Sketching the Human Experience

1. Kruti Hawkins⇑,Casey L. O'Brien andJustin L. Dwyer

© 2014 by American Society of Clinical Oncology+ 

Author Affiliations

1. From the La Trobe University, Melbourne; St Vincent's Hospital, Melbourne; The University of Melbourne, Melbourne, Australia.

1. Corresponding author: Kruti Hawkins, MA, Psychosocial Cancer Care, St. Vincent's Hospital, P.O. Box 2900, Fitzroy, Victoria, Australia 3065;  e-mail: krutikhatri24@gmail.com.

“I've always wanted to draw the human body. Can you teach me?” Paul asked before I had the chance to put down my sketchbook and pencils. “It's the most difficult thing to draw” he continued, leaving me to hurriedly introduce myself as the art therapy student in the psycho-oncology department.

The psychologist in our department had referred Paul in the hope that art therapy might offer him a way to express how he felt about his recent paralysis, feelings that he had only hinted at during their sessions. Art therapy is a powerful process that uses visual symbols created in the therapy to work through feeling states and experiences not easily articulated. It is especially helpful for those limited by language or held back by the ferocity of their distress.¹ A growing body of evidence in cancer care reveals improvements in symptoms such as depression, anxiety, pain and fatigue, the benefits particularly apparent where the treatment is delivered by a qualified art therapist.^2,3 Moreover, art therapy can reestablish a connection with oneself as coherent and enduring, a process described in the qualitative literature as “meaning making” and of special importance in cancer care where a disorienting sense of personal disintegration frequently accompanies diagnosis.⁴ My position in the psycho-oncology service acknowledged these benefits to patient care, and I was keen to meet Paul after I heard his story.

Paul was a single man in his fifties who worked as a health professional. He had a strong-willed and resilient personality bolstered by his athletic physique, which he had mobilized in his battle against lymphoma 9 years earlier. After many years of good health, he had been admitted to the hospital with relapsed lymphoma complicated by lower limb paralysis. In keeping with his usual coping strategy, he threw himself into his rehabilitation, insisting on “double doses” of physical therapy. He similarly embraced a psycho-oncology referral when his treating team anticipated he might need support adjusting to his paralysis.

At our first meeting, Paul struck me as friendly and approachable. His casual clothes and collegial manner suggested that he saw himself as a fellow professional rather than a patient. The process of art therapy privileges the patient's voice in guiding the work and understanding the symbols created. At Paul's bidding we began with technical aspects, using light and shadow to sketch real-life objects (Fig 1). After several quite structured sessions in which little emotionally salient material surfaced, Paul admitted to some frustration that his drawings did not emerge as he imagined. This dissatisfaction with the work he produced was apparent in his repetitive titling of each piece with “practice.” Our first sessions coincided with a plateau in his physical progress where his paralysis seemed permanent. In team discussion it became clear that Paul greatly valued achievement and saw himself as able to overcome any adversity with enough effort. This led him to become anxious with tasks he could not easily master, and now, confronted with an apparent stalemate in the presence of fellow health professionals, his attitude was one of self-reproach.

Fig 1.

To address Paul's frustration with artistic realism, I led him towards more abstract and spontaneous art making using less constraining materials. During our eighth art therapy session, Paul experimented with acrylic paints and took pleasure in the ensuing mess, a process that can bring people into contact with the child-like aspects of themselves where emotions are less guarded.⁵ The colors and shapes evoked childhood memories of earning his place among his older brothers through his sporting prowess, and he lamented the loss of this physical connection through the cancer. Another piece observed from a distance symbolized a shield (Fig 2), and Paul quietly admitted “I want this shield to protect me from my illness, but……I think that I may just have to live with it.” Holding this protective visual metaphor in mind, Paul was able to safely explore his feelings about the irreversible nature of his illness, a process Moon described as “arting out” that empowers the patient to reframe their story by altering or even painting over certain aspects.⁶ Paul's art helped to connect the cancer to his life story while offering a buffer against intolerable feelings that his body, and thus he himself, had failed in some way.

Fig 2.

The following week Paul was more confident in mixing colors, creating lines and shapes. The art making facilitated a freer dialogue between us as Paul continued to work through his feelings about going home in a wheelchair, even discussing the necessary accommodations for a return to work. The last painting Paul made that session was a simple one with different colored lines stretching across the page (Fig 3). The slick feeling of the paint as it drew out his unhurried lines offered him a moment of quiet contemplation. There did not seem to be any need to speak, and the need to get it right that I had seen in our earlier sessions was gone. Having these quieter, reflective moments with Paul emphasized the role of art therapy in providing freer, “breathing spaces” within the supportive care environment, benefits previously noted in the literature.²

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Fig 3.

A fearful anticipation built as the date of Paul's discharge came closer. On the penultimate day, Paul had an acute myocardial infarction. In the context of his advanced cancer, a decision was made that there would be no further escalation of therapy. At our ward round the next day Paul appeared traumatized by the utter failure of his body and a brush with death that the medical decision making seemed to accentuate. We were quite struck by the sudden change in his mood and loss of all vitality.

Over the following days he drifted in and out of consciousness. In more lucid moments I sat beside him drawing undulating lines on a pad as he spoke openly about death and afterlife without any trace of fear. I wondered how Paul's feelings about death, though not always verbalized, had colored his art therapy and how close they had sat to the surface. Yalom poignantly describes death as something that “whirs continuously beneath the membrane of life and exerts a vast influence on experience and conduct.”^7(p29) I ended the session with my customary promise of another time next week, and his cryptic response of “I'll see you when I see you” stayed with me.

Paul died a few hours later from another myocardial infarction.

Two months later, a thank you card arrived from Paul's mother with a photograph of Paul sitting upright, dressed in a white shirt and a tie looking every bit the confident professional. After commenting on how different Paul looked in this photograph, we realized that we had interpreted his initial demeanor as defensive bluff rather than a true depiction of who he was. With this photograph in mind I now see a story in our work that mirrors and continues Paul's story. It begins with a feeling of insecurity about one's position in the world, and the need for a safe place in which to practice and learn from mistakes. A gradual sense of acceptance followed that recalled the early sporting achievements that cemented Paul's standing among his siblings and his peers. The focus on anxiety and coping within the hospital obscured a broader view of his life, and the photograph opened my eyes to this rich hinterland. Paul taught me at an early stage in my career that art therapy is a synergistic process that goes far beyond being “taught” to draw as requested on our first meeting. The rewards of this experience arose from the collaborative therapeutic connection we shared. I realized that that although he had never sketched the human body, together we had both worked to sketch his human experience.