Drawing cancer chronicles: A qualitative study to evaluate narrative meaning-making over time and in response to a meaning-centred care intervention

Abstract

The diagnosis of incurable cancer can disrupt life stories, undermining meaning-making and challenging self-identity. People may therefore need to search for and create new stories about their lives that incorporate their diagnosis. Arts-based narrative interventions are being explored to support this existential process of narrative meaning-making. However, developing effective existential support may be limited by the lack of methods capable of investigating their impact. This study is the first to explore narrative meaning-making across time and a meaning-centred care intervention by longitudinally using 'Rich Pictures' (RPs) - hand-drawn visual narratives. We analysed repeated RPs about living with incurable cancer from thirty-eight participants in two studies: one incorporating an arts-based narrative intervention, and one without. RPs were compared across time and the two groups using an inductive, multi-level, and participatory analysis approach. Our findings highlighted six strategies variably used by participants to reconstruct their narratives over time: repeating, retaining, repurposing, reinforcing, reducing, and reassembling. Differences were found in the employment of these strategies between the two different studies, with arts-based intervention participants predominantly developing new ways of narrating and relating to cancer as a disruptive life event. We conclude that people living with incurable cancer employ a range of strategies in reconstructing their narratives. Arts-based interventions may support this existential process. The repeated use of RPs is a valuable method for investigating narrative meaning-making over time, across groups, and interventions, offering insights to evaluate and develop meaning-centred care in oncology.

Fig 1. Drawing repeated Rich Pictures in the ISOS and NI studies.

This figure depicts the overall processes for RP creation within the two ISOS and NI studies, and their relative convergences and divergences. The stepwise process shown on the inner-left of the figure depicts the ISOS intervention trajectory and the sequence of its modalities. The two-step process shown on the inner-right depicts the NI study trajectory and its two-month interval, without further intervention. Points at which RP1 and RP2 creation occurred within these trajectories are shown in bold. The dashed box in the centre of the figure, connecting all ISOS and NI RPs, highlights all convergences between and within the two study designs for drawing RPs. Dashed boxes on the outer-left and -right highlight divergences between the ISOS and NI study designs for RP drawing. Within these, dashed boxes on the outer-left, and positioned vertically at the top and bottom, indicate project-specific divergences between ISOS RP1 and ISOS RP2 drawing. Dashed boxes on both the outer-left and -right, and positioned central-vertically, highlight convergences between project-specific RP drawing, but divergences across the two projects.

Fig 2. Rich Pictures exemplifying the strategies of repeating, retaining, and repurposing.

(A) NI P13’s RP exemplifying the strategy of repeating. RP1 depicts a singular scene of travelling in-between the hospital – a common visualisation of transition and being ‘in-between’ in the RPs. By repeating this RP1, NI P13 may narrate the ongoing experience of being durationally suspended in transition. (B) ISOS P13’s RP1 and RP2 exemplifying the strategy of retention in relation to meaningful everyday activities. This can be seen in the re-use of the piano drawn in RP1 in RP2. (C) ISOS P3’s RP1 and RP2 exemplifying the strategy of repurposing in relation to the use of nature. This can be seen as nature shifts from a metaphor of disruption (e.g., being struck by lightning) to flow (e.g., depictions of flows of water or sunrays).

Fig 3. Rich Pictures exemplifying the strategies of reinforcing and reducing.

(A) ISOS P5’s RPs exemplifying the strategy of reinforcing in relation to positive metaphors of nature. This can be seen as the tree and sun depicted in RP1 are increased size, foregrounded and made central, and depicted with bolder colour and changed drawing style in RP2. (B) ISOS P15’s RPs exemplifying the complementarity of reducing and reinforcing in relation to social relations. This can be seen as the surrounding yellow sphere in RP1 becomes smaller in RP2, proximity to self becomes closer, and connections between people are made explicit (see now the connecting lines and hands in RP2 which were not present in RP1). (C) ISOS P26’s RPs exemplifying the strategy of reduction.* This can be seen in relation to, for example, medical and somatic aspects, as depictions of treatment and death in RP1, are no longer depicted in RP2. All other disruptions depicted in RP1 (e.g., lightning strikes, bombs, barriers) are also removed in RP2, and the narrative is refined to reduced aspects. Please note that these RPs also serve as an example of the strategy of reassembling. * These RPs, without amendments indicating strategies, were published before under the terms of the Creative Commons Attribution License (CC BY 4.0) [26].

Fig 4. Rich Pictures exemplifying the strategy of reassembly.

(A) ISOS P26’s RPs exemplifying the strategy of reassembling at the level of a RP scene. * This can be seen in the central scene of both RP1 and RP2 depicting ISOS P26 receiving a phone call about their diagnosis. Here, ISOS P26 repositions themselves from facing away in RP1, to facing forward in RP2. (B) ISOS P1’s RPs exemplifying the strategy of reassembling at the level of the whole RP. This can be seen as the scattered and largely disconnected components of RP1 are re-ordered in RP2 to have more compositional linearity and progression (see the linear formation of components within the centre of the RP, reading from left to right), and are framed as/by depictions of flow (see clouds above and flows of water or wind below). * These RPs, without amendments indicating strategies, were published before under the terms of the Creative Commons Attribution License (CC BY 4.0) [26].