RCTX 3263 Recreational Therapy Intervention Protocol

I. Modality category: Expressive arts

II. Name of Intervention Activity: Therapeutic use of watercolor painting

III. Materials Needed

 13 watercolor pallets (3 extra for backup)
 20 variety sized paint brushes
 20 sheets of watercolor paper (1 extra for each participant)
 Paper towels
 2 Long tables/ 13 chairs
 Disposable table cloths
 Bibs to cover clothes
 10 Cups for water
 Speaker for relaxing music
 Notebooks for journaling/reflecting
 13 pencils and erasers

IV. Treatment Population/Diagnosis : Depression and anxiety in adult cancer patients

V. Description of Treatment Population/Diagnosis: Cancer is one of the top leading

causes of death in America. Among the many physical and psychological effects that
cancer causes among individual’s approximately 25% of cancer patients meet criteria
for depression and or anxiety. Depression and anxiety has been linked to ongoing
fears in individuals that their cancer may return or progress and has even been
connected to prolonging lengths of hospital stays (Bar-Sela et al, 2007). As research
has shown in the Neuropsychiatric Disease and Treatment, “Emotional difficulties are
common among cancer populations and compromise patients’ quality of life,
negatively affect treatment adherence and lead to a higher risk of mortality (Sun et al.
2019, p. 858). This diagnostic group is extremely relevant for this modality which is
evident through a meta-analysis that indicated “that approximately 32% of cancer
patients experience some type of psychological distress during active treatment.”
(Sun et al, 2019, p. 858). By participating in expressive arts specifically water-color
painting, anxiety and depression symptoms can be decreased in cancer patients.

 Physical Domain : Fatigue, feelings of physical pain, low degree of physical

functioning, weight gain or loss, nausea, vomiting, hair loss, infertility, lack of
appetite, slowed body movement.
 Psychological Domain : emotional distress, feelings of anger, anxiety, apathy,
depression, fearfulness, decreased self-image, and persistent stress.
 Social Domain : Social isolation, disrupted relationships, decreased social
skills, and withdrawal engagement in activities and hobbies.
 Cognitive Domain : Reduced mind body communication, confusion, memory
impairment, decreased intelligence, decreased processing speed, and
decreased concentration.

VI. Recommended Group: While expressive arts is appropriate for any group size it is
recommended that this activity is facilitated with no more then 10 members. This size
is big enough to help others build connections with a diverse range of people but also
 small enough to allow members to connect on a deeper level with one another. It will
also allow the leader to have control over the group and the smaller the group the
more customized it can be towards the needs and goals of the members. Each member
will be encouraged to share their explanation of their finished painting including the
symbolic meaning, feelings, and emotions associated with it. By keeping the group to
a maximum of 10 this will allow enough time for each member to participate in a
meaningful way for themselves and other group members.

VII. ICF Functional Outcome Area Classification

1) Body functions: Emotional functions (b152): Specific mental functions related to the feeling
and affective components of the processes of the mind.
Inclusions: functions of appropriateness of emotion, regulation and range of emotion;
affect, sadness, happiness, love, fear, anger, hate, tension, anxiety, joy, sorrow; lability
of emotion; flattening of affect

2) Body functions: Openness to experience (b1264): Mental functions that produce a

personal disposition that is curious, imaginative, inquisitive and experience-seeking, as
contrasted to being stagnant, inattentive and emotionally inexpressive.

VIII. Treatment Goals and Objectives for Intervention

a. Goal: Decrease depression and anxiety

Objective:
1. The client will journal their emotional state before and following each session
(b152). Three positive thoughts should be included in the journal entry. Evidence
of increased positive emotions should be evident 2 weeks in.
2. The HADS depression and anxiety test should be completed at the start of the
first session and at the end of their last. Depression and anxiety scores should
have decreased by at least 25%.

b. Goal: Increase awareness of emotions

Objective
1) Member will show willingness to participate in watercolor painting (b1264) in
order to express their feelings. Participation during discussion will be tracked by
instructor each session. Members should show willingness to share and complete
painting by fourth session.

IX. Facilitation Process:

This is the first session of a month long group. They will meet twice a week for a
60 minute session.
1. For the first and last session only, each member will complete the HADS
assessment
2. The leader will introduce the group members and will explain the sessions goals
a) first session should include an ice-breaker
3. Once members have desired materials, they should be asked “what emotions are
you feeling right in this moment?”.
a) Members should record this in their journals. Will have up to 5 minutes.
b) Calming music can be played if members all agree.
 4. Give instructions for watercolor painting
a) Instructions: Members are given the freedom to paint whatever they would like to
express their current emotions and will have up to 30 minutes to complete their
painting.
5. Watercolor painting session should begin
a) instructor should walk around providing assistance when needed and to add words
of encouragement.
6. After 30 minutes members will share their painting with the group
a) Members should be encouraged to share the story behind their painting and what it
means to them
b) If a member is uncomfortable with sharing it is okay, they can be skipped.
7. After sharing is complete each member should have 5 minutes to individually
journal.
a) members should reflect on their current emotions and feelings as long as their 3
positive thoughts.
8. Processing questions can now take place
9. Session can conclude

X. Variations
 For those who are unable to paint they can color using pens, pencils, markers,
or crayons.
 Painting or journaling session time can be adjusted according to members
abilities and needs
 If unable to paint or draw during a session member can vocalize what they
would do if able.
 If 3 positive reflections is too easy more can be added

XI. Contraindications and/or Precautions

 If a client is uncomfortable with a group setting this activity can be facilitated
1:1
 Lack of motivation or participation may be common due to a number of
circumstances (feeling ill, fatigue, emotional well-being etc)
 Medications can cause side effects such as increased fatigue, nausea, and
decreased mental clarity. In this case, a member may not be able to participate
 HADS test is only appropriate for those who are aware of their emotions.

XII. Processing Questions

1. Explain what you were feeling while completing your painting
2. What made you choose to paint the piece that you did?
3. How did your feelings of depression and anxiety at the end of the session compare
to the start?
4. How can you incorporate the positive journaling activity in your daily lives?
 XIII. Evidence-Based Abstract

Bozcuk, H., Ozcan, K., Erdogan, C., Mutlu, H., Demir, M., & Coskun, S. (2016, November
24). A comparative study of art therapy in cancer patients receiving chemotherapy and
improvement in quality of life by watercolor painting. Retrieved November 8, 2019, from
https://www.sciencedirect.com/science/article/pii/S0965229916303302.

https://search.proquest.com/docview/1863564495/fulltextPDF/593136F83EEE4586PQ/1?acc
ountid=10639

This 12 week study was conducted in hopes to explore how art therapy, particularly water- color
painting played a role on quality of life and anxiety and depression levels in cancer patients. A
total of 97 patients took part in the study where 65 participated in the intervention while the other
32 served as the control group. The participating members were asked to complete an expressive
painting during their chemo therapy session. This intervention allowed, “the patients elaborations
of meaning and subject of their paintings enabled catharsis of negative feelings, and sharing and
discussion of associated problems, feelings and thoughts.” (Bozcuk et al. 2016, p. 68). Two
assessments were used to measure quality of life (domains of EORTC-QLQ-C30) as well as
depression and anxiety (HADS). These scores were assessed before and after the sessions and
were compared to the control group. When comparing the scores it was evident that scores in the
global quality of life and the depression scores had significantly improved “ With PATP, there
was significant improvement in global quality of life (F = 7.87, P = 0.001), and depression scores
(F = 7.80, P = 0.001)” (Bozcuk et al. 2016, p. 67). This study encourages further research of
which specific type of art therapy is more effective in improving the overall quality of life for
cancer patients (Bozcuk et al. 2016).

XIV. Reference list (for entire protocol)

Bar‐Sela, G., Atid, L., Danos, S., Gabay, N., & Epelbaum, R. (2007, March 12). Art therapy
improved depression and influenced fatigue levels in cancer patients on chemotherapy. Retrieved
November 8, 2019, from https://onlinelibrary.wiley.com/doi/pdf/10.1002/pon.1175.

Bozcuk, H., Ozcan, K., Erdogan, C., Mutlu, H., Demir, M., & Coskun, S. (2016, November 24).
A comparative study of art therapy in cancer patients receiving chemotherapy and improvement
in quality of life by watercolor painting. Retrieved November 8, 2019, from
https://www.sciencedirect.com/science/article/pii/S0965229916303302.

Sun, H., Yang, Y., Zhang, Z., Liu, T., Wang, H., Garg, S., & Bin, Z. (2019, April 8). Fear of
cancer recurrence, anxiety and depressive symptoms in adolescent and young adult cancer
patients. Retrieved November 8, 2019, from
https://search.proquest.com/docview/2229917676/fulltextPDF/E1A8EEF5CCB34B35PQ/1?acco
untid=10639.
XV. Name of Student(s) Submitting

Ashley Macha