Authors

1. Lang, Dora RN, BSN, Adv Dip Nsg (Oncology), PHD
2. Lim, Lay Cheng RN, BSN, Adv Dip Nsg (Oncology)

Abstract

Review question/objective: The objective of this review is to synthesize the best available evidence of the effects of art therapy for family caregivers of cancer patients.

Background: Cancer diagnosis is a family disease. It affects the individual patient as well as their family members.1 Cancer patients often receive cancer treatment for a substantial amount of time ranging from six to 12 months depending on the type and stage of cancer. Cancer treatment can disrupt the routine and daily functioning of family members who need to readjust their schedule to meet the needs of their loved one, especially when they play the role of caregiver.2 For some families, a disruption of their routine can be more profound and permanent. A majority of the caregivers have to give up their job to look after their loved one who is inflicted by cancer, resulting in an enormous loss in economic value. The national Survey on Income and Program Participation (SIPP) and the National Survey of Families and Households (NSFH) in the United States identified more than 24 million people as informal caregivers (individuals who provide care for ill or disabled friends or family members). In 1997, the total economic value of caregiver's unpaid contributions totaled $196 billion.3 This value doubled in the following ten years and at 2007, it reached an estimated $ 350 billion according to the AARP Public Policy Institute.4

A study by Mosher et al.5 reported that family caregivers of cancer patients also suffered distress throughout the patient's journey of cancer treatment. More than 50% of family caregivers reported reductions in time for social activities, as well as decreased levels of energy, emotional well-being and an ability to cope with stress.5 They also reported that their experience had a negative impact on their physical functioning. The least reported effects were on their self-esteem, and relationships with patients and other family members. Interestingly, these areas improved as a result of their caregiving.5

Bakas et al.6 discovered that the stressors on family caregivers are multiple and similar across age groups. The consuming tasks experienced by family caregivers of adults, children and spouses were also similar, namely, medical or nursing treatments, personal care, mobility, emotional support, monitoring symptoms, transportation, managing finances, household tasks, running errands, planning activities, managing behavioral problems, finding care while away, communication, services and resources, and communication with health care professionals. The family caregivers in this study reported providing emotional support, transportation, and the monitoring of symptoms as being the three most consuming tasks.6 Conversely, finding care while being away, the provision of personal care and assistance with mobility were reported as being the least consuming tasks.6 Family caregivers also reported that providing emotional support and managing behavioral problems as the most challenging.6

Caregiver stress can lead to psychological and sleep disturbances and changes in the caregiver's physical health, immune function, and financial wellbeing.7 From the authors' personal clinical experience, this is observed repeatedly in caregivers who are experiencing tremendous physical and psychological distress due to the threat of losing their loved one who is the central focus of the caregiver's life. It is extremely difficult for parents whose child has been diagnosed with cancer and for spouses whose partner has been a companion for decades.

Literature has identified certain characteristics that make some family caregivers more vulnerable compared to others. Those who have received a high school education or less experience significantly more depression, tension and mood disturbance compared to those with a post secondary education.8 Educational and income levels are positively correlated with physical functioning and general health.5 Male caregivers reported better physical functioning than female caregivers.5Adult caregivers of children showed better physical functioning and general health than spousal caregivers.5 Employed caregivers showed better physical functioning and general health than the unemployed or retired.5 Patients who received chemotherapy were associated with the worst role-functioning by caregivers.5 The patient with a better diagnosis and functional status was associated with better role-functioning by caregivers.5 Understanding the effects of art therapy on different family caregiver characteristics can help to inform the art therapy provider, who can provide appropriate art therapy interventions and evaluate the effectiveness across the various groups of family caregivers.5

Since 1990, the recommended support services for family caregivers have been related to diagnostic and medical treatment information, interpretation of course of illness, anticipatory guidance, interpretation of patient's emotions, interpretation of illness to school age children, cognitive processing of the meaning of illness for individual families, access to services for physical care, skill building classes, problem-focused services and referral services for the exceptionally distressed family.1 In recent years, there has been a proliferation of studies examining the effectiveness of distraction therapies such as art therapy, music therapy and relaxation for both patients and family caregivers. A recent systematic review found that these therapies were effective for patients across a broad spectrum of symptoms including emotional and physical as well as social and global functioning, and spiritual concerns.9 Art therapy aimed to promote psychological wellbeing and provide comfort. Patients reported feeling refreshed and spiritually enriched and found the experience mind transforming.9 Similarly, artwork activity has been reported as being beneficial for caregivers. For example, art piece creation has been found to provide diversion from the burdens of a caregiver's role, relief from worries, promote humorous responses and good memorable experiences, reduce stress and anxiety, and enhance positive communication between loved ones and with health care professionals.10,11

Clinically, it is common for the cancer patient to seek treatment with the companion of the caregiver. Therefore, family caregiver's needs should not be neglected as they could be a pillar of strength and support for the cancer patient. This review seeks to determine whether art therapy provides a similar positive experience for family caregivers as it does for patients. If so, it is envisaged that both family caregivers and patients could participate in art therapy together instead of caregivers simply watching on. This could create opportunities for caregivers to gather and network with each other and possibly relieve their stress in the hospital.12