Reliability and first validity of the inner correspondence questionnaire for painting therapy (ICPTh) in a sample of breast cancer patients
Introduction
Already in ancient Greece, philosophers knew about the transformational power of art, poetry and music.1,2 The idea of art being an expression of a patients’ inner life was discussed in works of Sigmund Freud and Carl Gustav Jung at the beginning of the last century.3, 4, 5 Also Rudolf Steiner, the founder of Anthroposophic Medicine assumed that drawings and other expressive art forms can bring ‘inner mental qualities onto surface’6 and ‘emotional aspects of the soul, such as mood, pain and happiness find externalization in the outer world’.7, 8, 9 Different forms of art therapy (ArT) have been implemented as complementary elements within treatment programs of psychosomatic, oncological rehabilitative and integrative medicine.10, 11, 12, 13, 14
Although a cathartic and subsequent transformational effect of ArT on psychological, spiritual and health-related dimensions is widely acknowleged10, 11, 12 there is still a lack of clinical studies with adequate sample sizes and randomized controlled designs. Two systematic reviews published by Wood et al.15 and Geue et al.11 report on studies investigating different forms of ArT and its impact on patients suffering from cancer and associated cancer-related fatigue (CRF). Other studies examining different patient groups found positive benefits for ArT such as improved emotional expression and regulation,16 capacity to change behaviors such as disease and life management,16,17 increased insight and comprehension,16 better health-related quality of life,18,19 improved social functioning,13 reduced symptom scores e.g. fatigue,11,19 reduction of depression, anxiety16,20, 21, 22 and stress.20,23 Despite the positive effects of ArT, it remains unknown how ArT works which should be subject of further research.
Anecdotal evidence of professional artists, healthy individuals but also patients who engage in the arts report a wide range of experience during painting (e.g. ‘trance like state’, pathway to the ‘here and now’).24,25 Similar experiences have been made by individuals practicing mindfulness-based therapies and relaxation techniques, such as mindfulness-based stress reduction,26 mindfulness-oriented body approaches (e.g. yoga, eurythmy), spiritual excerses (e.g. meditation) and therapeutic relaxation techniques (e.g. progressive muscle relaxation, autogenic training, body scans) which are increasingly used to complement treatment programs for various patients groups.27, 28, 29, 30, 31, 32, 33, 34 An improved ‘relaxation response’35,36 has found to positively impact clinical outcomes e.g. 37. We characterize being engaged with painting as ‘Inner Correspondence’ and hypothesize that this variable might contribute to an enhanced ‘relaxation response’. In our study, we adapt the conceptual framework by Büssing et al. (2011) who examined ‘Inner Correspondence’ with mindfulness-based movement therapies onto mindfulness painting therapy.
The primary goal of the study was to develop and preliminary validate a self-report outcome questionnaire to assess ‘Inner Correspondence’ with painting therapy (ICPTh).
Section snippets
Ethics and framework of the validation study
The validation study was embedded in the framework of the Cancer-related Fatigue Study (CRF-2) for breast cancer survivors with cancer-related fatigue. CRF-2 was conducted as tri-center, prospective, parallel, three-armed, active-controlled, open-randomized pragmatic trial in a comprehensive cohort design study from June 2011 to December 2013. A 10-week multimodal therapy (MT) was developed with four treatment components: Eurythmy therapy, psychoeducation, sleep education and anthroposophic
Participants
A total of 126 breast cancer survivors with CRF were included in the study. 71 patients (MT = 30 and CT = 41) completed the 10-week (T1) intervention and 68 provided data for analysis at T1 and T2. Two patients of the CT group refused to take part in the painting therapy (treatment too long; the treatment is not for me). One patient dropped out after completing all sessions of APT. Table 1 shows the sample description of all patients.
Reliability and factor analysis
During reliability analysis with a stepwise examination of
Discussion
To measure and operationalize ‘Inner Correspondence’ with painting therapy we developed a 22-item scale with robust psychometric properties showing an unambiguous four factor solution with the following subscales: 1.) therapy congruence and relaxation, 2.) inner development and mood 3.) artistic abilities and 4.) task congruence, explaining 79% of total variance. Overall reliability of the questionnaire was high. Additionally, all subscales were highly intercorrelated and showed very good to
Authors’ contributions
Conception and development of the questionaire: MK, AD, BGK, AB; development of the intervention program: MK, MR, RZ, MG, CG; Collection and assembly of data: MK, BB, FtB, RZ; Data analysis and interpretation: MK, AM, AD, BGK, AB MR, RZ, MG, CG; Manuscript writing: AM, MK, MR, AB. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Funding
The primary study was funded by Mahle Stiftung, Stuttgart, Germany, Christophorus Stiftung, Stuttgart, Germany, Dr. Hauschka Stiftung, Bad Boll/Eckwälden, Germany, Stiftung Helixor, Rosenfeld, Germany, Gyllenberg Foundation, Helsinki, Finland. The study sponsors had no involvement in the study design, collection, analysis or interpretation of data. MK, AM and RZ received financial support by Software AG Foundation, Darmstadt, Germany and Humanus Institute, Berlin, Germany.
Acknowledgements
The authors thank the CRF-2 study group collaborators: Danilo Pranga and Anette Zander for study coordination and documentation, Annette Weninger for documentation, Augustina Glinz, Andreas Nikolaou, Nina Klara for recruitment, Karen Baumhöver-Wegener, Birgit Lindemann and Sonja Steffens for painting therapy. We thank Ramona Beutke for the monitoring and all other scientists and therapist members of the CRF study group.
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Contributed equally to the publication.