Using Drawings to Measure Emotional Processing in Breast Cancer Survivors and Its Association With Depression, Pain, and Fatigue

ABSTRACT

Background

Conscious and unconscious emotional processing (EP) may be related to breast cancer survivors' (BCS) response to the stress of dealing with cancer and its treatment, and often entails myriad psychological and physical symptoms.

Aims

To examine the relationship between EP expressed by BCS in drawings made during art therapy and its relationship with depression, pain, and fatigue.

Methods

This cross‐sectional secondary analysis used data from the Role of Emotional Processing in Art Therapy study. BCS (N = 81) answered self‐report questionnaires measuring depression, pain, and fatigue at baseline. Their drawings were coded for EP using the Drawing‐Based Emotional Processing Scale (DRAWEP).

Results

Levels of depression, pain intensity and interference, and fatigue, were high, and a substantial percentage of participants were beyond the cutoff scores for severe symptoms. Controlling for background variables, EP subscales of making sense and organization were negatively associated with pain intensity, pain interference, and depression, but not with fatigue. These relationships are demonstrated with selected drawings.

Conclusions

Since drawing involves embodied processes and has the potential to capture latent aspects of EP, examining drawings can provide a means of investigating EP among BCS and its relationship to depression and pain and learn more about the emotional experiences of BCS.

Implications for Practice

The DRAWEP can assist art therapists in increasing their awareness of EP, which may benefit their ability to identify women at risk. Moreover, this article can contribute to the development and enhancement of art therapists' awareness of EP.

1. Background

Breast cancer is the most prevalent cancer among women and affects women worldwide [1]. Breast cancer survivors (BCS) cope with interconnected symptoms, including depression, pain, and fatigue, which are difficult to treat [2] and may negatively affect quality of life [3].

Depression in BCS is associated with higher rates of recurrence and mortality [4] with prevalence ranging from 9.4% to 65.1%, and 22% reporting severe symptoms [5]. Chronic pain is an unpleasant sensory and emotional experience associated with cognitive processing [6], which sometimes becomes chronic. Based on a systematic literature review and meta‐analysis, 44.5% of survivors experienced pain and 30.6% experienced moderate to severe pain [7]. Fatigue prevalence ranges from 26.9% to 43% among BCS [8] which impacts quality of life and the ability to adjust to life after cancer [9].

Emotional processing (EP) is defined as the conscious and unconscious processes through which an individual appraises, experiences, and expresses emotions and responds to life events [10, 11, 12]. Productive EP entails bringing emotional responses into awareness, symbolizing, exploring, and cognitively integrating them for generating adaptive meanings [13]. Difficulties in EP may occur when individuals are highly aroused but unable to identify and explore their emotions, preventing them from generating new adaptive emotions [14]. Difficulties with EP were related to higher depression, pain, and fatigue among BCS [2, 15]. Current EP measurement relies mainly on verbal self‐report and performance measures that capture conscious aspects of EP [11]. However, implicit somatic experiences, not yet conceptualized as emotions or defined in words, may not be reflected in self‐reporting tools and are important to assess [12].

Despite artmaking's benefits both for EP and symptom reduction [16], drawings as a form of artistic expression are seldom used to examine the relationships between EP and cancer symptoms. In two previous studies our team proposed a theoretical model for an art‐based EP, and developed and preliminarily validated the Drawing‐Based Emotional Processing Scale (DRAWEP) for quantifying both conscious and unconscious aspects of EP using analysis of artistic features in drawings [17, 18]. The art‐based theoretical model of EP propose that artmaking can simultaneously reveal conscious emotions and transform latent, unconscious emotions into explicit visual expression to potentially promote making sense of emotional experiences and affect EP productivity [17]. The DRAWEP assessment process involves the quantification of artistic elements in drawings that reflect both conscious and unconscious aspects of EP. e.g., artists may use complementary colors (e.g., red and green) either consciously or unconsciously as an emotional expression. DRAWEP scores high for intense or adjacent complementary colors and low for their absence, evaluating color adjacency and tone intensity as levels of EP [18]. DRAWEP has not been used to examine EP in clinical populations.

Our objective was to examine the associations between EP in drawings and psychological and physical symptoms in BCS as examined at a single time point following the completion of medical treatment. We hypothesized that negative associations would be found between EP (encompassing both conscious and unconscious components) and symptoms of depression, pain, and fatigue in BCS.

2. Method

2.1. Study Design

To examine the relationship between EP expressed by BCS in drawings and its relationship with depression, pain, and fatigue we conducted a cross‐sectional secondary analysis of data from the Role of Emotional Processing in Art Therapy study [19]. For the full protocol of the study see [19] and for the intervention protocol see [20].

2.2. Participants

Participants were 102 Hebrew‐speaking participants initially recruited for the AT group of the REPAT study, 21 of whom were excluded from analysis due to missing data [19]. Thus, our study data is comprised from81 women ages 26 to 70+, three to 18 months after completing primary treatment for breast cancer. The eligibility criteria were: (a) adult women (aged 18 or older); (b) with initial, recurrent, or second primary breast cancer who were at least 3 months but no more than 18 months after completing chemotherapy, surgery, or radiation therapy or some combination or at least 1 month after their latest surgery before the intervention began; and (c) could complete assessments in Hebrew. Ineligibility criteria were: (a) men or (b) women with a diagnosis or lifetime history of bipolar disorder, schizophrenia, or schizoaffective disorder; active suicide plan (prompt intervention was provided); dementia or assessment comprehension; anticholinergic medication use; recent myocardial infarction (6 months before recruitment); flareup in systemic autoimmune disease; or thyroid dysfunction requiring increased medication (relevant to inflammatory markers collected in the larger study). An a priori power analysis using G*Power for multiple regression analysis with three variables (study and background) showed that a sample of 77 participants would be adequate for analysis of medium effect size at a power of 0.80 and α = 0.05, R ² > 0 [21].

2.3. Procedure

Participants were recruited between May 2019 and March 2022 from various BCS organizations, associations, and community centers throughout Israel and at Rabin Medical Center. Participants in this study, were Jewish participants who were randomly assigned to the AT group. Anonymized self‐report questionnaires were collected and managed using REDCap, a data‐capture tool hosted at the University of Arizona [22]. We used baseline data and drawings from the first AT session held within 2 weeks of baseline data collection. In this session, they were asked to draw a safe place following guided imagery fostering somatosensory awareness of their safe place and a discussion intended to promote EP indirectly; see intervention protocol for more details [20]. The drawings were subsequently coded for EP by an expert art therapist. Using six drawings from the study sample, we will demonstrate what EP looks like in drawings.

3. Measures

3.1. Demographic Measures

Sociodemographic information was collected (e.g., age, education, marital status, income level, religion), along with lifestyle habits (e.g., art practice and smoking cigarettes) and medical information (e.g., cancer stage and treatment).

3.2. Breast Cancer‐Related Symptoms

Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale [23], which was translated and validated in Hebrew. The 10‐item self‐report tool uses a 4‐point Likert scale: 0 = never to 4 = to great extent. A score of 10 or higher is considered to indicate a clinical cutoff for depression [24]. Internal consistency in this study was good (Cronbach's α = 0.75).

Pain was measured by the Patient‐Reported Outcomes Measurement Information System with two abbreviated scales, translated and validated in Hebrew [25]. The Pain Interference Scale Short‐Form consists of six items with a Likert scale of 0 (had no pain) to 4 (very severe), assessing the degree to which pain interfered with various aspects of life during the past week. The Pain Intensity Scale Short‐Form features three items with a Likert scale of 0 (not at all) to 4 (very much) and assesses the degree of pain. The scores are centered around a median of 50, making higher score indicative of pain intensity and interference above the mean in cancer patients [26]. Cronbach's alpha in this study were 0.96 for pain interference and 0.88 for pain intensity. Throughout this paper, we refer to levels above 50 as high pain levels, and below 50 as low pain levels.

Fatigue was measured with the Fatigue Symptom Inventory [27], a 13‐item scale designed and validated to measure the intensity (four items), interference (seven items), and diurnal variation (two items) of fatigue in the context of cancer. Items are rated using an 11‐point scale ranging from 0 (not at all fatigued) to 10 (as fatigued as I could be) or 0 (no interference) to 10 (extreme interference). Duration is calculated based on experiences of fatigue during the prior week, from 0 (no days) to 7 (all days). The questionnaire has been validated in Hebrew. A mean score is calculated, and a score of three or more is the suggested clinical cutoff [28]. This scale had a Cronbach's alpha of 0.94 in this study.

3.3. Drawing‐Based Assessment of Emotional Processing

Emotional processing in drawings was measured using DRAWEP, which has been preliminarily validated [18]. EP is measured through drawing performance, combining conscious visual expression with latent emotions facilitated by tactile and embodied art processes. It consists of 14 indicators, each rated on a 6‐point Likert scale from 1 (low EP) to 6 (high EP), and an overall score range of 14–84. The DRAWEP's four subscales are as follows: (a) art creation, which represents the integration of conscious, unconscious, and somatosensory experiences that occur as part of drawing‐based EP (e.g., EP scores high both for purposeful and unintentional investment in themes and materials); (b) making sense, which entails cognitive conscious processes such as emotional awareness, linking emotions to an arousing event, and acceptance of emotions (e.g. EP scores high for high harmony level and high space usage); (c) organization, which is an articulation of conscious and unconscious aroused emotions (e.g., the EP scores high for low levels of fragmentation); and (d) embodiment, which represents both cognitive and embodied self‐expression (e.g. EP scores high for highly applying material with hands and no inscriptions). Internal consistency in this study was Cronbach alpha of 0.76.

3.4. Data Analysis

Statistical analysis was performed using IBM SPSS (version 27). Frequencies, means, and standard deviations were calculated for all variables. Missingness was up to 20%, and patterns were examined for missing completely at random or missing at random and then imputed with scale means. We conducted a multiple linear regression to examine the associations between the EP total score and each cancer‐related symptom (depression, pain, and fatigue), controlling for income level and art practice (which were significantly associated with the dependent variables). The VIF values were below 1.03, indicating minimal concern regarding multicollinearity. Pearson correlations were used to assess correlations of EP total and subscale (art creation, making sense, organization, and embodiment) scores with cancer‐related symptoms.

4. Results

More than half of the participants were between 46 and 70 years old, 19.8% had a high school education, and 79.0% had a college degree or higher education. Half of the participants were unemployed, and half reported average or above‐average income. Many participants (59.3%) reported not practicing art, whereas the rest either practiced art as a hobby (35.8%) or professionally (4.9%). Most (72.8%) participants reported a diagnosis of Stage 1 or 2 breast cancer. In this sample, 96.3% had surgery, 81.5% had radiotherapy, 59.3% had chemotherapy, 46.9% had endocrine therapy, and 19.8% had biological treatment (for full demographic and medical information, see Table 1).

TABLE 1.

Demographic and characteristics of Jewish breast cancer survivors women (N = 81).

		n (%)
Age	26–35	4 (4.9)
	36–45	15 (18.5)
	46–70	56 (69.1)
	Older than 70	6 (7.4)
Birth country	Israel	65 (80.2)
	Other	16 (18.8)
Marital status	Single	9 (11.1)
	Married	55 (67.9)
	Divorced	14 (17.3)
	Widowed	2 (2.5)
	Other	1 (1.2)
Children	0	9 (11.1)
	1	8 (9.9)
	2	24 (29.6)
	3	22 (27.2)
	4	12 (15.2)
	More than 4	4 (4.9)
	No information	2 (2.5)
Employed	Yes	39 (48.1)
	No	41 (50.6)
	No information	1 (1.2)
Income level	Below average	12 (14.8)
	Average	45 (55.6)
	Above average	23 (28.4)
	No information	1 (1.2)
Religiosity	Secular	45 (55.6)
	Religious	9 (11.1)
	Traditional	23 (28.4)
	Orthodox	3 (3.7)
	Other	1 (1.2)
Art practice	No	48 (59.3)
	Yes, as a hobby	29 (35.8)
	Yes, professionally	4 (4.9)
Education	High school	16 (19.8)
	Certificate program	18 (22.2)
	Undergraduate (BA)	27 (33.3)
	Graduate school (MA and above)	19 (23.5)
	Other	1 (1.2)
Cancer stage	Stage 0	3 (3.7)
	Stage 1	27 (33.3)
	Stage 2	32 (39.5)
	Stage 3	14 (17.3)
	Stage 4	3 (3.7)
	No information	2 (2.5)
Treatment (combinations existed)	Chemo	48 (59.3)
	Radio	66 (81.5)
	Surgery	78 (96.3)
	Hormonal	24 (29.6)
	Biological	16 (19.8)
	Endocrine	38 (46.9)
Smoke cigarettes		6 (7.4)

4.1. Emotional Processing and Cancer‐Related Symptoms

The means and standard deviations of the study variables are presented in Table 2. The average scores for depression, pain, and fatigue were high: 54.3% of the participants exceeded the cutoff score for depression, 77.8% had pain interference scores above the clinical cutoff, 69.1% reported mild or moderate pain intensity, and 82.7% scored above the cutoff for fatigue intensity. Cancer‐related symptoms were strongly correlated with each other (Table 2).

TABLE 2.

Means, standard deviations, and correlations between study variables (N = 81).

	M	SD	1	2	3	4	5	6	7	8
1. Art creation	26.46	5.45
2. Making sense	13.90	3.20	0.56***
3. Organization	11.62	2.66	−0.10	0.28*
4. Embodiment	7.45	1.71	0.35***	0.38***	−0.03
5. Emotional processing	4.24	0.63	0.91***	0.69***	0.27*	0.55***
6. Depression	10.49	5.45	−0.18	−0.05	−0.06	−0.24*	−0.19
7. Fatigue	58.62	27.30	−0.07	−0.13	0.06	−0.07	0.08	0.53***
8. Pain interference	57.84	9.91	−0.22*	−0.26*	0.00	−0.17	−0.27*	0.31***	0.53***
9. Pain intensity	57.07	13.43	−0.20	−0.24*	−0.08	−0.15	−0.22*	0.31**	0.40***	0.82***

*p < 0.05; **p < 0.01; ***p < 0.001.

A regression analysis was conducted to examine the association of EP (total score) with depression, pain interference, pain intensity, and fatigue, controlling for income level and art practice (Table 3). The independent variables together explained 14.5%, 10.6%, 12.4%, and 5%, of the variance in symptoms of depression, pain interference, pain intensity, and fatigue, with an adjusted R ² of 0.111, 0.070, 0.089, and 0.012, respectively. The variance explained by EP in drawings is highest for depression and lowest for fatigue. The regression models were significant for depression, pain interference, and pain intensity. Controlling for the background variables, the associations of overall EP with depression, pain interference, and pain intensity symptoms were negative and significant; its association with fatigue was not significant.

TABLE 3.

Multiple linear regression analyses of associations (standardized betas) between drawep variables and cancer‐related symptoms (N = 81).

	Depression				Pain intensity				Pain interference				Fatigue
	b	SE	95% CI	β	b	SE	95% CI	β	b	SE	95% CI	β	b	SE	95% CI	β
Income	−2.74	0.90	−4.52, −0.95	−0.33**	−4.43	2.20	−8.82, −0.05	−0.17	−2.32	1.64	−5.58, 0.94	−0.22*	−6.93	4.76	−16.42, 2.56	−0.15
Art practice	0.21	1.19	−2.16, 2.58	0.02	4.47	2.93	−1.37, 10.31	−0.13	2.12	2.18	−2.22, 6.46	0.17	−7.05	6.33	−19.67, 5.56	0.11
EP	−1.90	0.92	−3.74, −0.06	−0.22*	−5.37	2.27	−9.90, 0−0.85	−0.08	−4.46	1.69	−7.83, −1.10	−0.26*	−3.58	4.95	−13.45, 6.29	−0.29*
F	4.30**				3.58*				2.99*				1.30
R 2	0.145**, (R adj = 0.111)				0.124*, (R adj = 0.089)				0.11*, (R adj = 0.070)				0.050, (R adj = 0.012)

Abbreviation: EP, emotional processing.

*p < 0.05; **p < 0.01; ***p < 0.001.

We examined the relationship of overall EP and subscale (art creation, making sense, organization, and embodiment) scores with symptoms (Table 2). Both art creation (r = −0.22, p = 0.042) and making sense (r = −0.26, p = 0.02) were significantly and negatively associated with pain interference. A negative association was found between making sense and pain intensity (r = −0.24, p = 0.035). In addition, Embodiment was significantly and negatively related to depression (r = −0.24, p = 0.032).

4.2. Demonstration of the Findings in Drawings

Figure 1a is an example of a drawing by a participant who reported below average pain levels and had higher overall EP, making sense (i.e., balanced composition, harmony, and space), and art creation (e.g., investment in materials, investment in drawing, and line quality) scores. Drawings received high EP scores if they exhibited more investment, greater line quality, and use of page space in a harmonious coherent manner. In this example, the participant seemed to be engaged in the drawing, as evident by her use of art materials, and achieved a degree of communicative expression. In contrast, the drawings presented in Figure 1b and 1c are examples of participants who reported high pain levels and had low overall EP, making sense, and art creation scores. In these drawings, the artistic elements are less integrated, as evidenced in Figure 1b by the low degree of organization in the composition and low degree of balance between the elements and in Figure 1c by the incomplete and discontinuous line quality and the use of less page space. These factors made both drawings appear less coherent and integrated.

FIGURE 1.

(a) drawing by a participant who reported below‐average pain levels and higher emotional processing, making sense, and art creation scores. (b) Drawing by a participant who reported high pain levels and had low overall emotional processing, making sense, and art creation scores. (c) Drawing by a participant who reported high pain levels and had low overall emotional processing, making sense, and art creation scores. (d) Drawing by a participant who reported low depression and received high scores for embodiment. (e) Drawing by a participant who reported low depression and received high scores for embodiment. (f) Drawing by a participant who reported high depression levels and received low scores for embodiment.

Figure 1d and 1e are examples of drawings by participants who reported low depression and received high scores for embodiment (written words and direct contact with materials). In both drawings, there is evidence of direct contact with the pastel colors, with visible smears of paint, and no addition of words. In contrast, a participant who had high levels of depression and obtained a low score for embodiment drew the image show in Figure 1f, which features written words that explain her drawing. For the participant's privacy, the text has been removed from the drawings. A text box indicating the size of the text has been added to the drawing.

5. Discussion

This study's findings indicate that EP measured in drawings was negatively associated with depression and pain but not with fatigue. This is, to the best of our knowledge, the first study that examined EP, through drawings and found associations with symptoms. While several studies demonstrated a relationship between EP and symptoms in breast cancer patients [2, 29, 30]. However, they measured EP verbally, and thus were limited in their access to conscious aspects of EP.

In this study, lower EP in drawings were associated with higher levels of depression. Which is in line with previous research examining the relationship between EP and depression [13]. Acceptance of emotions was previously found to be associated with lower depression in the general population [14] and among BCS in the larger REPAT study population (Jews and Arabs) in Israel [31]. In an intervention study with 50 individuals with major depression, increases in EP during treatment predicted improvement in depressive symptoms [32].

The present study's pain levels were relatively high compared to those in a meta‐analyses [7], but they were like pain levels among BCS in a study in Israel [33]. Lower EP (e.g., emotional awareness, acceptance of emotions), was associated with high levels of chronic pain in studies that measured EP verbally [6]. BCS who were aware of their emotions yet refrained from expressing them experienced increased pain intensity and interference [34]. Thus, it is possible that being able to examine EP in non‐verbal form is also capturing some of the unexpressed implicit emotional content.

Questions arise, however, regarding the lack of association between EP in drawings and fatigue. The relationship between fatigue and EP has received relatively little attention in the literature. Fatigue may negatively affect the process of creating art, since art cannot be created without an active engagement with materials. Creating art requires the participation of the creators and active involvement in the process of creation [35]. The relationship between fatigue and drawing‐based EP should be explored further. In the REPAT study, we found associations between fatigue with avoidance and acceptance using self‐reports measures, in Jewish women, but not Arab, which may indicate that reporting fatigue (and maybe other physical symptoms) is culturally contexed [31]. According to this study, the Jewish BCS sample reflected individuals of Western society, while the Arab sample reflected more traditional values influencing EP coping approach [31]. A possible explanation to the present results could be that fatigue, in opposition to pain and depression may not manifest in drawings. To draw, individuals need to actively engage in art making. Several explanations are possible, individuals with high levels of fatigue may not be able to muster the energy to draw, or the act of drawing itself, as an enlivening activity may not capture fatigue that individuals experience in daily life, and that is measured in our study. A randomized controlled trial with 320 BCS found that engaging in group AT improved quality of life, but not fatigue [36]. One explanation the authors suggest is that when other symptoms, such as anxiety subside, fatigue appears. In our study, the participants were at the beginning of an intervention, and it would be interesting to assess whether the EP in drawings at the end of the intervention have a relationship with fatigue at the follow‐up time point.

We also found associations between the categories of the DRAWEP subscales and symptoms. Art creation indicates higher investment in the drawing, materials, and emotional engagement in the drawing, indicating an enhanced use of colors, and lines. We found that art creation was negatively associated with pain measures (Figure 1a to see high art creation while Figure 1b and 1c for low levels of art creation). While limited research has been conducted regarding pain and art creation, colors for example, may be used to depict pain intensity among participants experiencing chronic pain [37]. Pain is an unpleasant sensory and emotional experience, that has been assessed by other assessment tools supporting the notion that color and emotion expression are associated [38, 39]. Colors were also consistently found to be associated with specific emotions in a pattern‐similarity analyses of 4598 participants from 30 nations who were asked to report how different colors represent emotions for them [40]. This finding supports the notion that visual representation of emotions is related to colors, and this may or may not be culturally contextual.

Making sense is a sub‐category that includes composition, harmony and space, and indicates how an individual balances the elements in their drawing. In our study, making sense was negatively associated with pain intensity and interference, but not depression or fatigue (Figure 1a, to see high making sense and 1(b) & 1(c) for low levels of making sense). It is plausible that the way elements are organized on the page is reflective of the potential of the experience of pain to interfere with clarity of thought and cognitive‐emotional understanding of activating versus reducing emotions [6], for example. Further studies are needed to assess this idea.

Organization is a sub‐category that is reflective of repetitive visual elements, such as fragmentation and encapsulation and may be indicative of conscious awareness of an emotional experience, and an attempt to organize this content. This was seen in studies assessing military trauma in drawings and found that by creating a boundary symbol in drawings between the event and coping in the artwork, the encapsulation indicates attempts to cope with traumatic events that could reflect individuals' mental organization, for example [41]. Other studies have found correlations between high encapsulation and fragmentation in drawings of people coping with the adverse effects of sexual abuse and higher levels of dissociation [42]. In our study there were no associations between organization and symptoms. While coping with cancer is an adverse effect, we do not know what the level of traumatic history, other than cancer, our sample is experiencing. One possible explanation is that our sample has relatively good coping skills and normative trauma experiences.

Embodiment is the fourth subcategory and refers to how the body is directly involved with the materials, and how this is manifested on the paper. The use of words on drawings, is considered to indicate less bodily involvement and more distanced and cognitive approach to artmaking [18]. Engaging in art making is proposed to transform maladaptive EP patterns, partially through bodily engagement that incorporates tactile and somatosensory experiences [17]. In our study, embodiment was associated with depression, but not pain and fatigue (see Figure 1d and 1e for higher embodiment and Figure 1f for low embodiment). This aligns with the logic that individuals suffering from depression will have less energy to be fully involved in art making in an embodied manner. Future research is needed to establish empirical data about the relationship between embodiment in drawings and depression.

5.1. Implications for Policy, Practice, and Research

The examination of EP in drawings and its association with symptoms that adversely affect BCS, may provide psycho‐oncology clinicians with the ability to expand their holistic understanding of the multiple layers of EP and provide additional insight into elusive, and at times under‐reported symptoms, of depression, for example [4]. This may help with early detection and treatment that will help manage breast cancer symptom persistence and help BCS improve quality of life. Learning about additional facets of EP in drawings may help build better targeted interventions to help BCS cope with and reduce symptoms.

5.2. Strengths and Limitations of the Study

This study is unique in examining EP through drawings that may capture implicit emotional content, an integral component of EP not captured through words. Drawings may capture a more nuanced and complex experience of EP, bypassing difficulties in expressing stressful emotional material and providing access to unconscious content, for example [42]. Capturing both conscious and unconscious EP through drawings may assist BCS, their caregivers, and treatment teams, to better understand their emotions holistically, providing an additional avenue for insight when words to describe their emotions and process their experiences of coping with cancer are lacking. Our findings shed light on the importance of detecting EP for better understanding cancer‐related depression and pain. While these associations should be investigated further, this study can begin to help clinicians better recognize latent EP, which may assist in developing treatment goals and plans to reduce symptoms such as depression and pain.

The results of this study should be considered in the context of their limitations. In part, the data were collected during the COVID‐19 pandemic, which may explain the relatively high dropout rate, given prevalent mobility and contact restrictions, along with fears of becoming infected or infecting others. However, the results of a study conducted in Israel during COVID‐19 that analyzed both in‐depth interviews and quantitative data indicate that although cancer patients showed a fear of contagion, they were determined to continue their treatments [43]. This study relied on a cross‐sectional design, which limited our ability to draw conclusions regarding directionality and causality of symptoms. It is possible that pain and depression created lower EP to manifest in drawings, rather than the EP in drawing indicate higher levels of depression and pain. While there is no control group in this study, it will be interesting to compare the results in future studies. For this study, we used REPAT's first session drawings, in which participants were asked to depict a safe place. Our results may have differed with a different art assignment or at another study time point. Additionally, the findings of this study are limited to Israeli Jewish female BCS and may not be generalizable to other populations and cultures. Additionally, DRAWEP does not distinguish between conscious and unconscious emotional processing, although future research may explore this possibility. Finally, the DRAWEP tool is novel and requires further exploration and investigation.

6. Conclusions

Quantifying EP in drawings provides clinicians and researchers with more nuanced and holistic way of understanding experience and gaining access to implicit as well as explicit EP. This may provide greater insight into the relationship between conscious and unconscious aspects of EP, enhancing psycho‐oncologists interventions to help clients cope better, improve quality of life, and manage symptoms. Further empirical studies are required to examine the benefits of assessing EP in drawings in other psycho‐therapeutic settings with this and other populations.

Author Contributions

Asnat Weinfeld‐Yehoudayan: conceptualization, methodology, data curation, formal analysis, writing–original draft, writing–review & editing. Johanna Czamanski‐Cohen: supervision, conceptualization, methodology, formal analysis, writing–review & editing. Karen L. Weihs: conceptualization, writing–review & editing. Miri Cohen: supervision, methodology, formal analysis, writing–review & editing.

Ethics Statement

This study was approved by the Ethics Committees of Rabin Medical Center, Petah Tikva, Israel (Approval No. 0778–17) and the Faculty of Social Welfare and Health Sciences at the University of Haifa (Approval No. 234/18). All participants provided written informed consent prior to their participation and were informed that they could leave the study at any point without repercussion. To cover participation‐related expenses, participants received the equivalent of $200 in new Israeli shekels for participating in all sessions.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.