Published:
August 2022

Issue:
Vol.17, No.1

Word count:
5792

About the author

  • MCAT, GradDipCAT, BContpArts(Visual Arts), Student AthR

    Kelsey Leigh Cross is currently completing her last semester of external placement in the MCAT course at Murdoch University, Perth. Kelsey is a practicing visual artist in drawing and painting, her relationship with art has always been transforming, the latest using creative processes as a tool for healing. Kelsey has been involved with galleries and artist spaces for 8 years, all the time advocating the potentials of having art in people’s lives. As a soon to be creative arts therapist, Kelsey has a keen focus in providing creative therapies to people who are seeking new creative ways for self-improvement in physical and mental wellbeing and to find ways to authentically express themselves.

This work is published in JoCAT and is licensed under a CC BY-NC-ND-4.0 license.

How do arts practices support people with chronic physical pain? Exploring lived experiences of chronic pain with people using expressive arts

Kelsey L. Cross

Abstract 

This is an arts-based and arts-informed study, a central research platform for expressive arts therapy professionals in clinical practice. Participants and researcher discussed and shared artworks connected to pain experiences in their lives. Findings revealed the main themes of identity, pain, art, change and present experience. Art expression was experienced as an important process for psychological coping that had very broad-ranging positive effects on participants’ lives in terms of quality and capacity to live with and through their pain experience.

Keywords

Chronic pain, expressive arts therapies, arts-based enquiry, arts-based research, lived experience

Introduction

This study explores how people have used expressive arts to support themselves in living with chronic physical pain. The target group is women aged over 18 who have current or past experiences of chronic pain and have an existing relationship with expressive arts. Participants who volunteered all had a previous interest in art, two with lifelong arts practices, and two were encouraged by a health professional to try arts expression. The interviews explored how expressive arts have supported them in their experience of chronic pain. Recent research suggests the need for professionals in expressive arts to provide meaningful creative techniques for people with chronic pain (Reynolds & Prior, 2011). The study used arts-informed components to guide the interviewing process (Barone & Eisner, 2006; Barrett & Bolt, 2007; Knowles & Cole, 2008; Kossak, 2012; McNiff, 2004, 2013; Payne, 1993). Two interviews of one hour each were conducted in person and included a review of participants’ previous art-making. After each interview I created an expressive response, to explore the complex dialogue between the participants and myself; drawing on my own experiences of chronic pain informed the enquiry process.

Background: Capturing the pain experience

Perception of pain depends on interactions between the body and mind, which include all aspects of the person, such as any previous pain experiences, stress, and our life context when the pain started. Chronic pain is an unpleasant body experience that persists for more than three months, or longer than the expected normal healing time. It can be caused by a multitude of different conditions such as cancer, multiple sclerosis, lupus, all forms of arthritis, or as a consequence of body trauma (Chronic Pain Australia, 2021). A person's understanding of their chronic pain is an individual experience and can sometimes be elusive and difficult to describe due to its complexity (Olivier, 2007).

The term ‘expressive arts therapies’ is used to cover a wide variety of creative expressions such as music, dance, movement, art and drama (Malchiodi, 2020). It is becoming more prevalent in mental health interventions and there is a growing body of literature in recent years to support its benefits. Expressive arts therapies help in processing emotions and creating new life narratives as well as expressing the non-verbal aspects of ourselves (Malchiodi, 2020). In this study, the term ‘expressive arts therapies’ is used under the general way of “all arts in therapy” (McNiff, 2009, p.31), to allow for the variety of participants’ arts experiences.

By observing people’s lived experiences, this research studies the way in which expressive arts can be a source of self-regulation for the body's response to the traumas of pain (Malchiodi, 2020). “Art-based enquiry is at the heart of what we do as art-based therapists. Art-based research, a natural outgrowth of art-based enquiry, utilizes creative intelligence through immersion in creative process and scholarly reflection” (Kossak, 2012, p.21). This study uses arts-based enquiry as a primary mode for understanding and investigating experience through the artistic process of making expressive artworks in all forms of art (McNiff, 2004). This brings new ways of thinking about how the engagement with arts supports those with chronic pain. By researching with methods in the art-based research paradigm there is the prospect to “open up zones of possibility for intellect and imagination to launch analytic projects into unexplored space” (Jipson & Paley, 1997, p.5).

Literature review

To support and enrich an understanding of how expressive arts support people with chronic pain, a narrative literature review was conducted. Its objective was to help contextualise participants’ experiences in the field of health research around pain and the arts. This explored connections between research in the field of pain, patients’ lived experiences, and the role of art-making within the field. Points drawn from the literature included relating to pain, identity reflections, usefulness of arts in coping, and effectiveness of arts for improving pain experiences.

Current research literature suggests that “future research could explore whether and to what extent arts workshops could be used productively in other settings, including clinical ones” (Tarr et al., 2018, p.590). There are high levels of suffering among people with chronic pain, and previous qualitative studies confirm that therapies are needed for supporting emotional needs (Henare et al., 2003; Kirkham et al., 2015; Lynch et al., 2013; O'Neill & Moss, 2015). There needs to be further research on supporting chronic-pain experience in the expressive arts therapy professions. The collection of literature cited above reveals a gap in detailing the subjective experiences of people’s lives with chronic pain and how arts can help to improve their pain experiences.

Research aim

This research study was part of the Master of Creative Arts Therapies (MCAT) at Murdoch University, Perth. My initial interest in the topic arose from my experience of having an unresolved injury that resulted in chronic pain for seven years before it was resolved. During my MCAT studies, my chronic-pain experiences were a focus of the personal-reflection requirements. I found significant capacity for healing through improvised movement, which showed me how to listen to my body again; through expressive writing I gave a voice to my pain; and through drawing I could release emotions I didn’t want to verbalise.

I became curious as to whether creative practice assisted others to live better with their experience of chronic pain. In this study, participants with chronic pain needed to have an existing relationship with expressive arts: the focus was an exploration of their arts practice and its psychological impacts. I sought to answer the following question: Can arts practice resource the participant to explore their experience of pain emotionally/psychologically, and, if so, can it result in changes to the way pain impacts their life?

Considering the points suggested in the literature, the intention was to discover aspects of participants’ lived experience of art-making as it relates to their pain. The focus was not only on discussing benefits, but also on exploring the relationship between their pain and their art-making experience. The interviews had set questions, such as: Has your creative expression ever been about your pain? What links between art and pain have you experienced? Has your pain changed the way you express yourself and the way you make art? Have you experienced a deeper connection with your physical pain through creative expression? What has this meant to you?

Methods

The study is an arts-based enquiry, which reflects the inherent foundation of expressive arts therapy professionals in clinical practice (Kossak, 2012 p.22). This mode of enquiry in the research allowed “a process of systematic enquiry that includes experimentation and seeking out information with the objective of answering questions, solving problems and generating new understanding” (McNiff, 2013, p.5). This approach allowed me to achieve a first-hand involvement in the collection and generation of detailed data (McNiff, 2013), resourcing a deeper analysis of the material collected, and supporting the study with my own lived experience of chronic pain (Hannula et al., 2014, Knowles & Cole, 2008; McNiff, 2013). This is central to clinical practice that engages in art-making, lived experience, and autobiographical materials of myself and the participants (Barone & Eisner, 2006; Barrett & Bolt, 2007; Knowles & Cole, 2008; Kossak, 2012; McNiff, 2004, 2013; Payne, 1993).

Data collection

The participants were women aged over 18 years living with chronic pain for more than six months who have used art-making or arts therapies to support their pain management. The four participants were aged between 30 and 70 years, with physical problems including injuries, arthritis and connective tissue disorder. Their arts practices included sculpture, drawing, painting and dance/circus performance. The term ‘expressive arts’ is used to encompass all of the participants’ experiences of expressing through arts. Surprisingly, no participant had previously tried expressive arts therapies and only two participants had used expressive arts to explore their experience of pain on their own terms, as suggested by their health professionals. One of those participants was intentionally using their arts practice regularly as a source for coping with their pain.

The interviewing process was designed to be carried out over two one-hour interview sessions. At the initial interview, participants were invited to bring an artwork of relevance to them to discuss for this study. This was followed by a week in which the participants could reflect on their interview and create an expressive arts piece in response. Returning to the second interview with the newly created expressive piece allowed participants to reflect and extend their experience. The arts-based enquiry methodology (Barone & Eisner, 2006; Barrett & Bolt, 2007; Knowles & Cole, 2008; McNiff, 2004, 2013) also extended to my own artistic expression after each interview to explore the complex dialogue that occurred between the participant and me. This allowed me to respond reflexively to the learning emerging between us as the study unfolded, which enhanced my understanding of the data collected (Knowles & Cole, 2008; Kossak, 2012; McNiff, 2004, 2013; Payne, 1993).

Data analysis

As a course requirement, NVivo 12 software was used to organise collected data in the transcripts and images of the artworks (NVivo, 2021). This was in reference list but cited nowhere, so I've added a citation here.. Using NVivo 12 provided a grounded approach to the coding process, allowing for descriptive codes to emerge from the collected data and then reach full data saturation (Braun & Clarke, 2013; Hennink et al., 2011). The NVivo 12 coding process was used to describe the transcripts’ verbal, conscious content; each sentence was synthesised into descriptive terms such as mind–body connection, avoiding pain, and fear of body. Aesthetic analysis of the artworks added symbolic codes of description such as vortex, murky, waves, and strange creature. These descriptive codes were then grouped into like-meanings that started to form the emerging themes, such as the importance of art-making, living with pain, and making changes. The arts-based processes added subconscious and emotive details that made the full body of data multi-dimensional, so using NVivo 12 processes systematically collected all conscious and subconscious aspects into trends and similar themes. Each approach appeared to verify the other, giving consistent understanding through the emerging data.

Thematic analysis consisted of compiling, disassembling and reassembling the themes that emerged. With each grouping, the transcripts and my own experience were referred to for making interpretations. Transcripts were returned to participants, but emerging theme analysis was not shared with them, due to course time constraints. At weekly stages, the analysis was shared with the supervisor of the study to discuss emerging themes from the data and to be sensitive to all the possibilities present in the data (Braun & Clarke, 2013; Hennink et al., 2011). The supervisor explored and questioned my subconscious connections between data from my experience and the participants’ experiences. This prompted thoughts about how my experience compared, contrasted with or differed from the participants’ experiences, which allowed me to gain more perspective. A final NVivo mind map displayed the essence of the full interviewing process.

Research findings

Overview

The overarching themes emerged in different ways over the course of the two interviews and in the images selected and made. The first interviews identified themes of identity, pain, art and change; the second interviews had main themes of present experience, and art and pain. In comparing data from both sets of interviews, I observed that these themes merged and influenced each other. Symbolic codes collected from the participants’ and my own artworks were woven through most themes.

Figure 1. Relationships between themes.

Participants reported that the experience of the interviewing process had a profound impact on them. They described the relationships between these themes (see Figure 1), beginning with pain and art as separate aspects contributing to one’s identity. Pain begins as the dominating aspect influencing how one sees oneself. A traumatic cycle can occur between identity and pain, until the pain-identity is then expressed as art. They described their art as providing a place to exist, rather than pain being the only focus of their identity. The ability to create change starts to occur when one uses art as an adaptive tool to work with, around, or through pain. The pain-identity can then be realised and different versions of being and identity can re-emerge or be rescued from the consuming experience of pain. The present experience of the interview discussions included sharing existing pain in the present moment, which was brought to attention when reflecting on the new artwork. Being with the present experience alongside the art allowed participants to be intuitively connected with themselves in the now, and to reflect on how they had changed, or on where change could be created.

Pain is multi-dimensional

My and the participants’ stories of pain were described in the data collection as multi-dimensional experiences. Pain came with challenges, affecting physical and mental well-being, and medically related activity was part of this. Injury pain was described in clear detail, even if it had happened years ago. Injury events and pain were clear, either because participants had had to retell the incident to numerous medical professionals or others, and/or because they felt mentally and emotionally stuck in how the event has changed their way of life.

From the emotion perspective, that had been my life, my career, it was all just, that was it, it was over. (Participant 2)

Commonly, participants described their pain as tremendously difficult. For most of the time, the pain is hard to handle, including periods when it is too much to cope with the ongoing pain and there is a desperation to find help to get on with everyday life.

I won’t let it dominate my life sometimes. When I didn’t understand it, I’d be walking, and I’d just burst out in tears. It’s just draining. (Participant 1)

Pain experiences come with many challenges to quality of life, such as pain overriding other daily experiences. When it came to medical experiences, participants described their courses of medical treatments, and the medications they found most beneficial.

I use a TENs machine. I do lots of things, I do stretching, I do yoga, I do lots ’n lots of things. So… I’ve learnt to manage it and I’ve learnt to manage it with my art. (Participant 1)

Figure 2. Kelsey Cross, creative response to Participant 1, second interview, 2021, oil paint on canvas, 400 × 400mm.

All participants wanted to search for more alternative treatments on top of things they were already doing. Multiple treatment options were the defining factor that provided a sense of better pain management. There was a trend reported between participants that medical pain-treatments seem to come to a point where there are no more options. My powerful response to the second interview with Participant 1 allowed me to reflect on my experience of losing hope for treatment (see Figure 2). We all wanted to find new alternatives to deal with our chronic pain and Participant 4 found their ideal treatment plan.

My plan’s a bit different, I go to ballet, and I go to circus and I want to make things, my hands, or do like some drawing or, and that’s actually my therapy, physically and mentally like that’s, that’s how I manage mine. (Participant 4)

Art is multi-dimensional

Participants described the benefits and importance of art-making, what an artistic life is and means to them, and the range of mental and physical body experiences that can occur when making art. Artistic life allows one to have a space to create meaning that one can explore in realistic or imaginative ways, and have the freedom to create and reveal aspects of self.

It’s part of me, I think a part of me is a painter, I create, I’ve always created one way or another. (Participant 3)

During the first interview, participants described their art practice, methods and styles. Participant 2 was advised by their psychologist to try drawing how they viewed the pain in their body, and Participant 4 was advised by their physiotherapist to try circus/dance to work better with their body better. Participants 1 and 3 have had lifelong art practices that they have needed to adapt around chronic pain. No participant has experienced therapy with an expressive arts therapist.

From observation it was noticeable how deeply absorbed they became in talking about their art. This absorption and their commentary about art indicated the significance of art and the impact it has had on their lives, so much so that they cannot be without it.

Super important. Like a ritual… just as important as brushing my teeth and sleeping and eating, like it’s something I need… it’s a, like a basic need, that’s how much I hold on it. (Participant 4)

Art is experienced as an essential need, both to help define themselves existing with pain or to be without it for a time. Doing art becomes a form of triumph in achieving something, even with pain. It allows them to find new ways to cope with painful experiences and to continue doing what they enjoy.

I enjoy it more than it frustrates, you know, the pain frustrates me but still enjoy it more, at the moment it’s a bit of a balance between the frustration of the pain and the painting, but I’m trying to find ways to overcome that. (Participant 3)

For the study’s expressive artwork requirement, Participant 1 never expresses their pain in artwork, and decided not to create anything, Participants 2 and 3 created drawings, and Participant 4 created a song playlist. Participants 2, 3, and 4 indicated that they had achieved connections between mind and body when making their new expressive pieces between the first and second interviews. A better awareness of their pain experience was developed by creatively exploring how art can express their pain. Participant 4 and I found that we could desensitise fears of moving by exploring through music how movements can be safe and not cause pain. Improvised movements helped us to rediscover being in our bodies in ways that felt comfortable enough to enable us to work creatively and which could then be applied to everyday living habits.

I’ve learnt to be like really, like work, my proprioception, my awareness, and my pain and like work through like what I’m feeling with my pain so I can do those movements. (Participant 4)

Participants tended to use art to create spaces that allowed them to escape pain. However, when Participants 2 and 4 were requested to look at pain from an expressive perspective, their art represented pain directly (see Figure 3).

Figure 3. Participant 2, first interview expressive pieces, 2021, pencil on paper, 297 × 210mm.

This was something that I specifically did to specifically look at my pain, as opposed to finding something that provides me with a sense of solace, and a sense of maybe being able to feel better about myself, emotionally, and therefore dampen the pain that way. (Participant 2, see Figure 3)

 This art piece, which focused on the representation of pain allowed Participant 2 to have an experience of being able to review their pain from a distance. They still felt an innate sense of understanding the pain, yet it was now safe to reflect on.

With something like my feet, which I wouldn’t have particularly liked doing this one, but I would say it was cathartic in terms of making me focus on something I don’t like to focus on. (Participant 2)

Identity: Defining oneself

Participants’ lives are unique, yet they hold in common an awareness of how pain and art have an impact on their desire to be themselves. They expressed how the chronic condition of pain makes it hard to take control of what they do, opens them up to living with fear and caution, and they have to deal with a sense of loss due to restrictions in doing what they want to do. Participants described depression and emotional distress, as well as a disconnection from their bodies. When asked about their art practice, however, they described a space where the pain is lighter and less controlling in their lives.

I’ve like desensitised, the heaviness of some of the fears. (Participant 4)

They can be for a time without focusing on pain. Art-making to these participants is a chance to escape from their usual self in pain, their pain-identity.

I just see my body as more than in pain. (Participant 4)

Some of the participants considered creative expression as offering the possibility of feeling safer with their pain and feeling whole again even when in pain.

Your pain is valid yet – but you’re also still allowed to enjoy yourself, you’re actually still allowed to, like, smile and laugh, not just like cry and frown when you’re in pain, you can actually do lots of things. (Participant 4)

One of my creative responses appears as a gentle creature curled into a protective ball, its pain not visible but perhaps emotionally felt (Figure 4). I perceive this as a metaphor for the identity I held during my years with an injury. Participants recognised that they can be comfortable and connected with themselves while creating, that they can be kind to their bodies, and recognise more parts of themselves.

My next step is to try and picture them healthy and try to represent that. (Participant 2)

Change

Participants described ways they would change and adapt their pain experience to continue creating art. They described that the interview experience brought to their attention how beneficial being expressive through art has been. They felt that making art isn’t just an option to escape pain but is also a valuable way in which they can safely reflect on the pain as part of their lives. They described how their artforms always have a certain presence in their lives, that their making has changed from before pain, adapted with pain, and been created anew in the event of having chronic pain. Art has been an important aspect of the participants’ lives that facilitates a change in their everyday norm of pain, a safe place that can be retreated to, where they can feel satisfied in achieving something meaningful. Participant 3 trained their non-dominant hand to draw when arthritis troubled their dominant hand (see Figure 5). Their love for art expression provided the motivation to work with their pain by making changes in what they do.

Figure 4. Kelsey Cross, creative response to Participant 2, second interview, 2021, oil paint on canvas, 400 × 400mm.

Figure 5. Participant 3, first interview expressive piece, 2021, charcoal on paper, 594 × 420mm.

Present experiences

Three out of the four participants created an expressive piece after the first interview, which provided them with a chance to creatively reflect on the first interview and to deepen the discussion in the second interview around art and pain in their lives. Participant 1 described they had no desire to create an expressive piece in the study’s context:

My art is not about my pain. It has absolutely nothing to do with it. I don't create things that express my pain. It's either I don't want to or I'm incapable of doing it. (Participant 1)

For Participants 2, 3 and 4, the actual experience of the new expressive piece and reflecting on it in the second interview led to a conversation about their present experience, not the usual retelling of pain they were accustomed to. Each participant initially found it challenging to create this new expressive piece, as it was new for them to have a creative focus on their experience of pain. Though once their work was completed and they were interviewed again, they all described the positive impact of this creation.

That was different and actually quite challenging, was certainly challenging trying to find a way to put me, I guess, into a picture. (Participant 2)

When reflected on, their art piece became a symbolic container that revealed an individual’s unique experience and made new insights possible.

I’m in there somewhere, emerging, I guess it’s that emergence, which is why she looks like, I will, I could come out. (Participant 2, see Figure 7)

Participants felt more engaged with the new expressive piece, from developing a more purposeful thought process to their artform.

It actually gave me an opportunity to really reflect on how much I’ve been through. I’ve never like really let myself go back there. (Participant 4)

It allowed me to explore it in thought like more consciously, sort of summarise what we’ve been talking about. (Participant 3)

Comparing my experience of reflecting on my pain using therapeutic creative interventions to the participants’ self-guided art-making is the core difference that was discovered in the interviewees’ subsequent experiences. After the first interview, the participants were provided with a direct invitation to engage with a creative expression on a more deeply informed level than their usual intuitive art-making done alone. My experience with creative intervention gave me therapeutic emotional benefits over the course of my MCAT studies. By helping them to creatively reflect on pain experiences, the intervention gave participants a glimpse of how a therapeutic alliance might be of benefit.

Between art and pain

In the first interviews, participants described not being fully aware of how much their art practice influenced their ability to cope with their pain. During the second interview discussions exploring their experience of the new expressive piece, connections became apparent regarding the extent to which art has been a valuable resource in helping with pain management. While doing their new expressive piece task for the second interview, the participants reported realising that expressing themselves through art helped them to be mindful, to respect their bodies and to celebrate their achievements.

It was like a, that feeling of like I’ve just got to do lots of small things, and just kept trying to go, oh yeah that counts, that counts, that counts. (Participant 4)

As they talked, they explored their own experiences, and this showed them how creative expression was affecting their outlook on pain in ways they had not previously realised.

But I also think there’s the capacity, that if that’s actually how I feel about them that if I created something that was softer and kinder, that might help in the opposite way, as in it might make me feel better about my feet? (Participant 2).

During the second interview discussions about their new expressive piece, three of the participants described art-making processes that lessened their pain, providing other feelings such as joy or relief, and pain receding to being implicitly felt in the art rather than bring the topic of their expressions.

I’m surprised, actually I think it’s quite helpful. But I actually also think that the next piece that I’ll create will be, rather than focusing on the pain, focusing on if I can see something positive. (Participant 2)

It appeared that narratives of pain began to change through the time spent reflecting on the self in the interview process. Participants expressed that there is now more than just pain, that there may even be a concealed full self that could be allowed to exist even with the pain. They have a possibility to feel in charge of their life, not disempowered when pain is sometimes too much to work with.

I see it differently, yeah, then it’s more I’m in charge, I dictate things, my pain doesn’t and there are days where it flares up and I’m like, that’s fine. (Participant 4).

Discussion

During this study it became clear that expressive arts therapy had never been considered. Need to make clear you are referring to their experience BEFORE this study. or offered to the participants to help their chronic-pain experience. The participants’ experience of the study appeared to provide them with a newfound appreciation that creative expression could be a therapeutic source for better coping. While participants had not previously had deep discussions about relationships between their art and pain, they used the interviews to reflect on their past, and allow for explorative opportunities that appeared to help them gain further insight into their artform and its role in their pain management.

Recognising trauma in physical pain

Participants acknowledged using expressive arts as an escape from pain. Participant 1 had fun, playful expressive artworks, where they could absorb themselves into a safe space of colour and repetition (see Figure 6). Pain can insist on having control over one’s life, therefore the person in pain is often looking to focus on minimising the physical effect of pain to find a sense of normal life. From the interview data and expressive pieces, it seems pain clients in health services are looking for something to take away the pain or minimise its impact. However, treatment that only focuses only on removing pain with medication may not be treating the multi-dimensional effects of pain in their lives.

Clients and clinicians are jointly seeking the capability for clients to be able to live without pain. However, for those with chronic pain, or for whom there is no pain relief through medical intervention, what might be done? Trauma theory proposes that the disruption of the internal sense of being in one’s body as pleasurable and safe is an outcome of trauma (Malchiodi, 2020; van der Kolk, 2014). Chronic pain sufferers are often left with pain avoidance or minimisation strategies. It is, however, also vital to recognise the need for psychological resources that are required for coping in a more holistic way with the many effects of pain in their minds and bodies. It was evident that, for these participants, expressing one’s challenge with pain through arts allowed them to explore themselves on intrapersonal levels. They expressed a deepening perception of their own pain and realisation that these experiences of pain can be worked with and can come to have meaning.

Working with metaphor to understand pain experience

By taking an arts-based approach, the expressive pieces included in the interviews developed insightful metaphors for the participants’ experiences. The characteristics of the metaphors gave symbolic, descriptive codes that enhanced the participants’ stories. Creating expressive pieces opened experiential dimensions that widened our perspectives (Hannula et al., 2014; Jipson & Paley, 1997; Kossak, 2012) on what was already known in the participant’s experience and what was emerging learning. Participant 2 created a fragile shell metaphor of living in a fragile body, and an emerging new self that may be forming the courage to exist outside its fragile condition (see Figure 7).

Figure 6. Participant 1, first interview expressive pieces, 2021, acrylic paint on canvas, each 1000 × 1000mm.

Figure 7. Participant 2, second interview expressive piece, 2021, coloured pencil on paper, 297 × 420mm.

Participants displayed complexities of experience and I was able to better commit to actualising context by reviewing the expressive pieces they made, as well as what they said. Conversation was prompted by the expressive pieces, realising small details that became metaphorical storytelling opportunities. For example, Participant 2 found a fully intact nautilus shell, then later wove it into the likeness of the life experiences they described. Certain aspects of pain experience are not often shared with others due to feelings of uncertainty about being misunderstood, or fears about being dismissed as trivial. Participant 4 created a playlist that included describing their desire to exist outside of their body, relating this to songs such as ‘My body is a cage’ by Sara Lov (2008).

It allows you to actually have those thoughts and like actually reflect inwards and you go hmm, cause it’s not something, it’s not a discussion you really have with someone else about your pain. (Participant 4)

Expressive work instinctively reflects the metaphoric symbols of a person’s innate experience (such as a caged body), allowing these to be shown in their artwork rather than simply described in words (Malchiodi, 2020; Tarr et al., 2018).

The metaphors from the participants worked as holding containers in the expressive process, validating their feelings without necessarily intentionally verbalising them. Participants expressed that these metaphors allowed them to regain ownership over authentic connections to their lived experiences in ways they had not considered before. This enabled them to accept or be honest about previously unshared thoughts and feelings that felt true to their situation. For example, the feet drawings made by Participant 2 (see Figure 3) began with the drawing on the left. Realising that it didn’t reflect their true emotions, the participant created the drawing on the right, which felt truer to how they saw the pain in their feet.

There’s a level, level of honesty, you end up having with yourself often when you’re doing something creative, so there’s a level of honesty there that I think is probably important for me. (Participant 2)

Conclusion

Art expression appears to be a valuable process of psychological coping for people who experience chronic pain, with far-reaching potential effects in relation to many aspects of life quality and their pain experiences. The participants in this study were beginning to engage in their new expressive pieces with deeper psychological connections than they had previously in their personal arts practice. This can better inform how expressive arts therapy can help clinical practice provide better psychological outcomes for sufferers of chronic pain. Clients who access pain services may then be offered more-informed treatment options and receive better health outcomes.

The themes discussed in this research indicate that establishing a strong connection with arts practice for chronic pain sufferers can help them realise creative and personally intuitive methods for managing pain. Expressive arts as an enquiry process can support exploration of the multi-dimensional lived experience of pain and its impacts on people, leading to client-led insights that can help them psychologically.

The study indicates that expressive arts therapies could be useful for clients with chronic pain who are looking for psychological coping resources. Metaphorical orientation of expressive therapy processes allows for the expression of chronic pain’s unspoken trauma, creates opportunities for new realities and identities for clients to emerge, and enhances clients’ capability for being more attuned to themselves, their pain, and ways to live well with it.

Direction for future studies

This study could be viewed as a stepping stone to encourage further arts-based exploration in the field of expressive arts therapies to help support clients with chronic pain. To continue from this study, there could be an exploration of how an expressive arts therapist role can deepen the relationship between a person with chronic pain and their creative expression of it. This study is relevant to healthcare in Australia, where clients, clinicians and expressive arts therapies as a profession could converge to research and co-construct services for people with chronic pain.

Note

This study obtained ethics approval from Murdoch University Human Research Ethics Committee (Approval 2021/095), and was conducted at Murdoch University, Western Australia. Interested individuals emailed for an information letter and consent form to help determine their eligibility to participate. They provided written consent and upon attending their first interview the full consent form was signed.

References

Barone, T., & Eisner, E. (2006). Arts-based educational research. In J.L. Green, G. Camilli, & P. B. Elmore (Eds.), Handbook of complementary methods in education research (pp.95–109). Taylor & Francis Group.

Barrett, E., & Bolt, B. (Eds.). (2007). Practice as research: Approaches to creative arts enquiry. I.B. Tauris.

Braun, V., & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners. Sage Publications.

Chronic Pain Australia. (2021). What is pain? https://chronicpainaustralia.org.au/index.php?option=com_content&view=article&id=302

Hannula, M., Suoranta, J., & Vaden, T. (2014). Artistic research methodology: Narrative, power and the public. Peter Lang Publishing, Inc.

Henare, D., Hocking, C., & Smythe, L. (2003). Chronic pain: Gaining understanding through the use of art. British Journal of Occupational Therapy, 66(11), 511–518.

Hennink, M., Hutter, I., & Bailey, A. (2011). Qualitative research methods. Sage Publications.

Jipson, J., & Paley, N. (Eds.). (1997). Daredevil research: Re-creating analytic practice. Peter Lang Publishing.

Kirkham, J.A., Smith, J.A., & Havsteen-Franklin, D. (2015). Painting pain: An interpretative phenomenological analysis of representations of living with chronic pain. Health Psychology, 34(4), 398–406. https://doi.org/10.1037/hea0000139

Knowles, J.G., & Cole, A.L. (Eds.). (2008). Handbook of the arts in qualitative research. Sage Publications.

Kossak, M. (2012). Art-based enquiry: It is what we do! In S. McNiff (Ed.), Art as research opportunities and challenges (pp.19–27). Intellect.

Lov, S. (2008). My body is a cage [Song]. On The young eyes. Splinter Records.

Lynch, M., Sloane, G., Sinclair, C., & Bassett, R. (2013). Resilience and art in chronic pain. Arts & Health, 5(1), 51–67. https://doi.org/10.1080/17533015.2012.693937

Malchiodi, C.A. (2020). Trauma and expressive arts therapy: Brain, body, and imagination in the healing process. The Guilford Press.

McNiff, S. (2004). Research in new keys: An introduction to the ideas and methods of arts-based research. Journal of Pedagogy Pluralism and Practice, 3(1), article 2. https://digitalcommons.lesley.edu/jppp/vol3/iss1/2

McNiff, S. (2009). Integrating the arts in therapy: History, theory and practice. Charles C. Thomas Publisher, Ltd.

McNiff, S. (Ed.). (2013). Art as research opportunities and challenges. Intellect.

NVivo. (2021). NVivo qualitative data analysis and software 12th ed (Release 1.4.1 [851]) [Computer Software]. QSR International Pty Ltd.

Olivier, A. (2007). Being in pain. Peter Lang.

O'Neill, A., & Moss, H. (2015). A community art therapy group for adults with chronic pain. Art Therapy, 32(4), 158–167. https://doi.org/10.1080/07421656.2015.1091642

Payne, H. (Ed.). (1993). Handbook of inquiry in the arts therapies: One river, many currents. Jessica Kingsley Publishers.

Reynolds, F., & Prior, S. (2011). Strategies of adapting and replacing artistic leisure occupations to maintain participation and identity: A qualitative study of women with arthritis. Activities, Adaptation & Aging, 35(1), 21–42. https://doi.org/10.1080/01924788.2010.545970

Tarr, J., Cornish, F., & Gonzalez-Polledo, E. (2018). Beyond the binaries: Reshaping pain communication through arts workshops. Sociology of Health & Illness, 40(3), 577–592. https://doi.org/10.1111/1467-9566.12669

van der Kolk, B. (2014). The body keeps score: Mind, brain and body in the transformation of trauma. Penguin Books.