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June 18 – July 23, 2010


In conjunction with a research study focused on resilience in cancer patients and caregivers lead by Dr. Paul Brenner, MD, Ph.D. at San Diego Cancer Center and Research Institute – SDCC / SDCRI – in Encinitas, patients and caregivers have been offered the opportunity to look at their experiences through the lens of a camera and to express them in a new and potentially insightful visual story format by adding paint, texture and collage in a mixed-media expressive art therapy process called PhotoPainting.

PhotoPainting is offered in cycles of 6 weekly sessions, several times a year; the first pilot program started Friday, June 18, 2010 and ended Friday July 23, 2010. The program is free and includes all art materials and disposable cameras; participation has been limited to 12 people with reservations. At any given session, 6 to 10 participants showed up.

The PhotoPainting series is facilitated by Alessandra Colfi, Ph.D., Expressive Arts Therapist, and was co-created with Mary Hollander, R.N., and Paul Brenner, M.D., Ph.D.

PhotoPainting provides participants with the opportunity to tell their stories as they unfold through images, while they integrate them as a symbolic reflection and transformation of their healing journey. The PhotoPainting Playshop is designed as a process of exploration, celebration, creativity, and healing; it will be followed up with short and long-term evaluations and new sessions throughout the year.

Goals & Objectives

The purpose of engaging cancer patients and caregivers in the PhotoPainting – Expressive Arts Therapy sessions is to assess and evaluate individuals’ resilience, their ability to access their inner resources and cope with challenges; it also surveys any change occurring as a result of participating in the processes of working with feelings and events related to their experiences with cancer, through pictures, symbols and hands on painting.

The assumption is that the human psyche – or soul – needs to express itself in order to stay or become healthy, and being in support of the mind and body throughout life’s experiences. The Expressive Arts Therapy processes offered within the PhotoPainting format are designed to facilitate and allow for a non-threatening approach to self-expression and exploration; they are grounded in Jungian psychotherapy and in the patient-centered approach which aim at facilitating the unconscious to emerge and become a useful ally to each individual.

Participants have been engaged in simple processes of self-reflection and in transforming their internal dialogue into images and potentially forming new associations and connections; also, the visual and tactile experience facilitates reaching deeper into the unconscious and intuitive wisdom to potentially gain awareness, guidance, acceptance and inner peace.

The PhotoPainting process has generated a series of collages and paintings as a result of each session being designed to build up methods and skills, as well to create a welcoming space and opportunity to share; the culmination is a mixed-media painting made by each participant, incorporating their own photographs, painting layers of rich colors and interesting textures. A CD with images and video clips is included here.

Participants are engaged with ease and playfulness, stating clearly about the importance of their enjoyment and being engaged in a meaningful process, above any expectation of result or outcome. As stated and practiced in all Expressive Arts Therapy sessions, relieving stress and providing a meaningful and playful opportunity for self-expression or to provide a much needed respite is always our priority.

A local newspaper, the North County Times, published an article following up direct observations by a reporter and a photographer during one of the sessions. There is a coordinated effort in the works for a collective exhibition of the PhotoPainting artwork at the Encinitas Library, as well as at the Front Porch Gallery in Carlsbad, with the scope of increasing awareness and recognition of SDCC / SDCRI integrative and comprehensive care model and of providing an opportunity for our patients to be directly involved in such endeavor, engage family and friends and the larger community, as well as to keep supporting their healing process.


All participants were asked to participate in a 6-session series, and at the same time were given them the flexibility to miss 1 or 2 sessions; this provision takes into the account that cancer patients might not feel well on any given day or they might undergo treatment or testing in a different location at the same time our session occurs. Also survivors and caregivers might at times need to attend other commitments. Patients undergoing treatment at SDCC were always able to join in the activities and accommodations were made to facilitate their participation.

At the start of every session, all collages/paintings were displayed on the wall for everyone to surround themselves with their artwork and meaningful images, like being in their “art studio”, and for spontaneous comments to emerge. Participants were always invited to share their thoughts and to ask questions.

1st session – Welcome and Introduction
At the very beginning participants were welcomed and an informal sharing of information took place; they were ask to complete a self-assessment form focusing on surveying their resilience; in addition, all participants were asked to read and sign an informed consent form and provide personal contact info; also a release form for any picture or video taken during the sessions.

Once all these were completed, we started the process of collecting personal statements and interests; I gave a general explanation of what was going to happen during the session. The main concern in this type of group settings is to establish an atmosphere of safety and non-judgment, in order to allow freedom of expression and the best possible outcome for the participants. Moreover, in order to help participants staying ‘in the moment’ and just focusing on the tasks at hand, very little information was given as far as planning ahead, what was going to happen next, etc. This is intended to facilitate spontaneity and intuitive association. This approach works when participants have a certain degree of trust and confidence in the facilitator; in this case, it can be attributed to the fact that several of the same patients have been participating to my Expressive Arts Therapy sessions for about a year and were familiar with my approach and methods used.

All participants were invited first to familiarize themselves with making an intuitive magazine photo collage, by selecting 5 to 10 images they felt intuitively attracted to or somewhat uncomfortable with, from a random pool, without asking themselves why they liked them or not, or how they would fit with one another. Some participants had to be encouraged to pick out a few more images, while others dove in collecting as many as they could.

Participants chose a colored paper background to start arranging their images on, getting used to the more ‘hands-on’ tearing of the edges instead of cutting them, overlapping some of them, leaving space in between or covering the whole surface… all feedback and exchanges were visual and intuitive; questions for reflection and to facilitate the process of ‘telling a story’ as it appeared in front of them were offered. Some participants showed a specific intention in creating a story; some were open to let their story unfold.

All collages were displayed for the whole group to see and make comment on. Each participant was encouraged and prompted to reflect and ‘stay’ with their collages, in order to establish an open dialog with it, exchange questions and remarks with the images.

For example, one patient picked an image of a snowman looking sad and melting while sitting on a bench – she said she had no idea why she picked this one and what to read in it – a few minutes later, she had glued the image of the sun – either setting or dawning – over the earth’s curved surface, overlapping and a bit imposing over the snow man.


Live Life Unexpected, by N.D. Poway, CA

She said she felt in awe about the universe, and I suggested to further inquire about her feelings and the relationship between the snowman and the ‘cosmic’ image. A little time went by; I came back around, offered hints, made suggestions… she did notice a feeling of powerlessness, and at the same time ‘melting of the old self’, ‘letting go’ and hope given by the sunrise –in a way this is the beginning of her new life.

I feel it’s empowering for participants to come to their own insights, to stay with their own questions, as opposed to offer a reading. My role is to offer support, questions to help them continue their self-reflection and feedback for the participants to find their own answers.

At the end of the session each participant was given a disposable camera and invited to take pictures of what was meaningful, attractive and potentially supportive of them, and/or challenging or uncomfortable, during their healing journey. It was explained to them they had total control of what they were going to photograph and when. For their convenience, I would receive all the cameras back by the 4th session, so I would take care of processing their photos and making copies of each one and bring them at the 5th session. On the 5th session they would start selecting and playing with the layout; when they felt ready, they would glue the pictures and paint on their canvas, to integrate them into ‘their story’; then continue painting at the last session.

From now on, all participants were encouraged to display their work at home or at least keep their work where they could see it many times during the week.

2nd session – Introduction to Universal Symbols & Demo
Symbols are all around us and inside of us; we unconsciously and/or consciously notice them and use them in our lives… this is a ‘taste’ in learning how to notice them, use them consciously and make them our allies! The 5 universal shapes as explained by Angeles Arrien were used in a fun and insightful exercise. Consequently, participants were encouraged to keep those symbols in mind and use them in their PhotoPainting as they wish.

The second half of the session was dedicate to my demo of painting and texturing, while participants had practice sheets and materials available to become familiar with the paint and texturing techniques on their own. I feel this was the session that ‘hooked’ participants in wanting to learn this painting technique, keep exploring and come back for more!

3rd session – Demo & Practice
As we continued practicing the painting techniques, participants kept themselves engaged with exploring the materials and brainstorming ideas, which made for a very playful and bonding session.

4th Session: Putting it all Together
Participants were invited to start by collecting 5 to 6 magazine images according to the same criteria as they did the first time – no more this time! – and start tearing edges and playing with a layout that was pleasing to them, on a sheet of watercolor paper. After they were happy with the layout, we used this collage to practice layering paint and texturing to blend images into the painting, incorporating them and integrating them, as a symbolic process of the psyche integrating and making sense of life’s experiences.

Patients spent quite some time experimenting with the texturing techniques and learning the different painting effects.

5th & 6th Session – PhotoPainting in the Making
Several participants received and review their photos and photocopies; photocopies are better suited because of the thinner paper on which they are printed and because this eliminates the anxiety associated with using the original photos and risking ‘making mistakes’.

Everyone was given a canvas; individual guidance was offered as always, to process layout options and to monitor comments and feelings around their ‘real’ stories.

As the paintings started coming to life, so did friendships within the groups. Spontaneous sharing and new materials showed up as themes and images came into play.

Ideally 8 sessions instead of 6 would allow for ease and time to complete the process.


The survey on resilience taken at the end of the last session compares with the one taken at the beginning of the first session with a slight upward raise towards increased resilience in most areas. The chosen numbers which represent how each participant feels in each instance show a very slight improvement, and in some cases, a higher jump especially in regards with anxiety; verbal comments and testimonials are all very enthusiastic. A few participants assessed themselves high on each resource scale, most rated themselves high in some areas and mid- to low in other areas. Confidence has improved; playing and creating together and staying focused on the joy in their lives and to one another gives them strength and motivation.

Most participants would like to continue these kinds of sessions and feel they would benefit from individual sessions as well. Not only they all enjoyed the PhotoPainting activity, but they feel strongly that it helped them in their experience with cancer.

‘I enjoyed playing with the different things and feel proud of myself for what I have created so far’ ~ N.D., Poway
‘Thank you for everything! I am a new person when I get together with all of you. It really is a “pick me up!” ‘. ~ V.R. Encinitas, CA.
‘Enjoyed progression of artwork’ ~ I.G., Vista
‘Joy, healing and creative. Thank you!’. ~ N.K. Encinitas
‘Much needed – Opened new avenues I was hoping to find. It helps balance all my current experiences’ ~ K.K., Encinitas
‘I loved it and Alessandra too! It was something to look forward too!!’ ~ L.I., Carlsbad
‘I enjoyed the workshop. I knew I would! I was hoping it would stimulate to start my own projects and I already have.’ ~ V.C., Encinitas


This project is but one snapshot within a continuum; there needs to be a discussion with the whole research team on patients’ resilience and how to support and foster it in them. Clearly, there is a role for Expressive Arts Therapy in the medical setting, especially in the oncology arena, as a supportive adjunct to the clinical care associated with the traditional medical model. The incorporation of EXT into a comprehensive cancer care program brings an increased sense of connection and well being among those patients in active treatment who chose to participate in the EXT therapeutic process. Some patients brought in a family member for a session; they also participated actively and were very supportive not only of their own relative but also of the other participants.
Since studies have suggested that an increased sense of patient well being often results in increased patient compliance and better clinical outcomes, incorporating Expressive Arts Therapy into the oncology medical setting makes sense from the standpoint of progressive, patient-centered program development.


Some of the patients missed a few sessions and some the last session for a variety of reasons; I would incorporate at least one individual session to close the process and allow each participant to dialog with their artwork and acknowledge what they accomplished and the meaning it has on a very personal level.

Many participants also stated that they would like a 3-hour session, since it takes them a while to get started and once they are ‘in the flow’ and immersed in it, they don’t feel like stopping – 2 hours flew by very quickly each time!

A couple of participants didn’t have their cameras ready for me to process their film and promised to have it done on their own – which didn’t happen. In order to accomplish this task, I would have had to meet with these patients separately and figure out the logistics to have everyone’s pictures ready by the following session. Besides, taking a bunch of pictures in a few days ‘just to do it’ didn’t fit the purpose of this process and didn’t feel very meaningful to me. The fine line between coaching/allowing for people to take responsibility and expecting them to comply can be discussed.

My recommendation is to continue offering series of sessions to patients in partnership with the medical research to survey their resilience to diagnosis and their improved response to medical treatments, stress management and overall quality of life, including work, personal interests and relationships.

The creative activity of imagination frees man from his bondage to the ‘nothing but’ and raises him to the status of one who plays. As Schiller says, man is completely human only when he is at play.’ ~ C.G. Jung


Detailed Assessment Forms and Resilience Survey Results are available upon request.

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