زنان مبتلا به سرطان پستان و محدودیت جنسیتی و مرزها: هنر درمانی به عنوان یک فضای امن برای تصویب موضوع مورد جایگزین

This article takes its starting point from certain results from our randomized study on art therapy with women with breast cancer. Previous results from this study showed significant benefits on coping, quality of life, and symptoms for women who participated in an art therapy intervention. Analyses of interviews and diaries showed that especially women from the intervention group had distanced themselves from traditionally gendered understandings about cultural limits and boundaries. The aim of this study was to gain further knowledge about how women with breast cancer who participated in the art therapy intervention gave meaning to the gendered limits and boundaries in their daily lives, and to trace their trajectories, in therapy, towards helpful management of restraining boundaries. When analyzing the women's verbal reflections on the therapy sessions, we discerned five subject positions, defining them as follows: being someone who reacts to violation attempts; actively connecting body and self; actively locating oneself and moving forward; being in a position to see important connections throughout life; and being able to acknowledge and harbour conflicting emotions. The results of the study suggest that art therapy served as a tool that helped the women to get access to subject positions that enabled them to protect and strengthen their boundaries. This involved challenging dominating discourses and reacting against perceived boundary violations. Art therapy offered a personal, physical, and pictorial “safe space” with opportunities to deal with complex existential experiences and issues, and also make important connections throughout life. Looking back and summarizing important experiences acted as a way to prepare oneself for the future and moving forward.

Art therapy has been found to be helpful for patients with cancer to reduce fatigue and depressive symptoms (Bar-Sela, Atid, Danos, Gabay, & Epelbaum, 2007), and research on art therapy for women with breast cancer has shown to facilitate expression, provide opportunities to work through difficult experiences, reduce stress, and help in creating meaning (Borgmann, 2002; Collie & Long, 2005; Predeger, 1996). Art therapy has also been found to help women with breast cancer to give legitimacy to their own experiences and interpretations (Öster, Magnusson, Egberg Thyme, Lindh, & Åström, 2007). This article takes its starting point from certain results from our randomized study on art therapy with women with breast cancer. Previous results from this study showed significant benefits on coping resources (Öster et al., 2006), significantly lower ratings of depression, anxiety, somatic symptoms and general symptoms (Egberg Thyme et al., 2009), and significant increase in quality of life aspects (Svensk et al., 2008) for women who participated in an art therapy intervention; the intervention consisted of five individual sessions concurrent with the 5 weeks of radiotherapy, and the results were compared to a control group. Analyses of interviews and diaries showed that especially women from the intervention group had distanced themselves from traditionally gendered understandings about cultural limits and boundaries that give women less space and boundary protection. These women had increased their access to ideas and practices that made it legitimate to protect their boundaries against demands from people around them. A majority of the women in the study spontaneously brought up problems of gendered limits and boundaries. We therefore suggest that gendered limits and boundaries are central life themes for women with breast cancer (Öster et al., 2007). We assumed that a closer analysis of the interviews, diaries and art therapy processes of the women who participated in art therapy would enable deeper understandings of patterns of gendered limits and boundaries, and of ways to perceived helpful boundary management. This article aims to provide such analyses. By “boundary management” we here mean individual processes where gendered limits and boundaries are identified, reflected upon, and managed in different ways. Boundary management is a part of an individual's everyday life and social negotiations and boundary management processes can be perceived as more or less helpful and constructive. In analysing the interviews and diaries of the women in the intervention group, as well as referring to the field notes of the therapists, we used the concepts of “gendered limits and boundaries” as developed by the American psychologist Ellyn Kaschak (1992). Limits define the range of possibilities for a person to develop and explore her/his life-world. As a consequence of historical, social, and legal rights, men in general still occupy more physical and psychological space than women in society. Men's limits are often easily expanded, while women's limits are more firmly set and difficult to extend. Boundaries concern how much space for one's own and others’ needs are allowed in people's everyday lives and how easy it is to protect one's own needs and interests. Women's boundaries are generally weaker and more permeable than those of men: they are often defined by others and adjusted to people close to them. Violations of boundaries can be physical, psychological, and symbolic ( Kaschak, 1992). For example, women's main responsibility for household and emotional work within families is embedded in culturally dominant expected behaviour for women ( Magnusson, 1997 and Magnusson, 2006; Seymour-Smith & Wetherell, 2006; Strazdins & Broom, 2004). Women with breast cancer are confronted with intersecting social and cultural discourses surrounding the diagnosis, as well as issues of femininity, masculinity, ethnicity, sexuality, agency, and age (cf. Thorne & Murray, 2000; Wilkinson & Kitzinger, 2000). In constructing their own meaning and health repertoires women with breast cancer use available knowledge mediated by biomedical discourses, cultural metaphors, and discourses about illness and health within complementary and alternative medicine, as well as their own earlier and present experiences. This is often a process full of contradictions (cf. Winroth, 2004). The complexity of women's experiences and the disparate consequences for their life situations when diagnosed with breast cancer have been reported by a number of authors (e.g. Arman, Rehnsfeldt, Lindholm, Hamrin, & Eriksson, 2004; Arman, Backman, Carlsson, & Hamrin, 2006; Bassett-Smith, 2001; Broom, 2001; Langellier, 2001; Langellier & Sullivan, 1998; Manderson, 1999, Thomas-MacLean, 2004 and Thomas-MacLean, 2005). We assume boundary management to be a particularly salient concern for women with breast cancer. Cancer brings about bodily invasions and boundary violations and can be experienced as a condition of siege with specific regard to gendered limits, boundaries and gendered symbolism related to the body and the disease (Solheim, 2001). The body bears traces after operation, chemotherapy, and radiotherapy, which are constant physical reminders of the body out of control. Breast cancer both removes from the body (by surgery) and adds to it (by wigs, prostheses, and sometimes breast reconstruction). These removals and additions have different social and cultural connotations (Manderson, 1999). They raise issues of body image, normality, corporality, sexuality, and gender identity as well as boundary violation and the need for boundary management. Building on our previous published results, we further assume that boundary management can be facilitated by art therapy. Art therapy offers a space for expressing, reacting, and constructing and reconstructing stories of life experiences (Hogan, 2003 and Malchiodi, 1997; Waller & Sibbett, 2005). The picture can be seen as a micro-world where experiences, thoughts, and feelings can be expressed, explored and changed (Betensky, 1995). Art therapy contains boundary-defining activities such as respecting and encouraging constructive boundary management. The image maker's preferential right of interpretation is a cornerstone of art therapy and is an example of the respect for boundaries characteristic of art therapy (Hogan, 2003). Art therapy offers possibilities to make choices where existing limits can be challenged. In art therapy taken-for-granted truths and power-relations can be challenged through ways of imaging, seeing, and picture-making. Boundary management can be explored in image-making where new discoveries can often be made in the actual creative act. In order to create a safe place for these explorations, the art therapist has a containing function that includes setting explicit boundaries for the frames of each session. The image-making process is as important as the completed picture itself. Making pictures is about creating one's own knowledge—often in new ways. When experiences, emotions, and thoughts are given colour and shape, knowledge is made visible and may become easier to communicate. The picture's function is to expand limits through a process where the image-maker is given the opportunity to change her position from being the creator to being the spectator while reflecting on her own image(s). This process allows her to act from different positions as both sender and receiver of her own messages as mediated through the pictures (cf. Betensky, 1995; Waller & Sibbett, 2005). In our analysis we were mainly inspired by discursive psychology and the analytic concept of subject position, as developed by Edley (2001), Seymour-Smith and Wetherell (2006), and Magnusson (2006). Subject position is a relational concept. With culturally available interpretative repertoires or “mini-discourses” as powerful backgrounds, subject positions can be seen as “locations” within conversations when creating different identities (Edley, 2001; Seymour-Smith & Wetherell, 2006). In different specific situations people perceive different subject positions as being more available than others to choose among in order to appear trustworthy (Magnusson, 2006). With a discursive psychological approach it is possible to study what people are able to accomplish through accessing particular subject positions within local contexts. The availability of these positions can then give information about the broader ideological/discursive context. Subjectivity can be seen as an ideological effect, when people are constructed as “subjects” being positioned and positioning themselves within discourses (Edley, 2001). Nevertheless, within medical institutions, with their dominant biomedical discourse and hierarchy of power, patients often feel positioned as “objects” (cf. Mishler, 2005). Due to historical, cultural, and social discourses around, e.g. breasts, femininity, cancer patientness, and expert knowledge, women with breast cancer have encountered limitations on available subject positions when renegotiating identity after operations and treatments (Broom, 2001; Wilkinson & Kitzinger, 1993; Wilkinson & Kitzinger, 1994). Visual narratives can offer alternative subject positions in these negotiations (cf. Mishler, 2005 and Spence, 1986). Art therapy is built on interpretative repertoires/discourses which make possible a range of alternative subject positions in relation to one's own body, emotions, and boundary management.

Breast cancer brings about non-negotiable changes of the body and life-situation. When having been diagnosed with cancer the telling of one's own story can act as a tool for making sense of life and identity where the disease and illness is one part in that story (Mathieson & Stam, 1995). Visual narratives of experiences can challenge medical stories and can offer resistance to privileged understandings of breast cancer as well as new ways for constructing identity (cf. Langellier, 2001, Malchiodi, 1997 and Mishler, 2005). Our study showed that art therapy helped women to get access to subject positions that enabled them to protect and strengthen their boundaries through giving legitimacy to their own experiences and interpretations. This involved challenging dominating discourses and reacting against perceived boundary violations. Other researchers have shown that when women have been diagnosed and treated for breast cancer, their experiences of suffering related to health care are often made invisible and are rarely able to be verbalized. Experiences which can cause suffering are often related to violated boundaries and being positioned as bodies, numbers, or diagnoses (Arman et al., 2004). In our art therapy intervention the women gave examples of reaching constructive and helpful boundary management even after encountering such violations. Through the different subject positions made available the women were able to question and deconstruct other people's right to interpret their experiences. They were thus also able to reconstruct self, body, and meaning in their various situations. In art therapy, the act of creating pictures is a concrete and kinaesthetic experience. A picture such as the body outline can act as a container for painful experiences. To paint is to be active and to be in a position of having some control. The pictures can act as symbolic bridges between body and consciousness, and between reason and emotions (Englund, 2004). Art therapy offered a personal, physical, and pictorial safe space with opportunities to deal with complex existential experiences and issues, and also make important connections throughout life (cf. Malchiodi, 1997; Waller & Sibbett, 2005). Looking back and summarizing important experiences acted as a way to prepare oneself for the future and move forward.