The Art of War, the military treatise attributed to the ancient Chinese general Sun Tzu, has influenced more than warfare since it was written over 2,000 years ago. Its principles have been applied to not only military strategies and tactics, but political, economic and legal ones as well.
Today, Tzu's tenets can even be applied to the realm of cancer care, as being demonstrated by a unique program at the Abramson Cancer Center at Pennsylvania Hospital (ACC PAH).
First, let's get past the obvious associations. In 1971, then President Richard Nixon signed the National Cancer Act, signifying the launch of the "war on cancer" in the U.S. While many advances in cancer prevention, detection and treatment have been achieved (some battles won, if you will) the war is far from over.
In the very first chapter of The Art of War, Tzu states that war "is a matter of life and death." Captioning the obvious here, but this can certainly be relatable to facing a cancer diagnosis.
More interesting though is another line from the fifth chapter, which could also eloquently illustrate approaches to fighting cancer:
In battle, there are not more than two methods of attack - the direct and the indirect;
yet these two in combination give rise to an endless series of maneuvers.
Understanding that supportive care is the essence of compassionate care and very effective in helping to battle cancer, the Joan Karnell Supportive Care Services (JKSCS) of the ACC PAH integrates a complementary (Tzu's "indirect") approach to attacking cancer with conventional medical treatment. A total of 29 different services and programs are available to be used individually or in multiple combinations to best address each patient’s needs.
A cancer diagnosis and treatment can be overwhelming, to say the least. Through supportive care services and programs, patients and family members are better able to deal with the physical, emotional and financial distress of their situation. "We firmly believe that the less distress patients experience, the more energy they can direct toward their recovery and improve their overall quality of life," said Marylou Osterman, ACC PAH Patient Services coordinator.
One program at the ACC PAH - Mindfulness Based Art Therapy - helps cancer patients creatively come to grips and better cope with their situation. Officially titled Walkabout: Looking In, Looking Out, this special survivorship program decreases distress, including physical pain, anxiety, depression and fatigue through mindfulness-based art therapy using digital photography and art materials and mindful outdoor walks.
Walkabout is led by
Caroline Peterson, MA, ATR-BC, LPC, a board-certified art therapist and licensed professional counselor. An artist before becoming a therapist, Peterson founded and developed the program while working as an individual counselor and group facilitator at another Philadelphia hospital. During that time she was the co-investigator of two National Institutes of Health-funded clinical trials investigating mindfulness-based art therapy in oncology and with chronic pain patients. Both studies yielded very good results prompting Peterson to explore ways to further develop mindfulness based art therapy to treat patients.
Since 2008, Peterson has had a private studio and practice where she specializes in working with persons diagnosed with cancer and other medical illnesses and their family members. Yet, she wanted to be a part of something more. "I had heard a lot about the supportive cancer care at Pennsylvania Hospital, that it was a place that had a true supportive and palliative care program and that it was
right here," said Peterson. "So I called Mary Pat (Lynch, administrator for the ACC PAH), told her who I was and asked if she would speak to me. I was looking for a collaborative experience and really hoped and wanted it to work with the cancer team here.”
Peterson got her wish when Lynch, along with Arthur Staddon, MD, director of the ACC PAH, asked her to develop a program for young adults with sarcoma. And Walkabout was born.
Now in its fourth year at the ACC PAH, the program originally developed for young adult sarcoma patients aged 18 to 38 is now open to all patients with any type of cancer at any stage of care. Partners are also welcome to participate. So far, 72 patients ranging in age from 18 to 80 have completed the program. Free to all participants, the program is currently funded by the Kelly D. Heflin Foundation.
The full Walkabout program, in classes of ten participants max, consists of a four-hour orientation session followed by eight weekly, two-and-a-half hour workshops. According to Peterson, it is a transformative journey that enables participants to look deep inside and deeper at the world around them. The program literally provides patients with a change of venue and transcends the clinical medical system by taking them outside and walking through one of Philadelphia's loveliest sections, Washington Square West.
"When we go out as a group, we're simply going out to be present and awake in the world, with cameras in tow, to see what touches us. We're not going out with the intention of going anywhere specific. There is no destination," said Peterson. "With their cameras, they get to focus on and see what they want. They can make their own choices and capture what they like, what they find beautiful, or even what upsets them. This helps with concentration and attention."
Walkabout combines four key approaches proven successful in decreasing distress from illness, anxiety, depression, fatigue and worried thinking. They include (1) engagement with peers; (2) mindfulness meditation skills training to be more attentive and aware and less reactive to challenging events in daily life, with increased vitality and greater ease of mind; (3) physical activity, including mindful walkabouts with a camera; and (4) expressive therapy using digital photography, art materials and collage to explore the present and imagine a meaningful future.
Participants need not have any experience with photography or art to benefit from the program. "Humans are inherently tool users and we all like to makes things," says Peterson. "Art therapy is a more productive, interaction experience than watching TV or siting at a computer. This program gets people together with their peers and outside to where they are the producers." Through Walkabout, cancer patients - so much at the mercy of their treatment and the effects of it - shift from a passive to active role and feel more capable and in control of their lives. "They are less 'of the disease' and more themselves," said Peterson.
Sarah Guy, who was diagnosed with ovarian cancer in March 2011, explains how the positive effects of Walkabout evolved over time for her:
Initially, I valued Walkabout as a respite from daily distractions and the on-going, high-stakes decisions and actions of cancer treatment. It was uninterrupted time for myself - time to get reacquainted with myself, to relax, to play. For those 2.5 hours each week, everything was taken care of. Caroline would greet us with a sincere, “How are you doing? So glad you are here.” Dinner was provided. Parking was paid for. And it was place to be with others who shared the values of mindfulness, who were on a similar journey, and who appreciated each other's journey.
As the program went on, I found myself dedicating more time to creative projects, and it was becoming more natural for me to observe my thoughts, feelings, and reactions with less judgment and with more trust and patience. As I continue my cancer treatments, I now feel better equipped to handle the stress and decision-making processes, and to use my ability, as Caroline informed us, to confront the lion.
Leslie Kase, who was diagnosed with breast cancer in March 2014, originally decided to give Walkabout a try since she enjoyed drawing, painting and crafts. "I figured it was a sure way to relax so I couldn't resist," said Kase.
"What I appreciated the most about the program was, as a group of participants, we were all sharing the same stress, but it was a place where we all put that to the side and shared a space of encouragement. The quiet of working on your own project, but with others, was very calming and positive for me," said Kase.
Participant feedback shows that Walkabout is physically energizing without being physically demanding. Kase, who is still in treatment, also found the program to be personally freeing. "I found I was able to do collages outside the box of my former constricts and need for symmetry. After several weeks, I did very different kinds of work, which was liberating but also good experience for confidence and self-esteem," said Kase. "It was a fun two and a half hours at the hospital every week - how often does a patient say that? - and you leave more relaxed and centered, with a feeling of being productive, which is not always the case during tiring treatments."
Peterson has so much gratitude toward Mary Pat, Dr. Staddon and the funders, who she says have given her the chance to develop this program and explore its potential as an actual clinical intervention in cancer care. “It was very forward-thinking of them, and I'm very lucky to be here,” she said.