We could separate patients into 4 patterns along the Uncertainty theory by Mishel (1988) and showed characteristic arts like tree drawings or free drawings. We showed the typical case in each pattern.

A client B was 50 years, female, and had breast cancer with lymph nodes metastases. In the first session, a tree in a tree drawing was so small and located upper in a paper. She did not draw ground, so her reality testing ability might be low. In the second session, a tree drawing was sticking out of the paper and it showed that she was hard to control her mood or emotion. However, the size of the trees was bigger ( Figure 1 ).

Patient C was 70 years male, and had colon cancer. He received chemotherapy for 2 years over his prognosis. He lived over two years much longer than life expectancy. He had purpose of living as much as longer to observe his grandchildren. He made collage art ( Figure 2 ). He expressed close families, a pleasant memory in supper with a friend, and pleasant trip. He talked about his life to the therapist.

Patient D was 50 years female, and had breast cancer recurrence. In the first session, she received the announcement of life expectancy. Her son who turned

20 years at this spring with mental disorder entered a group home. She decided the separation from parents and separation from children and said, “My role is over.” The crown was bigger than the trunk in tree drawing, and there were many fruits. In the free drawing, she drew the grid picture shedding tears with color pencils ( Figure 3 ). She said that I am glad to have my own time to draw. In the second session，each apple was big with strong pen pressure，it seemed that a belonging of each family member was determined.

Patient E was 60 years female and had colon cancer of Stage 4 metastasis.

In the first session, she talked about her children and grandchild who lived near her house, and she found her meaning of life for grandchildren. In free drawings, she drew seedlings of summer vegetables in her garden. In the second session, she received the announcement of stopping chemotherapy because of not effects of treatments and recommendation of palliative care by her physician. When the researcher met her, she was very shocked, however she agreed with making art. In free drawing, she drew sunflower and oleander which seemed to stretch out lacking flexibility losing future. In the third session, In the free drawing, she drew the seedlings of autumn or others. Fruits of grape pointed downwards, and it might suggest sense of loss ( Figure 4 ).

We showed the result of categorization of patients’ recognition of illness and copings ( Table 1 ).

We used < >for subcategory, and 【】 for category. We obtained the following categories:

【Various ways to receive the announcement】, 【Regret of delaying medication】, 【Confronting side effects or aftereffects】, 【The desire to fight with cancer】, 【Letting things drift】, 【Recognition of living the day】.

We could know the patients’ psychological state from their arts. There are some characteristics of arts. Ground in the tree drawing shows reality test ability in art therapy. Although some patients did not draw ground in the first session, they drew it in the second session. It may suggest an increase of reality test ability. Moreover, the size of tree drawings or free drawings was small in the first session, but it became bigger in the second session. It may also suggest increasing power or energy. The reason for these effects may be interaction between a patient, psychologist, and image. Forzoni et al. (2010) showed the utility of triadic relationship, patient-image-art therapist. In the present study, using the triadic relationship, the patient and the psychologist could narrate their emotion or thinking through his art. Also, Liao et al. (2024) showed the promotion of social interaction by art therapy for old people. Patients in the present study might be promoted to interaction with the therapist in art therapy.

Addition to this effect, there was a catharsis effect. The chemotherapy room was very limited space, nurses were very busy, but patients sometimes experience much suffering or nervous moment like stopping chemotherapy. In the present study, a patient drew a picture with colored pencil shedding tears. She seemed to accept her situation including a family role and find her future way ( Figure 3 ). She could express her emotions freely. Patients can express both consciousness and unconsciousness through art therapy, and it leads to catharsis of patients’ mind. This effect is supported by a previous study ( Kirshbaum et al., 2017 ). They argue that art therapy provides patients with cancer the opportunity for self-development and optimistic reflection on life.

Integrated social interaction between patients and therapist and catharsis effect, art therapy may reinforce patients’ resilience. It supports a previous study ( Tagliaferri et al., 2022 ).

There were four patters like a) Treatment continue, patients’ psychology calm (two patients), b) Living beyond the life expectancy and continuing treatment, psychology calm (two patients), c) Receiving the life expectancy announcement, psychology instability (three patients), d) Stopping chemotherapy, psychology confusing (two patients). The arts of pattern a) or pattern b) seem to be stable.

Particularly, the patients of the pattern a) or b) were psychologically calm, though the cancer stage was advanced. The patient in the pattern c) was a little instability and the patient of the pattern d) was very confused. We can understand patients’ psychological states through their arts. The formal disease state is very important, but separation by the Uncertainty theory is another useful for medical staffs and patients to understand the present state of mind.

Guan et al. (2021) showed the promising potential of uncertainty management intervention, especially interventions involving multiple components including informational, emotional, appraisal, and instrumental supports. Physicians or nurses can propose informational support ( Mori et al., 2019 ). Clinical psychologists may propose emotional support through art therapy.

We could separate 9 patients into 4 patterns. However, there may be s case who sometimes positive and sometimes negative and difficult to separate. We need to think about how to separate in the future for better understanding patients.

Stopping chemotherapy and transferring to palliative care sometimes makes patients feel disaster. However, Mishel said that patients change their sense of value and human growth humanistic growing, there may be positive aspects. Previous studies support of positive aspect. Morriss et al. (2022) said that it is important to find what makes patients change from uncertainly to certainly. In this study, patients’ coping suggests thinking of change. Categories such as “Confronting side effects or aftereffects”, “The desire to fight with cancer”, “Letting things drift”, “Recognition of living the day” may be thinking from uncertainty to certainty. The recognition of “the desire to fight with cancer” may be common among other countries. The concept of “letting things drift” is characteristic in Asian countries. Mindfulness-Based Stress Reduction (MBSR) was proposed by Kabat-Zinn which is based on Buddhism. Carlson (2016) showed the usefulness of mindfulness for cancer patients. Mindfulness helps patients to recognize the importance of accepting reality for problem solving. Although the coping idea of “letting things drift” is like Carlson, it seems to be much more to be idea of Buddhism. The idea in Buddhism suggests that suffering arises when people try to control things that are beyond their power to change ( Portal Site Nichirensyu, 2024 ).

Compare with other culture, Philippines use religious coping ( Ahmadi et al., 2024 ). They say that religious coping is prevalent in the Philippine. It is used during natural disasters such as typhoons or earthquakes; people often come together to pray for safety and protection. In times of personal struggle, Filipinos may turn to prayer and meditation as a way to find inner strength and peace ( Manalo et al., 2023 ).