patients receiving
anytypeofmentalhealthcarehadtoobtainwritten
permission from their treating health professional
in order to enter the study.
Instruments
Psychological distress and stress-related somatic
complaints were assessed immediately pre- and
post-intervention (at weeks 0, 8 and 16), using
the Symptoms Checklist Revised (SCL-90-R)
(Derogatis, 1993). The SCL-90-R is a 90-item
inventory, which assesses nine symptom dimen-
sions and a summary score, the Global Severity
Index (GSI). The GSI is the best single indicator
of the current level of distress. The nine symptom
constructs are; somatization, obsessive-com-
pulsive, interpersonal sensitivity, depression,
anxiety, hostility, phobic anxiety, paranoid idea-
tion, and psychoticism. Respondents are asked
to respond to 90 items by how much they were
bothered by an item anchored to a specific time
frame on a five-point scale (0=not at all; 4=
extremely). The reliability of the SCL-90-R has
been demonstrated by internal consistency
(r¼0:77–0.90) and the test–retest reliability
(r¼0:78–0.90) for all scales (Derogatis, 1994).
The SCL-90-R is considered sufficiently sensitive
to discern changes in stress-related symptoms and
has been used specifically with cancer patients
A RANDOMIZED, CONTROLLED TRIAL OF MINDFULNESS-BASED ART THERAPY (MBAT)
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
(Derogatis et al., 1983). As an initial measure of
treatment retention and supportive information
regarding any treatment effects, the SCL-90-R was
administered at week 16 (i.e. eight-weeks post-
intervention for the experimental group and
immediately post-intervention for the controls
who were ‘crossed over’ to receive the intervention
at week 9).
Health-related quality of life also was assessed
immediately pre- and post-intervention (at weeks
0, 8 and 16), using the Medical Outcomes Study
Short-Form Health Survey (SF-36) (Ware, 1999).
This is a 36-item measure used to assess eight
health concepts: (1) limitations in physical activ-
ities; (2) limitations in social activities; (3) limita-
tions in role activities because of health problems;
(4) limitations in role activities because of emo-
tional problems; (5) bodily pain; (6) general health
perceptions; (7) vitality (energy and fatigue); and
(8) mental health (psychological distress and well-
being). Mental health items tap general well-being,
anxiety, and depression on a six-point scale.
Table 1. MBAT eight-week program curriculum
Week Mindfulness skills development:
MBSR curriculum content
a
Mindful art activity
Home and in-group practice discussion, didactic,
experiential components included in each session
Group discussion of direct experience of
process and pictures in each session
1 Introduction to Program and Intervention Introduction to art-making.
Embodied well-being: responding vs ‘Draw a complete picture of yourself’
Reacting to the stress of life Self-picture assessment (SPA) task
Body scan meditation
2 Body scan meditation
Attitudinal foundations of mindfulness
Anchoring attention with the breath (AOB)
Mindful exploration of art materials (colored
pencil, marker, pastel, watercolor crayon, paint).
Awareness of sensory stimulus and response
3 Gentle yoga and sitting meditation
Intending well-being/loving kindness meditation
Exploring the mind body relationship: pre–post
assessment of mind/body relationship before and
after gentle yoga
4 Cultivating receptive attention Creative problem solving/imaging self-care.
Gentle yoga and sitting meditation
Loving kindness meditation
Transforming mental, emotional and physical pain;
introducing self-care imagery into the picture
b
5 Expanding awareness
Sitting (meditation) with thoughts and feelings
Loving kindness meditation
Exploring meditation practice experience: art productions,
using collage element, serve as basis for increasing skills with
mindfulness practice in the realm of thoughts and feelings
6 The physiology of stress
Walking meditation
Loving kindness meditation
Stressful and pleasant event pictures as introduction to
the physiology of stress including stressful communication/
non-reactive communication skills
7 An evening (or) afternoon silent retreat:
guided meditation practices and open studio
Open studio: free art-making
8 Guided imagery to a place of healing Drawing from the healing place
Program review and discussion of program
close as new beginning. Closing ceremony
‘Draw a complete picture of yourself’
Self-picture assessment (SPA) task
a
Derived from Kabat-Zinn and Santorelli (1999).
b
Derived from Fleming and Cox (1989).
D.A. MONTI ET AL.
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
General health consists of five items measuring an
individual’s perception of wellness or illness.
Alpha coefficients ranged from 0.81 to 0.88 for
the patient sample (N¼11 186) and were similar
to those for the general population (N¼2008)
studied. Both convergent and discriminant validity
were demonstrated in these two groups. The
validity and reliability for the instrument has been
demonstrated in several chronic illness popula-
tions (McHorney et al., 1993).
Procedure
Over 16 months, in three study recruitment
periods, 7 groups of women with cancer who
met the inclusion criteria were enrolled in the
clinical trial. After informed consent was signed,
and after adequate subjects were accrued to form
two treatment groups, subjects were sorted by
age, and one subject of each successive pair
was randomized to either the intervention
group (MBAT) or to the control group
(wait-list) yielding 7 intervention groups and
7 control groups. After the eight-week study
period, wait-list controls were offered the inter-
vention.
The intervention groups received MBAT, a
supportive-expressive group therapy that includes
skills training in mindfulness meditation and
group art therapy tasks. The intervention con-
sisted of eight consecutive, weekly meetings of two
and a half-hours each in length. Each of the eight
weekly sessions had a standardized format and
agenda. Participants received training in the
practice of mindfulness meditation (including
body scan meditation, sitting meditation, gentle
Hatha yoga, and walking meditation), within a
MBSR program curriculum similar to the format
described by Kabat-Zinn and Santorelli (1999).
Home assignments included the practice of mind-
fulness meditation 6 days a week for 30 min. An
audiotape with guided body scan and sitting
meditation was provided to each participant for
this purpose. Recommendations for reading to
support the MBSR program curriculum were also
offered. The group art therapy component of the
intervention focused on non-verbal activities (i.e.
the making of directed and spontaneous art
productions) that were interwoven with the verbal
processes within the group. Specific art tasks were
directed to explore present moment experience and
learning related to the experiential and cognitive
elements of the mindfulness-based curriculum.
Study investigator C. Peterson, who is both a
registered art therapist and an advanced level
MBSR instructor, led the groups. The groups
followed the format of our standardized MBAT
treatment manual (unpublished).
STATISTICAL ANALYSIS
This trial was sized to have 80% power for a 0.62
standardized effect size, the smallest effect seen in
our pilot work among our three primary end-
points. We determined sample size based on a
1.67% test, adjusting for the three primary end-
points by the Bonferroni correction. After allow-
ing for an intra-class correlation of 0.05, with a
consequent sample size inflation of 35% with an
average class size of 8, and for 10% loss-to-follow-
up, we planned to accrue 96 subjects, or 48 per
group. Early in the study, we found that the
dropout rate was higher than we had planned for
and increased the planned sample size to 110.
The data were analyzed on an intent-to-treat
basis in that all subjects with week 0 (baseline) or
week 8 (post-experimental period) values were
included in the analyses in their treatment group as
randomized, regardless of extent of participation.
Missing data were not imputed. For the MBAT
arm, the mean number of groups attended was
approximately five (S:D:¼2:63), and median
number attended was six.
Subscales for the SCL-90-R and SF-36 were
each analyzed separately. The SCL-90-R scales
were transformed by taking square-roots of weeks
0 and 8 values; the SF-36 scales from weeks 0 and
8 values were not transformed. Transformation
was done so the distribution of residuals would be
better approximated by a normal distribution.
Weeks 0 and 8 scores were analyzed as a mixed
effects, repeated measures, analysis of variance.
Week, treatment (MBAT or control) and the week
treatment interaction were fixed effects and age
at start of treatment (included because of the
matching) was a continuous covariate. Recruit-
ment period (1, 2, 3) was a random effect. For the
repeated measures within subject, we used the
heterogeneous compound symmetry covariance
structure (allowing the variances at weeks 0 and
8 to differ) that was allowed to vary with treatment
group. Satterthwaite degrees-of-freedom were used
for all tests and contrasts.
A RANDOMIZED, CONTROLLED TRIAL OF MINDFULNESS-BASED ART THERAPY (MBAT)
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
A statistically significant week–treatment inter-
action constitutes an indication of a treatment
effect (indicating that the change in scores over
time was different for the two treatments). A
treatment effect was estimated by computing the
contrast of the treatment difference (week 8 mean
week 0 mean) for the MBAT (intervention)
group, minus the treatment difference (week 8
mean week 0 mean) for the observation group
(based on least-square adjusted means). This
analysis thus corrects for any difference between
groups at baseline (week 0).
No adjustments were made for multiple com-
parisons.
RESULTS
Subject characteristics
The mean age at baseline of the women was 53.6
years (S:D:¼11:5, range ¼26282) (Table 2).
Fifty-five of the women were in the control
group arm (mean age ¼54:1, S:D:¼10:7, range ¼
35282), and 56 were in the MBAT intervention
group arm (mean ¼53:1, S:D:¼12:4, range ¼
26276). Racial and ethnic distribution was as
follows: 75% of the women were Caucasian; 21%
African-American; 2% Asian; 2% Hispanic; and 1%
other. Cancer diagnoses were varied: breast (51),
gynecologic (19, including 12 ovarian), hematologic
(13),neurologic(5),rectal(6),andother(17).All
participants in the study continued their usual
medical care, regardless of group assignment. Of
the 111 enrolled subjects, 74 were in active treatment
during their participation in the study, receiving
either chemotherapy, radiation, treatment for side
effects or other outpatient cancer-related procedures.
Of the 111 women randomized, 93 provided eight-
week data (45 in the MBAT intervention group and
48 in the control group), yielding a retention rate of
84%. The majority of dropouts were due to
progression of illness and/or cancer treatment
complications. The intervention group and the
control group were at comparable stages of disease
(28/55 control and 29/56 MBAT intervention sub-
jects were of stage 0, 1 or 2, and 27/55 control and
27/56 intervention subjects were of stage 3 or 4).
Scores at baseline for the two groups though
somewhat different (Table 2), reflect higher levels
of reported distress and reduced health-related
quality of life for persons with cancer, as compared
to baseline scores for heterogeneous patients parti-
cipating in Jefferson’s stress reduction program
based on mindfulness meditation (Reibel et al.,
2001).
Psychological distress
Results for the SCL-90-R are presented in Table
3. Results are for data that have been transformed
by taking the square-root of week 0 and week 8
SCL-90-R scores for all subscales, as well as for
the overall GSI. Presented in the table are age
adjusted least-squares means, on the square-root
scale, for weeks 0 and 8, and differences of these
Table 2. Subject characteristics
Age at baseline (yrs) All subjects Control MBAT
ðN¼111ÞðN¼55ÞðN¼56Þ
Mean 53.6 54.1 53.1
Standard deviation 11.5 10.7 12.4
Range 26–82 35–82 26–76
N(%)
All subjects Control MBAT
ðN¼111ÞðN¼55ÞðN¼56Þ
Race
Caucasian 83 (75%) 38 (69%) 45 (80%)
African-American 23 (21%) 13 (24%) 10 (18%)
Asian 2 (2%) 1 (2%) 1 (2%)
Hispanic 2 (2%) 2 (4%) 0
Other 1 (1%) 1 (2%) 0
Cancer type
Breast 51 (46%) 19 (35%) 32 (57%)
Gynecologic 19 (17%) 8 (15%) 11 (20%)
Hematologic 13 (12%) 8 (15%) 5 (9%)
Neurologic 5 (5%) 5 (9%) 0
Rectal 6 (5%) 4 (7%) 2 (4%)
Other 17 (15%) 11 (20%) 6 (11%)
Mean (S.D.)
All subjects Control MBAT
Baseline SCL-90-R ðN¼111ÞðN¼55ÞðN¼56Þ
Overall 0.89 (0.29) 0.82 (0.54) 0.93 (0.53)
Anxiety 0.85 (0.42) 0.85 (0.77) 0.97 (0.78)
Depression 1.08 (0.36) 1.22 (0.82) 1.37 (0.74)
Mean (S.D.)
All subjects Control MBAT
Baseline SF-36 ðN¼111ÞðN¼55ÞðN¼56Þ
Physical composite score 38.9 (10.4) 39.8 (11.3) 38.0 (9.56)
Mental composite score 41.2 (12.2) 43.0 (12.4) 39.5 (11.7)
D.A. MONTI ET AL.
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
means. For example, for the depression subscale,
the mean for the control group for week 0 was 1.03
and for week 8 was 0.95; the score changed 0.08,
a slight improvement. For the MBAT intervention
group, the mean for week 0 was 1.13 and for week
8 was 0.85; the score decreased 0.27, also an
improvement. The difference of differences
(0:19 ¼0:08 ð0:27Þ) is the effect due to
treatment, and is statistically significant
(p¼0:001). Statistical significance was demon-
strated on both targeted endpoints (depression
subscale, p¼0:001; anxiety subscale, p¼0:022.
p-values reported are not adjusted for multiple
comparisons. However, using the Hommel (1988)
modification of the Bonferroni adjustment, the
reported p-values of p=0.001 for the depression
subscale and p=0.022 for the anxiety subscale
become, 0.004 and 0.044, respectively. That is, they
retain statistical significance. Significance also was
demonstrated on all of the other subscales pertinent
to the subject population (see Table 3). The overall
score (GSI) also was highly significant (p50:001).
Finally, we separated the sleep questions from the
‘additional items’ subscale, demonstrating high
significance on the sleep items.
In addition, we were able to obtain week 16
follow-up data on the SCL-90-R. For the MBAT
subjects from week 8 to week 16, the means altered
little, suggesting possible maintenance of treat-
ment of effect; the GSI was 0.73 and 0.74, anxiety
was 0.63 and 0.60, and depression was 0.85 and
0.85 (at weeks 8 and 16, respectively). (Full
analysis of week 16 data for both groups will be
presented in a future paper.)
Health-related quality of life
Results for the SF-36 are presented in Table 4.
Groups were similar at baseline. The data pre-
sented in Table 4 are age adjusted least-squares
means (not transformed), for weeks 0 and 8, and
differences of these means for the SF-36 subscales.
A statistically significant treatment effect was not
demonstrated on the physical composite score
(p¼0:19); however, there was significance on the
mental composite (p¼0:025) and on the general
health (p¼0:008), mental health (p50:001), social
functioning (p¼0:048) and vitality (p¼0:010)
subscales. Additionally, on the SF-36, after
accounting for change in the control group, we
report improvements of five points or more for
subscales related to physical functioning, bodily
pain, general health, vitality, social functioning
and mental health (Table 4). These improvements
are indicative of clinically or socially relevant
change (Ware, 1999). As in the SCL-90-R, there
was little change in means on the SF-36 from week
8 to week 16 for the MBAT subjects, suggesting
maintenance of improvements in general health,
mental health, vitality and social functioning.
DISCUSSION
Consistent with the first primary aim of the study,
subjects who received the eight-week MBAT
intervention demonstrated statistically signifi-
cantly greater decreases in symptoms of distress
as compared to subjects in the wait-list control, as
Table 3. SCL-90-R MBAT results summary table ðN¼111Þ
Adjusted mean score
a
Change in means Effect
SCL-90-R Control MBAT (week 8week 0) (control - MBAT)
factor Week 0 Week 8 Week 0 Week 8 Control MBAT (95% CI) p
Overall (GSI) 0.85 0.81 0.93 0.73 0.04 0.20 0.16 (0.08, 0.24) 50.001
Anxiety 0.82 0.72 0.89 0.63 0.10 0.26 0.16 (0.02, 0.29) 0.022
Depression 1.03 0.95 1.13 0.85 0.08 0.27 0.19 (0.07, 0.30) 0.001
Hostility 0.51 0.48 0.69 0.51 0.03 0.18 0.16 (0.04, 0.27) 0.007
Interpersonal sensitivity 0.69 0.67 0.77 0.60 0.02 0.17 0.15 (0.03, 0.26) 0.012
Obsessive-compulsive 1.01 0.96 1.08 0.90 0.05 0.18 0.13 (0.03, 0.24) 0.012
Somatization 0.91 0.92 0.93 0.75 0.01 0.19 0.20 (0.09, 0.31) 0.001
Additional items 0.96 0.96 1.09 0.84 0.00 0.26 0.26 (0.14, 0.38) 50.001
Sleep
b
1.03 1.07 1.20 0.91 0.04 0.29 0.33 (0.15, 0.51) 0.001
a
Square-root scale.
b
Sleep questions from additional items subscale.
A RANDOMIZED, CONTROLLED TRIAL OF MINDFULNESS-BASED ART THERAPY (MBAT)
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
measured by the SCL-90-R anxiety and depression
subscales. In addition, subscales related to hosti-
lity, interpersonal sensitivity, obsessive-compulsive
and somatization were significantly improved in
the intervention group. There was also a highly
statistically significant change in the Global
Severity Index (GSI) score. Additionally, for the
MBAT subjects, means at week 16 were similar to
those at week 8.
The second aim of the study was to assess the
effects of MBAT on health-related quality of life,
as measured by the SF-36. As compared to wait-
list controls, subjects in the MBAT intervention
group demonstrated statistically significant im-
provement on some, but not all, of the SF-36
scores and subscales. Significance was not demon-
strated for the physical composite summary scale,
although it was for the mental composite summary
scale. High statistical significance was demon-
strated on the mental health, general health, and
vitality subscales. Social functioning also was
significantly improved.
Overall, the results of the study provide
preliminary support for the hypotheses that the
MBAT intervention can help cancer patients
decrease distress levels and improve quality of life.
Results of this study are consistent with those of
other mindfulness studies of heterogeneous patient
groups and cancer patients (Reibel, 2001; Speca,
2000), although, we note that this is the first
randomized, controlled mindfulness-based study
reporting significant outcomes for cancer patients
predominantly in active treatment. In addition, the
results indicate a possible advantage over standard
support, when comparing SF-36 results of a recent
study by Helgeson et al. (2001). Clearly, further
testing is required to assess whether the synergy of
the proven techniques incorporated in the MBAT
protocol provides an advantage for cancer patients
in active treatment over any one of these
techniques alone.
It is noteworthy that two of the three endpoints
we chose for the study did not demonstrate the
greatest therapeutic effect as compared to other
measured endpoints. For example, changes in the
anxiety subscale of the SCL-90-R were significant,
but not as large as the changes in the depression
subscale. Certainly, the most sensitive indicator of
change on the SCL-90-R for this study group was
the GSI, which is considered to be the best single
indicator of current level of emotional distress
(Derogatis et al., 1983).
Likewise, we predicted that quality of life
improvements would best be reflected in the
physical composite summary scale of the SF-36.
The results revealed statistically significant im-
provements on four of eight SF-36 subscales, and
to a lesser degree on the mental composite
summary scale. Statistical significance was not
demonstrated on the physical composite summary
score as hypothesized. However, there were
improvements, greater than or equal to 5 points,
on 3 of the 4 subscales of the PCS, which is
indicative of clinically or socially relevant change
(Ware, 1999). One possible explanation is that
symptoms that comprise the physical composite
score, such as bodily pain and physical function-
ing, were not significantly moderated by the
Table 4. SF-36 results MBAT summary table ðN¼111Þ
Adjusted mean score
a
Change in means Effect
SF-36 Control MBAT (week 8week 0) (control - MBAT)
factor Week 0 Week 8 Week 0 Week 8 Control MBAT (95% CI) p
Physical composite score 39.64 39.71 37.78 40.06 0.06 2.29 2.23 (5.60, 1.15) 0.19
Physical functioning 64.37 64.42 58.23 65.01 0.05 6.78 6.73 (13.8, 0.37) 0.06
Role-physical
a
0.0 25.0 0.0 50.0 0.0 0.0 0.0 0.64
Bodily pain 58.14 58.74 54.23 60.14 0.60 5.91 5.31 (14.1, 3.50) 0.23
General health 55.78 55.19 47.13 55.09 0.59 7.97 8.56 (14.8,2.29) 0.008
Mental composite score 42.82 44.86 39.64 46.13 2.04 6.49 4.45 (8.32,0.58) 0.025
Vitality 42.63 42.91 40.26 50.06 0.28 9.79 9.52 (16.7,2.37) 0.010
Social functioning 60.04 64.91 51.22 66.60 4.87 15.38 10.5 (20.9,0.10) 0.048
Role-emotional
a
33.33 66.67 33.33 66.67 0.0 0.0 0.0 0.84
Mental health 64.91 67.07 56.90 69.95 2.16 13.05 10.9 (16.8,4.96) 50.001
a
For role-physical and role-emotional because of non-normality of the data, observed medians (and median differences) are
presented, and p-value is for the Wilcoxon rank sum test.
D.A. MONTI ET AL.
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
intervention. This would be surprising for the pain
aspect, given that relaxation is part of the
intervention. Other possible explanations are that
the study time period was not sufficient for newly
acquired skills to affect those variables or that the
receipt of active treatment (radiation, chemother-
apy, etc.) for their cancer diagnosis by the majority
of subjects inhibited a response. It was not
surprising that the mental health subscale was
highly significant, since, like the SCL-90-R, it is an
indicator of psychological distress.
The high statistical significance on the general
health subscale of the SF-36, an indicator of
perception of wellness or illness, may reflect the
intervention’s success at helping patients focus on
a life perspective that is broader than that of
having cancer. In the MBAT intervention, parti-
cipants receive support to develop tools for
observing and assessing their experiences. MBAT
is intended to facilitate a sense of control in
participants through awareness that they have the
choice to hold their illness experience as is, or alter
their relationship to particular aspects and events.
In the MBAT model, this goal is accomplished by
learning self-awareness through directed observa-
tion (mindfulness practices) and creative expres-
sion of internal thoughts and emotions (art
therapy), and by enhancing self-acceptance
through verbal and non-verbal bonding and social
support (group therapy).
The high statistical significance on the vitality
subscale of the SF-36 was of interest given that
there was also significant improvement on the
sleep items embedded in the ‘additional items’
dimension of the SCL-90-R. Together, these data
strongly suggest that women in the experimental
intervention felt more rested, and perhaps less
fatigued. This is noteworthy because fatigue is a
well-documented problem among cancer patients
(Hann et al., 1998), and it negatively affects quality
of life by limiting participation in activities of daily
living (Jacobsen and Stein, 1999). Other para-
meters of fatigue might be explored in future
studies.
There were several limitations to the study.
First, this was a pilot study that had an inactive
control group (wait-list). Since MBAT is a multi-
modal intervention, the control group for the next
level of investigation should be an active compo-
nent of the MBAT intervention, such as a support
group without the other components. This also
would control for contact time with study person-
nel. Second, for logistical reasons, week 0 assess-
ments were done post-randomization, and thus
may reflect some psychological response to group
assignment, though we do not see this in the
between-group comparisons of week 0 data. Third,
we report only on short-term effects of the
intervention. The eight-week post-intervention
SCL-90-R data are encouraging, but not sufficient
to predict long-term effects of the intervention.
The results of the study cannot be generalized to
all female cancer patients. The study participants
tended to be middle-aged, about half of them had
breast cancer, and three quarters of them were
white; this demographic distribution is consistent
with national trends of those seeking and partici-
pating in cancer support groups (Barg and
Gullatte, 2001).
In summary, this randomized, controlled inves-
tigation of MBAT provides encouraging initial
data regarding the intervention’s potential for
reducing symptoms of distress and improving
key aspects of quality of life in women with
cancer. Currently, there are few randomized,
controlled, clinical trials on standardized alter-
natives to the usual supportive-expressive cancer
group model. Although there are some study
limitations, the results provide support for further
investigation of this novel intervention.
ACKNOWLEDGEMENTS
This research was supported by grant R21-AT-683 from
the National Institutes of Health.
REFERENCES
American Cancer Society. 2003. Cancer Facts and
Figures. American Cancer Society: Atlanta, GA.
Barg F, Gullatte M. 2001. Cancer support groups:
Meeting the needs of African Americans with Cancer.
Semin Oncol Nurs 17(3): 171–178.
Carlson LE, Speca M, Patel KD et al. 2004. Mind-
fulness-based stress reduction in relation to quality of
life, mood, symptoms of stress and levels of cortisol,
dehydroepiandrosterone sulfate (DHEAS) and mela-
tonin in breast and prostate cancer outpatients.
Psychoneuroendocrinology 29(4): 448–474.
Chapman L, Morabito D, Ladakakos C et al. 2001. The
effectiveness of an art therapy interventions in
reducing post-traumatic stress disorder (PTSD) symp-
toms in pediatric trauma patients. Art Therapy:JAm
Art Ther Assoc 18(2): 100–104.
A RANDOMIZED, CONTROLLED TRIAL OF MINDFULNESS-BASED ART THERAPY (MBAT)
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
Cohen M, Kunkel E, Levenson J. 1998. Associations
between psychological stress and malignancy. In
Handbook of Stress Medicine:An Organ System
Approach, Hubbard JR, Workman EA (eds). CRC
Press: Boca Raton; 205–228.
Davidson RJ, Kabat-Zinn J, Schumacher J et al. 2003.
Alterations in brain and immune function produced
by mindfulness meditation. Psychosom Med 65:
564–570.
Deane K, Fitch M, Carman M. 2000. An innovative art
therapy program for cancer patients. Can Oncol Nurs
J10(4): 147–151, 152–157.
Derogatis L. 1994. SCL-90-R:Administration,Scoring
and Procedures Manual (3rd edn). National Computer
Systems, Inc.: Minneapolis.
Derogatis LR, Morrow GR, Fetting J et al. 1983. The
prevalence of psychiatric disorders among cancer
patients. J Am Med Assoc 249(6): 751–757.
Ell K, Nishimoto R, Mediansky J et al. 1992.
Social relations, social support and survival
among patients with cancer. J Psychosom Res 36(6):
531–541.
Fawzy I, Fawzy N, Arndt L et al. 1995. Critical review
of psychosocial interventions in cancer care. Arch Gen
Psychiatry 52: 100–113.
Folkman S. 1984. Personal control and stress and
coping processes: A theoretical analysis. J Pers Soc
Psychol 46: 839–852.
Gabriel B, Bromberg E, Vandenbovenkamp J,
Kornblith AB, Luzzatto P. 2001. Art therapy
with adult bone marrow transplant patients in
isolation: A pilot study. Psycho-Oncology 10(2):
114–123.
Goodwin PJ, Leszcz MD. 2001. The effect of group
Psychosocial support on survival in metastatic breast
cancer. N Eng J Med 345(24): 1719–1726.
Hann DM, Jacobsen PB, Azzarello LM et al. 1998.
Measurement of fatigue in Cancer patients: Develop-
ment and validation of the fatigue symptom inven-
tory. Qual Life Res 7: 301–310.
Heim E. 1991. Coping and adaptation in cancer. In
Cancer and Stress:Psychological,Biological and
Coping studies, Cooper C, Watson M (eds). Wiley:
Chichester; 197–231.
Helgeson V, Cohen S, Schulz R et al. 2000. Group
support interventions for women with breast cancer:
Who benefits from what. Health Psychol 19(2):
107–114.
Helgeson V, Cohen S, Schulz R, Yasko J. 2001. Long-
term effects of educational and peer discussion group
interventions on adjustment to breast cancer. Health
Psychol 20(5): 387–392.
Hewitt M, Rowland J. 2002. Mental health service use
among adult cancer survivors: Analyses of the
national health interview survey. J Clin Oncol
20(23): 4581–4590.
Hommel G. 1988. A comparison of two modified
Bonferroni procedures. Biometrika 75: 383–386.
Jacobsen P, Holland J. 1991. The stress of cancer:
Psychological responses to diagnosis and treatment.
In Cancer and Stress:Psychological,Biological,and
Coping Mechanisms, Cooper C, Watson M (eds).
Wiley: Chichester; 147–169.
Jacobsen PB, Stein KD. 1999. Is fatigue a long-term side
effect of breast cancer treatment? Cancer Control
6: 256–263.
Kabat-Zinn J, Santorelli S. 1999. Mindfulness-Based
Stress Reduction Professional Training Resource Man-
ual. U Mass Memorial Health Care, Center for
Mindfulness in Medicine, Health Care and Society:
Worcester, MA.
Kabat-Zinn J. 1990. Full Catastrophe Living:Using the
Wisdom of Your Body and Mind to Face Stress,Pain
and Illness:The Program of the Stress Reduction Clinic
and the University of Massachusetts Medical Center.
Delta Trade paperbacks: New York.
Kabat-Zinn J, Lipworth L, Burney R et al. 1987. Four-
year follow-up of a meditation-based program for
self-regulation of chronic pain: Treatment outcomes
and compliance. Clin J Pain 2: 159–173.
Krizek C, Roberts C, Ragan R et al. 1999. Gender and
cancer support group participation. Cancer Pract
7(2): 86–92.
Leventhal H, Diefenbach M, Leventhal EA. 1992.
Illness cognition: Using common sense to understand
treatment adherence and affect cognitions interac-
tions. Cognitive Ther Res 16: 143–163.
Leventhal H, Zimmerman R, Gutmann M. 1984.
Compliance: A self-regulation perspective. In Hand-
book of Behavioral Medicine, Doyle Gentry W (ed.).
Guilford Press: New York; 369–436.
Lusebrink V. 2004. Art therapy and the brain: An
attempt to understand the underlying process of art
expression in therapy. Art Therapy:J Am Art Ther
Assoc 21(3): 125–135.
Luzzatto P. 1998. From psychiatry to psycho-oncology:
Personal reflections on the use of art therapy with
Cancer patients. In Art Therapy in Palliative Care,
Pratt M, Wood M (eds). Rutledge: New York; pp.
169–175.
Malchiodi C (ed.). 1999. Medical Art Therapy with
Adults. Jessica Kingsley Publishers: Philadelphia.
McGarvey EL. 1998. Evidence of acute stress after
diagnosis of cancer. South Med J 91: 864–866.
McHorney CA, Ware JE, Raczek AE. 1993. The MOS
36-item short-form health survey (SF-36): II. Psycho-
metric and clinical tests of validity in measuring
physical and mental health constructs. Med Care 31:
247–263.
Mishel M, Padila G, Grant M et al. 1991. Uncertainty
in illness theory: A replication of the mediating
effects of mastery and coping. Nurs Res 40:
236–240.
Nelson J. 1996. Struggling to gain meaning: Living with
the uncertainty of breast cancer. Adv Nurs Sci 18(3):
59–76.
D.A. MONTI ET AL.
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
Pennebaker JW, Mayne TJ, Francis ME. 1997. Linguis-
tic predictors of adaptive bereavement. J Pers Soc
Psychol 72: 864–871.
Reibel D, Greeson J, Brainard G, Rosenzweig S.
2001. Mindfulness-based stress reduction and
health related quality of life in a hetero-
geneous patient population. Gen Hosp Psychiatry 23:
183–192.
Sanson-Fisher R, Girgis A, Boyes A et al. 2000. The
unmet supportive care needs of cancer patients.
Cancer 88(1): 226–237.
Schiffer F, Teicher M, Papanicolaou A. 1995. Evoked
potential evidence for right brain activity during the
recall of traumatic memories. J Neuropsychiatry Clin
Neurosci 7(2): 169–175.
Shakin E, Rowland J, Holland J. 1989. Psychological
aspects of breast cancer: One nation’s approach to
an international problem. In Breast Cancer,Hoog-
straten B, Burn I, Bloom H (eds). Springer: Heidelberg;
89–99.
Siegel D. 1999. The developing Mind:Toward a Neuro-
biology of Interpersonal Development. Guilford Press:
New York.
Smyth JM. 1998. Written emotional expression: Effect
sizes, outcome types and moderating variables.
J Consult Clin Psychol 66: 174–184.
Speca M, Carlson L, Goodey E et al. 2000. A
randomized wait-list controlled clinical trial: The
effects of a mindfulness-based stress reduction pro-
gram on mood and symptoms of stress in cancer
patients. Psychosom Med 62: 613–622.
Spiegel D, Bloom J, Yalom I. 1981. Group support for
patients with metastatic breast cancer: A randomized
prospective outcome study. Arch Gen Psychiatry 38:
527–533.
Stanton AL, Danoff-Burg S, Cameron C et al. 2000.
Emotionally expressive coping predicts psychological
and physical adjustment in breast cancer. J Consult
Clin Psychol 68(5): 875–882.
Ware JE. 1999. SF-36 Health Survey Manual and
Interpretation Guide. The Health Institute, The New
England Medical Center: England.
Wortman C, Lehman D. 1985. Reactions to victims of
life crises: Support attempts that fail. In Social
Support,An Interactional View, Sarason J, Sarason
B (eds). Wiley: Chichester; 463–489.
A RANDOMIZED, CONTROLLED TRIAL OF MINDFULNESS-BASED ART THERAPY (MBAT)
Copyright #2005 John Wiley & Sons, Ltd. Psycho-Oncology (in press)
