Support Care CancerDOI 10.1007/s00520-005-0012-7 ORIGINAL ARTICLE

Kate CollieJoan L. BottorffBonita C. LongCristina Conati

Received: 5 October 2005Accepted: 15 December 2005# Springer-Verlag 2005

Distance art groups for women with breastcancer: guidelines and recommendations

Abstract To overcome barriers thatprevent women with breast cancerfrom attending support groups, inno-vative formats and modes of deliveryboth need to be considered. Thepresent study was part of an inter-disciplinary program of research inwhich researchers from counselingpsychology, psycho-oncology, nurs-ing, computer science, and fine artshave explored art making as aninnovative format and telehealth as amode of delivery. For this study, we

conducted focus groups and inter-views with 25 people with expertiseabout breast cancer, art, art therapy,and distance delivery of mental healthservices to generate guidelines fordistance art-based psychosocial sup-port services to women with breastcancer. A qualitative analysis of thefocus group and interview datayielded guidelines for developers andfacilitators of distance art groups forwomen with breast cancer pertainingto (a) emotional expression, (b) emo-tional support, (c) emotional safety,and (d) accommodating individualdifferences, plus special consider-ations for art therapy groups. Furtherresearch is needed pertaining to theuse of computers, involvement of arttherapists, and screening out vulner-able clients.

Keywords Breast cancer .Support groups . Art therapy .Telehealth . Canada

Introduction

Psychosocial support services such as support groups havebeen shown to significantly reduce distress and improvecoping for women with breast cancer (e.g., [4, 10, 35, 51,55]). There is even some evidence that group psychosocialinterventions can bring physiological benefits for peoplewith cancer [2, 20, 21, 54]. However, many women withbreast cancer do not participate in professionally led sup-port groups. Studies in English-speaking countries have

found rates of participation between 2 and 33%, with manystudies showing rates of about 10% [18, 33, 65]. Partici-pants tend to be white, middle or upper class, educated,professional, and young [8, 18, 42, 59, 60, 65].

Certainly, some women with breast cancer receive ad-equate support without participating in structured inter-ventions [24, 42, 65]. However, it is important to addressbarriers that prevent participation in support groups, suchas lack of services in remote locations and lack of trans-portation [18, 25], and to provide services that are cul-

K. Collie (*)Department of Psychiatryand Behavioral Sciences, StanfordUniversity School of Medicine,401 Quarry Road,Stanford, CA 94305-5718, USAe-mail: krcollie@stanford.eduTel.: +1-650-736-2689Fax: +1-650-4986678

J. L. BottorffHealth and Social Development,University of British ColumbiaOkanagan, 3333 University Way,Kelowna, BC V1V 1V7, Canada

B. C. LongDepartment of Educationaland Counselling Psychologyand Special Education,University of British Columbia2125 Main Mall,Vancouver, BC V6T 1Z4, Canada

C. ConatiDepartment of Computer Science,University of British Columbia2366 Main Mall,Vancouver, BC V6T 1Z4, Canada

turally appropriate and appealing. Support groups based ontalking may not appeal to women who are not fluent or whoare not comfortable discussing illness openly [25, 65].

Innovative approaches are needed to make supportgroups widely available to women with breast cancer. InCanada, where this study was conducted, there is greatcultural diversity, with many people living in remote lo-cations. Alternate modes of delivery and formats both needto be considered to meet the needs of women of differingbackgrounds who may live in sparsely populated areas. Asan interdisciplinary team from counseling psychology,psycho-oncology, computer science, nursing, and fine arts,we have been exploring telehealth as an alternative mode ofdelivery and art making as an alternative format for breastcancer support groups [12–15].

Alternate mode of delivery: telehealth

The expanding domain of behavioral telehealth (i.e., the useof telecommunication technologies to deliver psychologicalservices and education from a distance) provides uniqueopportunities for improving access to specialized supportservices. Pilot studies of telephone and Internet supportgroups for womenwith breast cancer have shown high levelsof participation and satisfaction (e.g., [16, 28, 36]), and thesepilot studies have demonstrated that both telephones and theInternet are practical ways to deliver psychosocial support torural or isolated women with breast cancer and to ethnic-minority women who might not join in-person groups. Thesheer number of online support groups for women withbreast cancer (e.g., http://www.bcsupport.org, http://www.cancersociety.com/forum/index.cfm and http://www.health.groups.yahoo.com/group/breastcancer2/) is further indicationof the potential for using telecommunications technologiesto provide support services to women with breast cancer.Contrary to what stereotypes might suggest, telehealthdelivery may be particularly appropriate for older womenand women from outside the mainstream [27].

Distance communication has not been shown to beintrinsically inferior to in-person communication for psy-chosocial support services. Studies comparing differentmodes of communication (e.g., in person, audio-only, andvideo) have shown only slight differences between modeson measures such as relationship formation, intimacy, trust,emotional support, and effectiveness of communication,especially if there is some initial in-person contact (for areview, see [11]). The lack of clear differences betweenmodes may be explained by the human capacity to adapt towhatever communication means is available [63] and bypossible advantages of mediated modes of communicationsuch as increased attention to communication when visualsocial cues do not have to be monitored [56, 62], roleenhancement during no-sight encounters [49], privacyand decreased feelings of vulnerability [22, 26, 64], andidealization of people who cannot be seen [62].

In a study of a 16-week moderated psychoeducationalgroup in which 32 women with breast cancer (half of whomwere rural, 34% of whomwere over 50) communicated oncea week using Internet relay chat, Lieberman et al. [36] foundsignificantly lower levels of depression and pain at posttest,with two thirds of the participants saying the interventionwas beneficial. Similarly, in a randomized controlled trial ofa 12-week moderated, Web-based social support group inwhich 72 women with breast cancer (age range 30–69)posted written messages on a weekly topic, women in theintervention group reported significant reductions in de-pression, perceived stress, and traumatic stress symptomscompared with those in the wait-list control group. Theeffect sizes in this study were similar to those found instudies of in-person groups [66]. These two studies aresignificant because they showed therapeutic gains usingonly text communication. If a mode of communication thatemploys only one sense and contains very little nonverbalinformation can be used with some success, then other low-cost modes of distance communication, especially those thatemploy additional senses and provide more nonverbalinformation, should also be explored as ways to makepsychosocial support more widely available.

Alternate format: art making

Nonverbal expression through art offers a promising alter-native for women with breast cancer who do not wish toparticipate in support groups based entirely on talking. Art-based interventions are a good fit for telehealth because visualimages activate the sense of sight, provide considerablenonverbal information, and can be transmitted easily andinexpensively fromoneplace toanotherbymail, fax,ore-mail.

Art therapy (i.e., psychotherapy in which people workwith art therapists to express and elaborate thoughts andfeelings with visual images and words) and therapeutic artmaking (in which therapeutic benefits come through theprocess of creating) have been used in the context of majorillness to address a variety of therapeutic goals. These includefacilitating emotional expression, especially about tabootopics [7, 43]; increasing sense of control [29]; promotinginner strength and sense of purpose [41, 44]; reducingfeelings of isolation [23, 41]; strengthening identity [38];facilitating meaning making [15, 19, 39, 48]; and bolsteringimmunity [5, 29]. It does not require previous skill or talent toparticipate in art therapy or therapeutic art making.

There is abundant clinical and anecdotal evidence andgrowing research evidence that art making, in the contextof art therapy or otherwise, can be health-promoting forpeople with cancer (e.g., [1, 15, 17, 29, 37, 44, 48]). Therich tradition of breast cancer art suggests that visual ex-pression has special significance for women with breastcancer who may experience their illness as inescapablyvisual and who may wish to assert themselves visually—whether or not they have previous art experience [40].

An innovative approach: art and telehealth

In the first phase of our program of research, a computersystem for Internet delivery of group art therapy was de-veloped and evaluated to identify issues to consider for con-tinuing development [12–14]. One of the main findings wasthat clinical procedures that are specific to distance deliveryare needed to offer art therapy from a distance. As devel-opment continued, we shifted away from our original idea ofusing the Internet for synchronous communication to moreflexible formats thatwould not necessarily require computersand that would be less vulnerable to technical problems.

A second research phase was initiated to specify clinicalcontent for a distance art-based psychosocial support servicefor women with breast cancer. In this phase, a narrativeanalysis of women’s descriptions of their experiences of artmaking and art therapy in relation to breast cancer wasconducted to identify therapeutic mechanisms and possibletherapeutic goals for a distance art-based support service[15]. Many of the therapeutic benefits described by thewomen (e.g., stress relief, emotional release, vitalization, andself-affirmation) were reported whether or not a therapist/facilitator was involved. This supported the idea that directcontact with a therapist or facilitator may not be necessary inall cases and raised the question of when and how therapistsor professional facilitators should be involved.

Thepurposeof thepresentstudywastogeneratebothclinicaland technological guidelines for developing art-based psycho-social support services for distance delivery to women withbreast cancer using any means of distance communication.

Method

We began by conducting three in-person focus groups withwomen with breast cancer, art therapists, and other peoplewith relevant experience from the greater Vancouvermetropolitan area in western Canada. To tap the expertiseof people from outside Canada and to include local peoplewho could not attend a focus group, we also conductedinterviews by e-mail and telephone. One person whoarrived at a focus group late also participated by e-mail.

Participants

We used purposive sampling to recruit 25 people withexpertise about breast cancer, art/art therapy, and/or dis-tance delivery of psychosocial support services. They were(a) nine women who had used either art making or arttherapy in relation to their breast cancer, (b) nine art ther-apists with experience working with clients with cancerand/or experience using computers in art therapy, (c) fiveother therapists with experience working with clients withcancer and/or experience with distance delivery of psy-chological services, (d) one computer expert with knowl-

edge of Internet delivery of art therapy (who participatedboth in person and by e-mail), and (e) one graphic designerwith experience developing support services for womenwith breast cancer in rural and remote communities.

The participants in the first focus group were six womenwith breast cancer; in the second, two art therapists; and inthe third, one art therapist, three women with breast cancer,one computer expert, and one therapist from a cancerhospital counseling center. We chose homogenous compo-sition for the first two groups to help the participants speakfreely [34]. The third group was composed to foster cross-pollination of ideas between women with breast cancer, arttherapists, and others.

The participants who responded by e-mail were six arttherapists (five from the USA and one from Australia),one narrative therapist with experience doing counselingby e-mail (from Canada), one computer expert (fromCanada), and one graphic designer (from the USA). Thosewho responded by telephone were all therapists (two fromCanada and one from the USA).

The age range of the entire sample was 31–67. Three ofthe 25 participants were male. On the whole, the par-ticipants were white and well educated. All but one of thewomen with breast cancer had experienced art therapy; fiveof these women had no previous art experience as adultsprior to being diagnosed with breast cancer.

Data collection

Focus groups Focus groups are considered economicaland effective for generating and elaborating views—bothareas of consensus and diverse/alternative perspectives—about products, services, or programs by tapping into thehuman tendency to develop opinions through interactionwith others. Due to the novelty of our topic, we wanted toharness the power of focus groups to elicit tacit knowledgeand personal opinions that may not have been articulatedpreviously [34, 45].

Prior to each 2-hour focus group, each participant wassent an information letter and the following stimulusmaterials: a 10-min video illustrating the first phase of thisresearch [12], a 1-page summary of the second researchphase [15], and a list of hypothetical formats for providingart-based support services from a distance. The video wasmade to give viewers a feel for the experience ofsynchronous group art therapy via the Internet (with allmembers in different places). The summary of the secondphase of the research outlined possible therapeutic goals asdescribed by women with breast cancer. The list ofhypothetical formats was provided to encourage partici-pants to think of formats (e.g., fax, telephone, and mail)other than the one illustrated in the video.

During each focus group, one of the investigators servedas a moderator, a second investigator was present, and aresearch assistant audiotaped the sessions and noted the

speaker order. Informed consent for participation andaudiotaping was obtained. The discussions were based onthree broad questions that addressed (a) the necessity of atrained facilitator, (b) women’s different motivations forengaging in art-based psychosocial support and how toassess these, and (c) essential guidelines for developingdistance art-based psychosocial support services forwomen with breast cancer and whether these would bedifferent for art therapy and therapeutic art making. Duringthe following week, members of the research team con-ducted follow-up telephone interviews that ranged from 5to 30 min to ask the participants if they had additional ideasto offer. Their comments were included in the data set.

E-mail/telephone interviewsWe sent e-mail letters explain-ing the project to 21 potential participants with a consentform to sign and return by fax. Upon receipt of a signedconsent form, each participant was sent three questions viae-mail and asked to respond via e-mail within 2 weeks or torequest for a telephone interview if e-mail was incon-venient. We received 16 consent forms. Those who did notrespond to our questions within 2 weeks were sent areminder e-mail or telephone call. Of the 12 responders, 9answered the questions via e-mail, and 3 completed atelephone interview. The e-mail responses ranged in lengthfrom 250 to 500 words, with one long response of 1,800words. The telephone interviews ranged from 30 min to 1 h.

The three interview questions were modified based on thefocus group responses and were introduced with a summaryof the findings from phase two of the research. The questionswere (1a) “What guidelines do you think should beconsidered as essential for developing these types (referringto the findings from phase two) of art-based activities forwomen with breast cancer that could be delivered from adistance?” (1b)“Would the guidelines differ if the art-basedactivity was considered “therapy?” If so, in what way?” (2)“Based on your experiences, what do you think areinnovative and practical ways to provide art-based psycho-social support services from a distance to womenwith breastcancer—using any type or combination of types of distancecommunication (mail, telephone, internet, etc.)?”

Data analysis

The transcriptions of the focus groups, telephone inter-views, and e-mail responses were analyzed using a sys-tematic inductive approach that involved content analysis.The analysis began with a close reading of the data focusingon the words used, the intensity or emphasis of views, thefrequency and consistency of comments, and wheredivergent opinions and consensus were represented [34].Using this process, three investigators (K.C., J.B., and B.L.)reviewed the data independently to identify potentialthemes. Through discussion, themes relevant to the re-search purpose were clarified, and a coding framework was

developed. The entire data set was coded using Nvivosoftware. Data related to each theme were synthesized byone of the four investigators, paying attention to similaritiesand differences across the focus groups and amongparticipants. Differences in interpretation of the data wereresolved through discussion. During the final stages of theanalysis, the principal author reread the transcripts to ensurethat our analyses accurately reflected the coded data.

Results

In this section, we give an overview of the participants’comments and present the major themes that emerged fromthe analysis. The themes that represent areas of substantialagreement among the participants are framed as guidelinesfor developers and facilitators of distance art groups forwomen with breast cancer—with some special consider-ations for art therapy. These are followed by a discussion ofissues about which there was significant disagreement amongthe participants. All quotations are provided verbatim, withminor editing to improve clarity and any identifiers removed.

The participants came into the study with an interest inmaking art-based psychosocial support more widely avail-able to women with breast cancer, particularly women inrural areas. Although one participant was opposed to theidea of delivering art-based services from a distance, theoverall view was that distance delivery was a good idea,and that any means of communication could be used (e.g.,mail, telephone, and e-mail).

The participants did not view distance delivery as a wayto allow anonymous participation and put high value onclose personal interaction with as much in-person contactas possible. Their comments were mainly about group artexperiences because there was a pervasive assumption thatwomen with breast cancer would benefit from being incontact with each other and with a therapist or facilitator.

General guidelines for distance art groups for womenwith breast cancer

The primary guidelines that emerged pertained to (a) emo-tional expression, (b) emotional support, (c) emotional safe-ty, and (d) accommodating individual differences (seeTable 1).The guidelines are for both developers and facilitators ofdistance art groups for women with breast cancer.

Emotional expressionAlthough the art therapists discussedemotional expression as one of many possible therapeuticoutcomes of art therapy and therapeutic art making, in-cluding increased insight, ego strength, stimulation ofcreativity, improved communication, and reduction of fear,shame, and isolation, the women with breast cancer talkedabout emotional expression as the primary and most sig-nificant outcome. They described the potential of art

making to bring forward emotions that they described as“deep” and “primal,” as in this comment:

And primal emotions, if they surface, can be thestrongest ones, I think... I think that art does that. Thatis why I think it is so wonderful. Because it gets youdown to your primal level, so all the rest of the dailystuff falls away from you.

Many of the participants expressed a strong belief in thetherapeutic value of working with physical, tactile art mate-rials. They recommended offering a wide choice of physicalart materials as a way of facilitating emotional expression.There was considerable interest in mailing workbooks con-taining instructions and templates for art activities andresource information to support ongoing involvement increative expression. One participant suggested:

Something like a think-and-do book that led you on ...and allowed you to become absorbed in it so that youcould stop thinking about having cancer and startthinking about maybe some bigger issues in your lifethat that you would like to be thinking about.

Emotional support The women with breast cancer whohad experienced group art therapy said it was therapeuticto make art in a supportive and nurturing environment.One woman said, “The most important thing about (group)art therapy was being looked after so well.”

Several participants said the kinds of emotions that canarise while making art should not be experienced alone. Itwas generally agreed that while a woman might make arton her own, it should be with the understanding that the artwill soon be shared with others and/or with a facilitator/therapist, and that each woman should have access to localback-up support. One woman with breast cancer said:

Once you start getting to these deep emotions that itbrings up, I hope that they would at least have a phonenumber of somebody that would be there ASAP ifstuff really started. Because some of this stuff thatcomes up is incredible.

Emotional safety Both art therapists and women with breastcancer said that because emotional expression through artmaking can involve emotional risk and feelings of exposure,emotional safety and a trusting nonjudgmental atmosphereare necessary for deep and authentic emotions to come for-ward. As she described her need for emotional safety, awoman with breast cancer said, “I was desperate for a safeplace,” which she found in an art therapy group.

The participants offered suggestions for how to ensureemotional safety, which included (a) obtaining informedconsent relating to all aspects of the experience, includinghow the art will be handled and the possibility that strongT

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feelings might be invoked; (b) establishing ground rules fornonjudgmental viewing of art works; (c) maintaining con-fidentiality; (d) allowing participants as much choice andcontrol as possible; and (e) providing structure and pre-dictability. One participant suggested that a private Web sitefor sharing images could create the feeling of a private room.Others discussed the necessity of having procedures in placefor maintaining confidentiality and emotional safety in theevent of a technical breakdown and clearly explaining limitsto confidentiality imposed by Internet communication if theInternet was used.

Accommodating individual differences As the participantsimagined women with breast cancer participating in groupart activities from a distance, they wanted to be sure thatdifferent levels of familiarity and ability with art makingcould be accommodated—as well as different levels of ex-perience and ability with computers if computers were used.Cultural differences were alsomentioned, as in this commentfrom an art therapist: “In developing a successful ‘artreach’program, cultural and ethnic values would need to be openlyincorporated and encouraged as a conscious part of anyactivity for women to identify personally and spiritually.”Several participants pointed out that women with disabilitiesand women who speak different languages would needprojects suited to their abilities.

There was general agreement that women’s preferencesshould dictate the means of communication used, and thatthe art activities should be offered by more than one means(e.g., Internet and ground mail) so that each woman canuse technology that is familiar and available to her and nothave to learn a new technology while she is sick.

Special considerations for art therapy

Only therapists and art therapists discussed significant differ-ences between therapeutic art making and art therapy. Thosewho commented on this issue did not think there should becompletely different guidelines for the two approaches butsaid that in the case of art therapy, extra guidelines would beneeded, particularly with regard to confidentiality, personalcontact, and training. Moreover, some of the general guide-lines would be even more important than for therapeutic artmaking, especially those pertaining to emotional safety andaccommodating individual differences. Clear parameterswould be crucial.

One art therapist was strongly opposed to the idea of of-fering art therapy from a distance. She said it would probablynot be possible to conduct art therapy if the therapist couldnot observe the art making process directly. She also said itwould be necessary to have more information about a wom-an’s mental health, background, cultural context, and med-ical status than in an in-person situation, and that this mightbe difficult to obtain. Another art therapist said it might takeextra time to establish therapeutic relationships, and that the

healing effect of physical presence would be lost. The otherseven art therapists were in favor of offering art therapy froma distance.

Several of the art therapists framed the difference betweenart therapy and therapeutic art making in terms of depth ofemotional expression, explaining that in therapeutic artmaking, creative expression brings “pleasure,” “ego strength,”and “recognition of one’s own identity,” whereas in arttherapy, the emphasis is on deep thoughts and feelings thatmay not have been expressed before. Because of the emo-tional vulnerability that is likely with art therapy, they saidsome personal contact would be desirable during a distanceart group, and that “the development of trust and the feelingof being cared for must be attended to at every contact.”

A therapist claimed that “ethics and training” are whatdistinguish therapy from other forms of support and wenton to say that if the service being offered was art therapy,the facilitator would need to be a credentialed art therapistwho adheres to the ethical guidelines of a professionalorganization and who has clinical training in working withclients from a distance.

Closed groups were recommended for art therapy (i.e.,no new participants may join after a group begins), and itwas pointed out that women would need suitable privatespaces for art making if they were in an art therapy group.Special care would be required to ensure the safety andconfidentiality of art sent from one place to another. Atherapist with expertise in therapy via e-mail emphasizedthat Internet transmissions would need to be encrypted,with images and text stored on disks and not on hard drives.

Areas of disagreement

There was significant disagreement among the participantsabout (a) the use of computers, (b) the involvement of arttherapists, and (c) screening out vulnerable clients. Someparticipants were in favor of using computers, and otherswere opposed to using a “dehumanizing” and “isolating”technology in the context of psychosocial support; someparticipants said it was crucial to have art therapists involvedeven for therapeutic art making, and others did not think thiswould always be necessary; and there were differences ofopinion about whether women who are emotionally fragileshould be excluded from participating in distance art groups.

The use of computers Although we had encouraged par-ticipants to consider a range of communication options, mostof them assumed computers and the Internet would be used insome way if they were available and saw this as a positivething. However, one participant was strongly opposed to theuse of computers, and others had reservations about usingtechnology that is “impersonal,” expensive, and possibly“toxic” and that perpetuates an “overreliance on technology”within our culture. An art therapist with extensive experienceworking with people with cancer said, “The therapeutic

relationship is strongly compromised by the introduction oftechnological devices such as the computer that dehumanizethe process and can isolate the patient even further.”There alsowas concern that if computers were used, inexperience andtechnical breakdowns could cause distress. Participants withmore computer experience spoke more favorably about theuse of computers than those with less computer experience.

There was considerable support for using computers as atool for sharing images via the Internet. However, computerswere not favored for regular verbal communication. Voicecommunication (e.g., by telephone) was recommended overe-mail because it is more personal, more appropriate for so-cial and emotional support, and less susceptible to problemsof miscommunication than e-mail. Neither were computersfavored for making art because of inherent limitations suchas the small size of the screen, the lack of a tactile dimension,and the standardization of computer-based tools that couldimpede emotional expression. There also was concern thatthe use of computers for art making could put the emphasison the art product rather than the art process, and thatcomputers could become the focus rather than a transparentmedium. It was assumed that the cost of electronic art toolsthat favor emotional expression would be prohibitive, andthat difficulties in learning how to use new tools wouldimpede the therapeutic process.

Most of the participants had never tried making art withcomputers. Some of those who had made suggestions aboutadditional ways computers could be used, for example, forlooking at art images together on computers in differentplaces and electronically pointing to things, for collaboratingon a single art work from different locations, for preservingthe stages of development of an image, and mounting onlineexhibitions. One participant suggested that computers couldbe used for multimodal expression, perhaps combining im-ages, words, and sounds. For women with certain disabil-ities, computers could facilitate expression that would not bepossible with physical materials.

Involvement of art therapists On the whole, the arttherapists took the position that an art therapist is essentialto any therapeutic art experience. However, other partici-pants spoke at length about peer-led art experiences andexperiences facilitated by nonart therapists who would besupervised by art therapists. A woman with breast cancerwho had lived in rural communities imagined a peer-led artgroup for rural women with breast cancer that would includeconsultation with an art therapist:

Perhaps they would like to elect one of their number tobe the main contact with the art therapist, and they arejust going to meet informally at Betty’s house everySaturday morning and they are just going to slap paintaround until they have painted all the pigs in the yard,you know what I mean.

One art therapist made the point that it often is hard forpeople in art therapy groups to see what the art therapistdoes to make a group run well, and that it is easy for themto erroneously assume that the art therapist is not essential.

Screening out vulnerable clients Art therapists pointed tothe “vulnerability” of women with breast cancer and urgedcaution when working with this population. One recom-mended excluding anyone who seemed particularly emo-tionally vulnerable. Although the women with breast canceragreed that emotions can run high, and appropriate carewould need to be taken for handling emotions that arise, theywere not in favor of screening out women who are “fragile.”They argued for democratization of therapeutic decisionsand said judgments about emotional fragility and decisionsabout the appropriateness of therapeutic activities should bemade by women with breast cancer themselves. One womanmade the point that it may be those who are the most fragilewho need help the most, and it would be wrong to screenthose women out.

Discussion

We conducted a focus group study as a step in the devel-opment of an innovative service, the aim of which is to makethe benefits of support groups available to more women withbreast cancer. We sought input from women with breastcancer and other people with relevant expertise to generateguidelines for developing and facilitating art-based psycho-social interventions for women with breast cancer to bedelivered from a distance. A qualitative analysis of focusgroup and interview data revealed areas of agreement that wecould translate into guidelines for developing and facilitatingdistance art groups. These pertained to (a) emotionalexpression, (b) emotional support, (c) emotional safety, and(d) accommodating individual differences, with special con-siderations for art therapy groups. The analysis also revealedareas of disagreement pertaining to (a) the use of computers,(b) involvement of art therapists, and (c) screening outvulnerable clients. The findings shed light on which aspectsof delivery and where new procedures would be needed.

Emotional expression and support emerged as key issuesand important therapeutic goals. The guidelines pertaining tothese two themes echo guidelines used in in-person supportgroups for women with breast cancer. For example, the“Supportive–Expressive Therapy” (SET) model of groupsupport for women with breast cancer [53] specifically pro-motes emotional expression and social support—both ofwhich have been associatedwith better health andwell-beingfor womenwith breast cancer [9, 30, 57, 61]. The idea that artmaking is a powerful vehicle for promoting the expressionof emotions that might not be expressed otherwise is afundamental assumption of art therapy (e.g., [46]).

Guidelines pertaining to confidentiality and emotionalsafety are standard for in-person therapeutic groups. Thefindings of this study suggest that for distance groups, moreattention might need to be given to explaining the limits toconfidentiality than for in-person groups to adequately ex-plain limits imposed by particular communication technol-ogies, and that the methods used to ensure emotional safetymight be different. For example, each person would needaccess to immediate local support in case a crisis arose inconjunction with the group experience, and procedureswould need to be established for what to do if technicalproblems disrupted communication. These proceduresmightinclude having back-up communication systems in placesuch as using fax or ground mail to send images if e-maildoes not work and having access to an alternate phone line.

The guidelines pertaining to confidentiality and emotionalsafety are similar to guidelines that have been outlined pre-viously in discussions of online therapeutic interactions (e.g.,[6, 14]) and that have informed ethical guidelines for onlinecounseling and therapy (e.g., National Board of CertifiedCounselors and the British Association for Counselling andPsychotherapy). The guidelines about using a mix of tech-nologies and accommodating individual differences extendexisting guidelines.

The guidelines pertaining specifically to art therapy alsopointed to procedures beyond those used in person such asproviding guidance to participants for creating suitableprivate spaces for art making and taking extra time toconduct assessments. Art therapists would need training inoffering art therapy from a distance. Although this is notavailable through existing art therapy training programs,training in general distance therapeutic skills is availableonline (e.g., http://www.therapyonline.com; http://www.OnlineCounsellors.co.uk).

The areas of disagreement had to do with the use of com-puters, the involvement of art therapists, and screening outvulnerable clients. Computers were seen as an ideal tool bysome participants and as antitherapeutic by others. Arttherapists felt strongly that art therapists should be directlyinvolved even for therapeutic art groups,whereaswomenwithbreast cancer were open to other possibilities such as peer-ledgroups, with art therapists playing consultative or supervisoryroles. Some art therapists were in favor of screening outemotionally fragile women, but women with breast cancerclaimed that emotionally fragile women might be the veryones who would benefit the most; therefore, women withbreast cancer favored self-selection and inclusiveness.

Research is needed to determine if it is possible to harnessthe potential of computers while avoiding any constrainingor antitherapeutic effects. In the interim, the intention tomaximize access and choice would suggest using computersif this iswhatwomen choose—for sharing images rather thanfor regular verbal communication or art making. Screeningand leader expertise are complex issues that speak to thepotential democratization of support groups and to issues ofpower and control. New therapeutic models may need to be

developed. A starting point would be the identification ofrelevant outcomes for therapist- vs peer-led groups andinclusive vs exclusive groups. A safe interim assumptionmight be that art therapy groups need to be facilitated by arttherapists, and that facilitators of therapeutic art groups whoare not art therapists should be supervised by art therapists.Rather than excluding women who are emotionally fragile,extra precautions could be taken to ensure the emotionalsafety of anyone who is particularly vulnerable.

If more of the participants had been aware of the range ofelectronic art making tools currently available, they may havebeen less certain that physical artmaterials aremore conduciveto emotional expression than electronic tools. Another pos-sible line of future research has to do with understanding therole individual differences play in determining the effective-ness of particular technologies and modes of communication,and how existing technologies might be improved to ac-commodate individual differences. In exploring computers asa means of expression and communication, it could be usefulto add to existing computer art programs some form ofintelligent help that can follow a person’s interaction with thesoftware and provide support when necessary.

Emotional expressionwas at the core of the findings of thisstudy. There is a large body of research about the healthbenefits of written emotional expression, especially the ex-pression of previously unexpressed emotional material (e.g.,[47, 58]), and there is growing interest in online self-helpinterventions using emotionally expressive writing (e.g.,[52]). Research is needed that investigates the use of visualexpression for the kinds of emotionally expressive interven-tions that have been shown to be beneficial for women withbreast cancer, especially those that can easily be offered froma distance.

The participants liked the idea of physical workbooks thatcould be sent through themail. Previous research about usingworkbooks to provide psychosocial support from a distanceto women with breast cancer in rural areas has yieldedpromising results. The breast cancer workbook–journal OneIn Eight: Women Speaking to Women [32], which uses theSET model, has been shown to increase self-efficacy andfeelings of emotional support and to reduce depression andtraumatic stress symptoms for rural women with breastcancer [3, 31]. Our findings suggest that art workbooks mayalso have value and indicate a need for more research aboutthis very nontechnological telehealth modality.

Certain limitations of this study need to be mentioned.Although the participants were from four continents, theywere predominantly white and well educated, and all thewomen with breast cancer were from one region in Canada.Although the participants were not intended to be repre-sentative, other people from other cultural or socioeconomicgroups might have said very different things. For example,others might have endorsed anonymous participation, some-thing that has been described as an advantage in studies aboutInternet and telephone support groups for womenwith breastcancer (e.g., [50]). Other limitations are the low participation

in one focus group, which may have constrained the devel-opment of ideas in that group and the fact that the participantsdid not have hands-on experience with distance art groups,such that many of their comments were hypothetical ratherthan being rooted in direct experience.

Despite these limitations, this interdisciplinary studymakes a significant contribution to the effort to reducedisparities in access to psychosocial support for womenwith breast cancer through the development of innovativeservices. It provides guidelines that can be used in the

implementation of distance art groups and future pilotstudies. It offers a creative and flexible behavioraltelehealth paradigm that favors emotional expression andemphasizes inclusiveness and flexibility.

Acknowledgements We wish to thank our research assistant,Jennifer Wilson, and the 25 people who offered their time and ideasfor this study. The research was supported by a Hampton Fundresearch grant from the University of British Columbia.

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