3D PRINTING & MEDICAL ART THERAPY

Three-Dimensional Printing and Medical Art Therapy in Oncology

Ashley M. Engler
Department of Counseling
Pennsylvania Western University
Art Therapy Research
Summer, 2024

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Table of Contents
Abstract...........................................................................................................................................4
Section I: Introduction....................................................................................................................5
Problem to be Investigated.................................................................................................5
Purpose Statement...............................................................................................................6
Justification.........................................................................................................................6
Terms Related to this Study................................................................................................8
Section II: Literature Review.........................................................................................................11
Medical Art Therapy..........................................................................................................11
Use of Technology and Digital Media in Art Therapy......................................................12
Digital Media and the Expressive Therapies Continuum..................................................14
Three-Dimensional Printing Technology..........................................................................15
In Medicine and Oncology................................................................................................16
Applications in Mental Health..........................................................................................18
Transitional Objects..........................................................................................................18
In Bereavement..................................................................................................................19
In Emotional Processing...................................................................................................20
Ethical Considerations.......................................................................................................21
Section III: Methodology...............................................................................................................24
Target Audience.................................................................................................................24
Program Structure..............................................................................................................24
Environment and Equipment.............................................................................................25
Program Outline.................................................................................................................26

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Section IV: Resource Guide..........................................................................................................32
Section V: Discussion...................................................................................................................33
Summary of Research........................................................................................................33
Discussion..........................................................................................................................34
Limitations.........................................................................................................................35
Suggestions for Future Research.......................................................................................37
References.....................................................................................................................................39
Appendix........................................................................................................................................46

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Abstract
A cancer diagnosis can be a deeply disruptive experience that has lasting physical and
psychosocial consequences. At all stages of treatment and survivorship, art therapy can be a
beneficial holistic mental health service that can mitigate the long-term psychological risks for
cancer patients. However, there are severe environmental limitations to accessibility of services
in many oncology settings, including physical isolation, presence of medical machinery, small
spaces, or time restrictions. In the overtly sterile environments of hospitals and clinics dedicated
to cancer care, medical art therapists are challenged to creatively innovate tools and methods of
their practice to ensure patient safety, equitable access to services, and provision of meaningful
and effective intervention tools. Contemporary practice in art therapy has overall reflected a
moderate shift toward digital media and technology-based intervention tools such as tablets,
photography, or virtual reality. Unifying the benefits of three-dimensional (3D) printing
observed in surgical-medicine literature with the reported best practices of medical art therapy in
oncology, this research explores clinical use of digital media and proposes the utilization of 3D
printing for art therapists working in hospital settings. The proposed resource guide included is
based on transitional object theory and uses a dialectical approach to narrative therapy to provide
cancer patients with opportunities to tell their stories, process feelings, reconceptualize life
events, and find profound, meaningful resolutions.

Keywords: Art Therapy, Oncology, 3D Printing, Transitional Objects, Narrative
Therapy, Dialectical Therapy

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Section I: Introduction
The psychological impact of cancer diagnosis, treatment, and survivorship can be
deepened by the challenges faced by the medical environment, including social isolation,
traumatic medical experiences, and threat of infection (Devine, et al., 2018; Nainis, 2011). The
imposition of limitations on accessing holistic services presents a barrier to patients’ accessibility
to the critical support needed to mitigate the immediate risks and long-term effects of these
psychosocial burdens, and mental health professionals working in these settings are challenged
to innovate ways of providing services. Medical art therapy is a holistic and integrative
intervention modality for effective psychosocial care in hospital settings (Nainis, 2011). This
research explores the nuanced practices of medical art therapy and ways that the “art therapist’s
toolbox” can be expanded in oncology care. Specifically, 3D printing is proposed as another tool
for medical art therapists to bypass accessibility challenges in hospital settings and provide
meaningful, safe, and effective psychosocial support to cancer survivors.
Problem to be Investigated
Cancer patients can experience a variety of disease-related stressors that disrupt
normative functioning and impact overall quality of life at all stages of treatment and
survivorship (Currin-McCulloch, Kaushik, & Jones, 2021; Devine, et al., 2018; Wang & Feng,
2022). Growing research suggests that art therapy is an effective tool for mitigating the
psychosocial risks of disease, hospitalization, treatment, and bereavement for oncology patients,
caregivers, and communities. In medical settings like hospitals, there are heightened barriers to
the use of traditional art therapy media and materials, resulting in a modern trend toward
innovative digital and technology-based interventions. Inspired by the psychosocial benefits of
providing patients with access to 3D printing in surgical contexts, there is arguably therapeutic

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potential to the use of 3D printing as a tool for medical art therapy with cancer survivors in
hospital settings. Currently, there is minimal research on the efficacious use of 3D printing in art
therapy.
Purpose Statement
The purpose of this research is to identify existing use of digital media in art therapy, best
practices for medical art therapy in oncology, and to inform a proposal for 3D printing in art
therapy with cancer patients.
Justification
In 2016, a video surfaced online that featured a ten-year-old boy celebrating the
completion of cancer treatment by smashing a three-dimensional-printed replica of his tumor,
“Boris". Casey Doyle was treated at the University of Michigan’s C.S. Mott Children’s Hospital,
where his doctors collaborated with biomedical engineers to re-create the synovial cell sarcoma
mass previously residing in his throat. Casey explained that he nicknamed his tumor “Boris,” to
ease medical conversations with his caregivers, later personifying Boris as “evil” and “in need of
bashing” (Michigan Medicine, 2016). “Bashing Boris” was a ceremonious occasion that not only
marked the end of Casey’s weekly chemotherapy appointments, but also served as an important
symbol of empowerment in the triumph of overcoming a life-threatening illness. Observing
Casey’s story through the lens of art therapy poses some unique and intriguing possibilities for
3D printing technology in medical art therapy with cancer survivors.
According to the American Cancer Society, cancer is the second-leading cause of death
in the United States (Siegel, 2024). Cancer diagnoses and treatment, especially during the
formative years of life, can cause disruptions in achieving normative life milestones and have
lasting mental and physical health consequences affecting overall quality of life (Devine, et al.,

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2018; Greup, et al., 2018). Minimizing these risks involves the provision of psychosocial
interventions focused on emotional processing (Czamanski-Cohen, et al., 2020),
psychoeducation & coping skills (Councill, 1993), reducing social isolation, promoting meaningmaking, and providing patients with holistic resources (Greup, et al., 2018). It is estimated that
cancer survivors are 55% more likely to commit suicide than the general population, and 58% of
cancer survivors believe that their physical health is prioritized over their psychological
wellbeing (Transformation Partners in Health and Care, 2024).
Meeting the psychosocial needs of cancer patients in clinical settings can be challenging
because of the barriers of the medical environment and limitations to access of services. Because
the risk of disease transmission can have life-threatening consequences for patients receiving
immunocompromising medical treatments, hospitals often have strict social isolation protocols
and limit access to items or materials that cannot be sanitized thoroughly. To bypass some of
these barriers, technology-based delivery methods for services have emerged in recent years,
including mental health-related apps, online groups (including social-media-based), and digital
sensory experiences. While mental health practitioners have shown interest in these tools as
supplemental aids to traditional talk therapies, rigorous empirical research on their efficacy
remains limited (Lehtimaki, et al., 2021).
Balancing the core job of providing psychosocial support with navigating the restrictive
medical environment is a unique challenge for art therapists working in oncology treatment
centers. Traditional art media and materials like chalk pastels or sculpting tools may not be
welcomed in cancer hospital environments due to safety risks to medically fragile patients.
Therefore, art therapists have the added responsibility of creatively innovating methods for

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bridging the accessibility gaps to meaningful psychosocial care in these settings, including the
use of digital media and technology.
Terms Related to the Study
For this research, the following terms are used.
3D Printing
An additive manufacturing process whereby a three-dimensional (3D) object is created
from a digital 3D model produced using CAD software.
Active Treatment
The period in which a patient is having radiation, receiving chemotherapy, undergoing
surgery, or other treatment to cure, stop, or slow the progression of cancer and related disease.
Adaptive Tools
Modifying equipment that aids individuals in the use of daily items, typically in response
to a disruption in normative motor functioning. These additive adjustments are tailored to the
unique needs of the individual and provide opportunities for mastery and control when
conducting a task.
CAD
Computer-Aided Design software used to create, modify, optimize, or analyze digital 3D
models.
Digital Art Therapy
Technology-based art therapy methods and materials including digital collage,
photography, film, digital photo/film editing, animation, digital drawing/sculpting,
virtual/augmented reality, digital storytelling, social media, light painting, mobile apps, or
artificial intelligence.

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Materials/Media
Anything used to create artwork or provide engagement with the creative process. In art
therapy, media and materials refer to the physical intermediaries between a person’s inner and
external worlds.
Medical Art Therapy
A type of art therapy practice based in medical (hospitals, clinics, etc.) settings that
provides people with medical illness opportunities to express their emotions, process
experiences, aid in grief/bereavement, provide family support, and reduce a range of physical
symptoms related to medical illness.
Remission
A period in which the cancer responds to treatment and is under control. This does not
mean that the cancer is completely gone, or the person is cured; rather, it has stopped progressing
and symptoms have minimized or gone away completely.
Survivor/Survivorship
Anyone who has been diagnosed with cancer, no matter where they are in their cancer
journey, is considered a cancer survivor. The American Cancer Society believes that “each
person has the right to define their own experience with cancer and considers a cancer survivor
to be anyone who describes themselves this way, from diagnosis throughout the rest of their life”
(2024).
Conclusion
The landscape of digital and technology-based interventions in art therapy is
continuously evolving as clinicians embrace the use of advanced digital media simulation, haptic
tools, recording, augmented & virtual reality, and three-dimensional printing. In hospital settings,

3D PRINTING & MEDICAL ART THERAPY
it is critical for medical art therapists to embrace innovative media and materials as adjunct
intervention modalities to bridge accessibility gaps in psychosocial care for oncology patients.
The purpose of this research is to intersect the benefits of 3D printing in medicine and medical
art therapy to suggest an innovative approach to psychosocial care for cancer survivors in
hospital environments. The following literature review explores digital media and materials in
medical art therapy, current trends of 3D printing in medicine, and art therapy theories.

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Section II: Literature Review
This literature review discusses definitions and applications of 3D printing technology,
art therapy, technology-based mental health interventions, and applications for art therapists in
medical settings. The goal of this review is to explore the implications for the use of 3D printing
in medical art therapy for cancer survivors.
Medical Art Therapy
Overview
Medical art therapy is an integrative approach to supporting the psychosocial needs of
patients and families experiencing a range of health-related issues. Non-pediatric medical art
therapy literature largely focuses on adults with cancer diagnoses and emphasizes use of art
therapy to support emotional expression & meaning making, offer a sense of control &
empowerment, provide opportunities for normalization, offer potential symptom relief, develop
coping skills, and address existential concerns (Kinney & Mueller, 2018). Potash (2018) expands
upon this, suggesting that medical art therapists are integrated into the interdisciplinary care
team, and assume niche additions to their traditional roles as clinical mental health professionals,
which might include communicating with interdisciplinary teams, coordinating patient care,
promoting effective prevention/treatment practices, advocating for best practices, innovating art
therapy delivery methods, and ensuring patient safety. Medical art therapy with oncology
patients is an even more refined niche of art therapy practice that emphasizes trauma-informed
interventions structured around creating a sense of safety, addressing psychosomatic symptoms,
providing opportunities for choice and control, and building resilience (Czamanski-Cohen &
Weihs, 2016), as well as specialized insight to media and materials, and delivery of clinical
mental health services (Nainis, 2008).

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In medical settings like hospitals or clinics, art therapists are faced with a variety of
barriers to traditional art media because of stringent rules regarding infection control, patient
safety, and scheduling/space restraints. In addressing the unique challenges of oncology medical
settings, Nainis (2008) noted that cancer patients are critically vulnerable to environmental risks
due to immuno-compromising medications, sensitivity to external stimuli, and susceptibility to
non-coagulation (also known as “bleed risk”). The author explains that art therapists must be
mindful of the types of media provided to cancer patients, so as not to impose further harm. For
example, the author noted that art therapists should avoid particularly fragrant materials because
cancer patients can be extremely sensitive to smells, as they might cause headaches or nausea
(p.116). Art therapists must use professional discretion to discern appropriate materials and
methods for providing services in these highly sensitive environments.
Use of Technology and Digital Media in Art Therapy
Perhaps the most prevalent use of technology in clinical mental health is that of creative
arts therapists, who engage in use of digital tools for interventions including (but certainly not
limited to) consumption of art, video, or music, sound editing and digital music-making,
photography and image editing, digital artmaking, digital filmmaking, virtual reality, online
content-sharing, and digital storytelling/creative writing. Digital artmaking, for example, offers
useful features for real-time collaboration between client and therapist and is ideal for situations
in which there are restrictions to workspace or limitations to physical material use, including
availability or personal discomfort with tactile/sensory qualities (Scala, 2023). The use of
technology in art therapy practice is relatively new in the history of art therapy methods and
materials. Digital art therapy has historically been defined as “all forms of technology-based
media, including digital collage, illustrations, films, and photography that are used by therapists

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to assist clients in creating art as part of the process of therapy” (Malchiodi, 2011, p.33). The
field of art therapy is challenged to meet the rapid evolution of technology-based art media that
has become more sophisticated and is increasingly more accessible to everyday consumers. The
existing definition of digital art therapy can be expanded to include things like mobile apps,
image/film editing software, animation, virtual reality, light painting, social media, digital
storytelling, and artificial intelligence (Malchiodi & Huet, 2018).
In a 2012, review of survey data collected in 2004 and 2011, Dr. Penny Orr looked at the
evolution of art therapists’ understanding and use of digital media over time, and how that
evolution compares to the pacing of the general population. Orr (2012) observed that, over the
seven-year period, art therapists are overall increasing their knowledge and use of technologies
in their everyday lives at the same rates as the general public but are still slow to integrate
technology use in clinical practice overall. Themes emerging from the two survey data sets
highlighted a need for more digital media education and training for art therapists, particularly
regarding ethics and safety, as well as questions about the therapeutic value of technology-based
tools and interventions (Orr, 2012). The outcomes of this study emphasize a dichotomy of risks
and benefits that art therapists encounter when considering the use of technology-based
interventions.
For practitioners interested in using 3D printing technology in art therapy, many
accessibility factors must be considered, including time and cost investments. Private consumer
model 3D printers typically come with accompanying CAD software that can function on
everyday computers and laptops, but still pose a high cost for the printer machinery, filaments,
and other start-up materials such as external digital storage devices. Further, learning to use the
software and addressing troubleshooting throughout the design and printing processes requires a

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considerable amount of time. For many art therapy graduate programs, digital media and
technology are not part of the core art therapy curriculum, nor are digital media studio courses
where students might gain exposure to- or experience with novel technologies like 3D printing.
Individuals seeking to learn more about these technologies might seek out continuing education
opportunities, training, or other resources beyond their core education, which can require
considerable time and financial commitments.
Digital Media and the Expressive Therapies Continuum
Contemporary discussion about the use of digital technology in art therapy has centered
around what constitutes meaningful artmaking (Thong, 2007), the benefits and drawbacks of
using technology as media (Hinz, 2020), and the triatic relationship between therapist, client, and
artwork (Gussak & Rosal, 2016). To summarize this discourse, a major challenge for integrating
technology into art therapy practice is aligning digital tools with the accepted foundational
theories, pedagogy, and methodology of art therapy practice; including, for example, the
Expressive Therapies Continuum.
The Expressive Therapies Continuum (ETC) organizes the spectrum of haptic and
cognitive levels of engagement with art media and serves as a framework for guiding clinical
decisions in expressive arts therapies at four levels: sensory/kinesthetic, perceptual/affective,
cognitive/symbolic, and creative. Art therapists use the ETC to assess imbalances in clients’
wellbeing and map out a course for treatment using media and materials that reflect the clients’
strengths, weaknesses, readiness for change, and level of introspective conceptualization. Digital
media might be criticized for being impersonal and lacking sensory and tactile experiences that
align with physical media, despite advances in artificial haptic devices and assistive technologies
that make art-making more accessible to those with disabilities.

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In Expressive Therapies Continuum: A framework for using art in therapy (2020), Lisa
Hinz argues that technology used in art therapy is advantageous when clients are unwilling to
engage with the messiness of physical media, experience anxiety around the art-making process,
or are thought to benefit from multi-sensory experiences. In one example, Hinz discusses the
benefits of using illustration apps and pressure-sensitive styluses to minimize the negative
feelings that might discourage clients from engaging in traditional artmaking. Skill-related
anxiety can be mitigated by familiar technologies, such as tablets or smartphones, as well as
integration of software that corrects mistakes or produces images easily (Hinz, 2020, p.35). In
this way, the underlying media properties of restrictiveness, boundaries, and
alternativeness/novelty become therapeutic, as the client is offered a cognitive experience, which
is accompanied by confidence derived from having a sense of control. Hinz (2020) concludes
that, “As more media options are added to the art therapy arsenal, the Expressive Therapies
Continuum model offers a theory to recognize that numerous features of the media properties, art
experience, and finished product can aid healing” (p.37).
Three-Dimensional Printing Technology
Overview
Three-dimensional (3D) printing is an additive process wherein a 3D object is created
from a digital model by layering materials such as plastics, biodegradable filaments, polymers,
metals, organic media like ceramics, or even biological matter. Manufacturing begins with a 3D
blueprint using computer-assisted design (CAD) software. Akin to a hot glue gun, the 3D printer
uses a heating element to soften material that is extruded in successive layers. Based on the CAD
software specifications, the printed item is constructed in successive layers, then allowed time
for the material to cool, dry, and harden. Depending on a number of factors such as design

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complexity, material type, or size, print time can vary from minutes to days. The type of 3D
printer and the materials used to print depend on a variety of factors, including scale/size of
project, intended use of printed object, setting (industrial, commercial, or private), and cost
investment. Advancements in 3D printing technologies have broadened the spectrum of possible
uses, from high school students creating plastic robots to full-scale homes printed using cement
or biomedical engineers printing working organs using biological material (US Department of
Energy, 2014).
Three-Dimensional Printing in Medicine and Oncology
According to the World Health Organization’s International Clinical Trial Registry
Platform, there have been 158 clinical trials in oncology that feature the use of 3D printing
technology between 2015 and 2024 (WHO, 2024). 3D printing can be used for personalized
preoperative treatment, custom surgical protheses, personalized drugs, custom synthetic organs,
patient education, and the refinement of medical education (Aimar, Palermo, & Innocenti, 2019).
Though there have been many ways that 3D printing has been explored in medicine, its use in
oncology, specifically, has largely been understudied. In a 2021 comprehensive review on the
literature surrounding 3D printing in oncology medicine, Li, et al. discuss the unique ways in
which 3D printing has revolutionized oncology medicine, including 3D printed apparatuses for
drug administrations (such as portacaths), post-tumor surgery prosthetics, bioprinting of cell
models for education and case conceptualization, and patient-specific devices used in osteorepair (bone reconstruction). Importantly, the authors found that a major limitation to 3D printing
in oncology relates to the quality and safety standards established by the FDA for general
population patients. Because cancer patients are largely immuno-compromised, the
biocompatibility standards for human consumption must be more rigorously tested to minimize

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risks of infection, monomer leaching, or degradation of materials because of medical
intervention such as chemotherapy or radiation (Li, et al., 2021).
Non-consumable uses for 3D printing in oncology largely focus on patient education and
decision-making. In one example, Wake, et al. (2019) looked into the use of three-dimensional
pre-operative models for patient education by surveying 200 adult renal and prostate cancer
patients receiving surgical interventions. All 200 participants reviewed their disease and surgical
plans with their doctors using magnetic-resonance imaging (MRI) images. 127 of the participants
reviewed the MRI images plus a three-dimensional pre-operative model, which was either 3D
printed, visualized in augmented reality (AR), or viewed in 3D on a computer monitor. The team
found that patients who received 3D printed models better conceptualized their disease, had
greater understanding of their surgical procedures, and were more comfortable with their overall
treatment plans (Wake, et al., 2019). Because the nuances of cancer present unique challenges
across patient populations, oncologists and treatment teams are challenged to provide tailored
intervention strategies that not only support favorable health outcomes, but also reflect the
agency patients hold in their medical decision-making. In a 2021 study evaluating the
relationship between 3D printed tumor models and decision-making conflict in breast cancer
survivors, Santiago, et al. found that patients reported higher rates of assurance in their treatment
choices when provided with visual tools. The authors suggest that 3D printed models were
successful in minimizing decision-making conflict because of the ways that visual and sensory
information bypasses the barriers of language or education level (Santiago, et al., 2021). A major
limitation to both studies is small sample size and narrow population diversity, though the
implications for further research are encouraging. Larger-scale studies could validate the efficacy
of 3D printed models for oncology patient education and decision-making.

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Three-Dimensional Printing Applications in Mental Health
Despite the reported positive effects 3D printing technology has on patient satisfaction,
agency, and health outcomes in medical literature, there is a notable lack of reporting on its use
in tangential healthcare fields like rehabilitation and mental health. Adaptive tools are perhaps
the most widely discussed applications for 3D printing in non-surgical healthcare literature
(Schwartz, et al., 2018), but there is little existing evidence to support its efficacy in diverse
contexts. Based on anecdotal reports on the use of 3D printing in mental healthcare, there
presents a unique opportunity for researchers to explore its utility in art therapy; specifically, as it
relates to the spectrum of artmaking processes and products in medical art therapy.
Transitional Objects
In art therapy, transitional objects can be defined as tangible objects, such as artmaking
media and artwork, that hold therapeutic value or personal meaning. Winnicott (1971) used the
term ‘transitional object’ (TO) to describe an object that is external to oneself but embodies a
symbolic connection to someone or something else of importance. During infancy and
toddlerhood, comforting objects such as blankets or teddy bears are TOs used to physically
embody the attachment a child has to their caregiver until they develop a sense of self
(understanding what is “me” and “not me”) and can create a mental representation of that
attachment internally. Metcalf and Spitz (1978) built upon Winnicott’s (1971) theories by
studying how TOs can be used to demonstrate the relationship between object consistency,
memory, and ego development in childhood. Maintaining TOs throughout the lifespan is a
phenomenon that has inspired a variety of psychotherapeutic interventions, including projective
techniques and use of symbolism or metaphor. Arthern & Madill (1999) suggest a four-level
embodiment model comprised of physical, process, contextual, and conceptual levels to describe

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how TOs can be used in therapy. This early study challenged how therapists considered
nonverbal elements of experiences, such as touch and smell, to explore the developmental
context in which TOs emerge and how they work for clients. They explain, “By holding the TO
the client is able to touch what cannot be touched; to gain through sensory contact a holistic and
powerful awareness...In this way a presence is made of absence” (Arthern & Madill, 1999, p.19).
Transitional Objects in Bereavement
Transitional objects can be an exceptionally powerful tool for trauma-informed art
therapy for loss, complicated grief, and bereavement. Currin-McCulloch, Kaushik, & Jones
(2021) found that the disorientation of diagnosis combined with sudden changes in health
functioning and the missed opportunities for achieving developmental milestones due to
treatment creates a unique sense of physical and psychological distress, which they refer to as
disoriented grief. The authors explain that for adolescent and young adult (AYA) cancer patients,
disoriented grief is characterized by an acute awareness of the reality that the “life to which they
had become accustomed and futures they once envisioned no longer exist” (Currin-McCulloch,
Kaushik, & Jones, 2021, p.E358). Throughout treatment, AYA cancer patients might experience
compounding levels of grief as they mourn the internal losses of independence, identity,
ability/functioning, or aspirations, as well as external losses like that of social relationships or
death of peers within the patient community. Likewise, caregivers and family members are
uniquely affected by multiple layers of complicated grief throughout their loved one’s cancer
treatment and are uniquely vulnerable to the hardships of bereavement at the end of a patient’s
life (Bogetz, et al., 2021). In Complicated Grief, Attachment, and Art Therapy, Brianna
MacWilliam (2017) speaks to importance of TOs in art therapy for bereavement. She explains,

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“We attach ourselves to the relics of our [loved ones] because...they are symbols for not only the
absent person, but your vision of the absent person” (p.22-23).
To reduce emotional suffering during the various types and stages of grief in cancer care,
including bereavement, it is not uncommon for interdisciplinary hospital practitioners such as art
therapists, music therapists, child life specialists, chaplains, or social workers to provide
opportunities for meaning-making through art-based activities and projects. Living legacy is a
framework for intentional intervention and is defined by Child Life Specialist Jessika Boles as “a
passing of self, stories, belongings from one to another, a meaning-making process, and a vehicle
for being remembered,” (2021, p.529-551). Cahalan, et al., (2021) describe the use of living
legacy to minimize emotional suffering for pediatric cancer patients at the end of life by
providing means for self-expression, encouraging family bonding through collaborative
activities, engaging in life-review, and presenting opportunities for patients to have agency over
their otherwise uncontrolled circumstances. The authors provide examples of individualized
legacy-building projects and activities such as plaster hand molds, fingerprint charms, written
storytelling, heartbeat recordings, memory albums/scrapbooks, and video journaling (Cahalan, et
al., 2021). These items serve as tangible reminders of the dying person, encapsulate bonding
experiences (including the process of artmaking), and house collected memories. Through this
lens, transitional objects serve as an encapsulation of a person’s entire existence and their
significance in the lives of those around them.
Transitional Objects in Emotional Processing
At Westwood Preparatory Academy (“Westwood Prep”), a system of residential
treatment centers for juveniles in Ohio and Pennsylvania, John Sorvillo and art therapy program
director Josh Kale collaboratively use 3D printing as a therapeutic intervention to help students

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personify their feelings. In one example, Sorvillo and Kale led students through the process of
designing and 3D printing “anger monsters.” These visual representations of the students’ anger
allowed them to better understand the origins of their feelings, identify triggers, develop emotion
management skills, and externalize their experiences to better understand them (Lissy, 2021).
The Westwood Prep team demonstrated that personification of feelings allows clients to observe
the narratives that unfold because of the ways in which feelings affect thoughts, behaviors, and
interpersonal relationships. Additionally, the team demonstrated the use of metaphor using the
3D printed characters using what Sorvillo describes as the “Voldemort Principle: when you’re
afraid of something and refuse to name it, it has power over you” (Lissy, 2021). Creating a totem
like the “anger monsters” grants the students ownership over their recovery journeys by
empowering them to decide when and how they address their feelings, serving as a metaphor for
the therapeutic process.
Ethical Considerations
Because of the rapid, exponential advancements in digital technology, governing
agencies and professional bodies are challenged to provide necessary legislation and standards to
protect the public. For example, the compliance standards for the Healthcare Insurance
Portability and Accountability Act (HIPAA) rigidly uphold protections for protected patient
information, but healthcare (or related) organizations are responsible for ensuring that their
institutional policies and procedures are aligned with the law. According to the HIPPA Journal
(Adler, 2023), technology use provides various risks to HIPAA compliance, including
encryption, monitoring user access, messaging security, and information storage. In medical
technology, this might include the use of electronic healthcare records, digital diagnostic imaging
(such as X-rays or MRIs), telehealth, and any business-related internal communication systems

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such as emails or text messages. 3D printing technology in medicine presents its own specialized
challenges to HIPAA compliance. For example, the systems used to create three-dimensional
tumor models, prosthetics, or other consumable devices (Cacciamani, et al., 2019) rely on
importing and analyzing the diagnostic images from patient medical records in order to
accurately render models using CAD systems (Wake, et al., 2019). The computers used to run
CAD software, wireless 3D printer onboard information storage, user long-in procedures, data
storage, provider-to-patient delivery methods, and the 3D printed product itself are all factors to
upholding HIPAA compliance.
Another ethical quandary for use of 3D printing technology is the concept of ownership
over intellectual property. Medical literature discussing the use of 3D printing is lacking in
consideration of ownership over intellectual property of the product produced (Aimar, Palermo,
& Innocenti, 2019; Zhang, 2023). By contrast, Section IV of the Ethical Principles for Art
Therapists (2023) outlines how art therapists regard client artwork as a form of protected
information. At the intersection of institutionally provided technology, devices, and media, and
the ideas generated by patients, perhaps including their participation in the process, is the
definition of ownership over the product produced. A biomedical engineer using machinery
provided by a HIPAA compliant hospital might argue that the institution owns the 3D printed
object because of the institution’s ownership over the means of making the object; whereas an art
therapist would argue that the product is the property of the patient because it is produced as a
result of the creative process using 3D printing as artistic media. Alders, et al., (2011) describe
the ways that technology is transforming the clinical environment for art therapists, and how
clinicians must respond with ethically-sound judgement. The authors use four case vignettes to
illustrate the ethical principles for art therapists using digital media and, in summary, conclude

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that anything clients produce using technology is entitled to the same protections as that which is
produced using traditional art media (Alders, et al., 2011).
Accessibility to 3D printing is greatly limited by the cost of machinery and materials, as
well as the time invested to training users (Li, et al., 2021; Aimar, Palermo, & Innocenti, 2019;
Zhang, 2023). Though costs of computers, printers, software, and printing media have become
more accessible to the everyday consumer, differences in quality and safety standards between
public, private, and commercial variations of 3D printing tools can impact overall financial
burden. Notably, the use of 3D printing in art therapy is incredibly niche, witch accessibility
being one of the greatest limiting factors to its use (Alders, et al., 2011; Malchiodi & Huet,
2018), along with the already observable lack of technology use by art therapists more broadly
(Orr, 2012).
Conclusion
The landscape of digital and technology-based interventions in art therapy is
continuously evolving as clinicians embrace the use of advanced media simulation apps, haptic
tools, and digital recording/editing in practice. 3D printing has not yet been conceptualized in art
therapy literature but is rich with potential for its application in clinical use as an intervention
tool, particularly in medical contexts like oncology. The methods used and meaning ascribed to
3D printed media can serve as a therapeutic avenue for meaningful applications at all stages and
milestones of cancer care, from diagnosis, through treatment, bereavement, and the transition to
long-term survivorship. The following section outlines the methodology of an art therapy
program designed to integrate 3D printing into medical art therapy clinical work with oncology
patients.

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24

Section III: Methodology
Medical art therapy is part of holistic cancer care and a valuable resource for addressing
the psychosocial needs of cancer survivors at all stages of their cancer journeys. In an effort to
minimize barriers to access for patients and families in hospital settings, it is important for
medical art therapists to find creative and innovative ways of integrating art therapy practice into
the otherwise sterile clinical environments. One of the ways novel interventions can be used in
these settings is the use of technology and digital media, including the use of 3D printing. This
program guide was developed in response to the lack of knowledge about emerging 3D printing
technologies and their applications in art therapy (particularly medical art therapy in hospitals).
Target Audience
This resource guide is designed for licensed and board-certified art therapists working in
medical settings with cancer survivors. Cancer survivors refer to anyone who has been diagnosed
with cancer, no matter what stage they are at in their cancer journey (American Cancer Society,
2024); including all stages and milestones from diagnosis, through treatment, bereavement, and
the transition to long-term survivorship. The intervention methods outlined in this guide are
intended to benefit individuals over the age of 10, or those with the cognitive capacity to
understand symbols, metaphors, or abstract thoughts who are experiencing the complex
psychosocial impact of cancer.
Program Structure
The underlying theoretical stance for this resource guide builds upon Winnicott's (1953)
theory of transitional objects and uses a dialectical approach to narrative therapy. Dialectical
Theory suggests that two seemingly conflicting things can be true simultaneously, and
intervention strategies rest on the dialect of acceptance and change. Narrative Therapy is rooted
in the assumption that narrative is a basic human means of bearing experiences of time, events,

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change, thoughts, and feelings. Inspired by the work of Arthern & Madill (1999), this program
uses a four-phase model. One of the overarching goals of this integrative approach is to provide
clients with opportunities to reframe life events and give them profound meanings.
Because of the extended duration of cancer treatments, including frequent outpatient
clinical visits, unpredictable medical events, and/or inpatient hospitalizations, this program guide
is not bound by a specific timeline. Rather, it is designed in stages to provide flexibility. It can be
started at any point in a patient’s cancer journey and can be repeated any number of times. Art
therapists should use sound clinical judgement when assessing appropriateness of this
intervention to meet treatment goals and minimize risk of harm.
Environment and Equipment
This program is designed to be implemented during individual sessions with oncology
patients either at bedside, in a designated maker space, or in clinical spaces deemed appropriate
for art therapy practice. Materials and technology needed are:
Laptop/Computer
To run the CAD software of choice, it is important to use a computer with enough
internal memory and graphics capabilities. Most software websites will list the computer
requirements necessary to run the programs. It is recommended to use a portable laptop
computer for settings where the 3D printer itself is not fitting, safe, or appropriate, such as
infusion centers or the patient bedside.
CAD Software
Many 3D printers have accompanying CAD software that can be downloaded from the
company’s website. It is important to use software that is compatible with both the computer and

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26

the printer, as well as the information technology framework of the hospital (including
addressing the use of cloud-based technology and internet firewall restrictions).
USB External Storage
Though some 3D printers may use wireless data transfer options, such as Bluetooth or
wireless networking, it may be necessary to use a “hard” transfer like a USB flash drive. This
method provides a safer transfer of information between machines.
3D Printer
There are a variety of 3D printer models and types, each with its own unique features and
capabilities. Choosing a 3D printer for hospital settings, particularly with the intent for patient
use, includes consideration of space, user-friendliness, cleanliness, and need for ventilation.
Filament
Each unique project will require consideration of filament type. The complexity of
design, intended purpose, color, size, and durability are all factors that will influence this
decision. It is important to discuss filament options early in the design process, regarding it as its
own media throughout, as the final product will depend on this choice. For example, if the
intended purpose of the 3D printed object is to be destroyed, a breakable filament would be
chosen; whereas if the final 3D printed object is to be preserved for long periods of time, a more
durable filament would be appropriate.
Program Outline
The following outline provides a framework for this program.
1) Early Stages – Based on Arthern & Madill’s (1999) Physical stage of TO embodiment,
this stage focuses on acclimating clients to the physical media and art-making methods.
a) Art Objective: Introduction to media, materials, and processes.

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27

i) Like work with traditional art media, this is a time to “play” and explore
the technology and materials, including a possible “test” or “practice”
print with a non-therapeutic or “fun” object.
b) Client Objectives: Introduction to self (if necessary), provide a safe environment
to build or deepen rapport, begin to explore their experiences, identify and
personify the problem, and create opportunities for the story to be told.
c) Some suggested discussion points or prompts for this stage might include (but not
limited to):
i) Getting-to-know-you questions, such as favorite things, hobbies, interests,
school/job, or family.
ii) Laying the foundation for concepts of changes over time, including getting
to know how the individual conceptualizes their ‘self’ before, during, or
after diagnosis and treatment.
iii) Understanding the cancer journey, including questions about when the
person was diagnosed, what their understanding of treatment is, what the
current medical plan is, what the person’s support system is like, who is
involved in their care, what they perceive to be their biggest/smallest
challenges.
2) Middle Stage - Based on Arthern & Madill’s (1999) Process stage of TO embodiment,
this stage emphasizes the client’s ability to attribute meaning to physical material. This
stage might include physically holding a 3D printed object and identifying means of
externalization.

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a) Art Objectives: Deepen fluency with technology media; Design and print first
design.
i) This might be the first print from the introductory phase, or the first
“draft” print of a client’s unique design.
b) Client Objectives: Deconstruct the patient experience, help client to develop new
relationship to challenges, further explore the narrative, ask questions to elicit
stories, externalization, and assess progress.
c) Some suggested discussion points or prompts for this stage might include (but not
limited to):
i) “If you were going to give your [identified problem] a name, what would
it be?” “If you could talk to it, what would you say?”
ii) “What does [identified problem] mean to you?” or “What power does
[identified problem] have in your life?”
iii) “How does [identified problem] affect your family/social/romantic
relationships?”
iv) “How would you change/solve/deal with [identified problem]
successfully?” “What would life be like if that happened?”
3) Late Stage - Based on Arthern & Madill’s (1999) Context stage of TO embodiment, this
stage deepens exploration of meaning and draws connections between the present
moment and the wider therapeutic context through which the artwork emerged.
a) Art Objective 1: Finalize choice of filament media, refine final design, and
creative final print of object.

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b) Art Objective 2: Identify resolutions and begin discussing concluding art
methods, including (but not limited to):
i) Manipulating 3D printed objects, such as destroying or altering them. This
might include the use of traditional art media for things like assemblage,
painting the object, or creating new art from the fragments created by
destruction.
ii) Preserving 3D printed objects, including provision of containers, resin
casting, varnishing, etc.
c) Client Objectives: Reinforce and extend client story, encourage future-oriented
thinking, identify ritual or ceremonious activity, deepen personification of
transitional objects, explore meaning, reconfigure narrative, process emotions.
d) Some suggested discussion points or prompts for this stage might include (but not
limited to):
i) “Now that you are holding [named print] in your hand, what thoughts or
feelings come up for you?” “What is it like to hold [named print] in your
hand?”
ii) “What was it like to see [named print] in the real world for the first time?”
iii) “Does holding [named print] in your hand change the way you think/feel
about it?”
4) Concluding Stage – Building upon Arthern & Madill’s (1999) Concept stage of TO
embodiment, this stage focuses on the integration of client artwork into their own lives.
This might mean identifying ways to preserve, destroy, or manage the artwork at the
intervention's end.

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a) Art Objective: Finish conclusive artmaking. Based on client choices, this might
include containment, secondary art pieces, preservation, disposal, and/or HIPAAcompliant artwork archiving.
b) Client Objective: Process emotions and experiences, emphasis on concluding this
process, and answer questions.
c) Some suggested discussion points or prompts for this stage might include (but not
limited to):
i) “Where is [named print] going to ‘live’ when you take it with you?”
ii) “Who will you show/share [named print] with?” If the client prefers to
keep it private, discuss ways of concealing, destroying, or otherwise
protecting the artwork.
iii) Identify key takeaway themes that emerged from the artmaking process.
Conclusion
Cancer affects each patient in unique and profound ways, with nuanced experiences
varying widely based on lifespan development, nature of disease, stage of survivorship, and
diversity of culture, race, socio-economic status, and gender. This program reflects the
individualized nature of the cancer experience and is designed by a licensed and board-certified
art therapist working with cancer survivors, at all stages of survivorship, in medical settings.
Medical art therapists are aware of the unique ways that the nature of chronic, life-threatening
illness can impact patients’ psychosocial wellbeing, and further understand the imposing
challenges to traditional art therapy methods and interventions in a hospital setting. Threedimensional printing is one way that medical art therapists can embrace the use of technology in
clinical practice and provide safe alternatives to immunocompromised patients. A narrative-

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based approach with a dialectical stance was chosen for this proposed intervention because of the
potential benefits from methods for self-expression, externalization of feelings,
reconceptualization of challenges, fostering of hope/empowerment, and emergence of selfdetermination. The following section presents the program in its entirety.

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Section IV: Resource Guide
This section includes the resource guide for use of 3D printing technology for medical art
therapists working with cancer survivors in clinical settings. The resource is designed to have
flexibility to adapt to diverse concepts such as location, resources available, time commitments,
and other environmental factors. Therapeutic benefits are enhanced through responsive creative
engagement and attunement to the individual needs of each participant. An example from the
point of view of a helping professional is presented in the resource guide. The complete resource
guide is included in the appendix.
Conclusion
The resource guide included in the appendix of this paper provides a four-stage program
for implementing 3D printing technology in medical art therapy for oncology care. Art therapists
working in hospital settings must have a keen awareness of the unique needs of their
environments and populations, as well as an openness to innovating art therapy media and
methods to meet those needs. 3D printing is one way that art therapists working in oncology care
can circumvent the infection control and space limitations of their settings, while providing
opportunities for meaning-making and creative engagement. The four stages of this program are
designed to enhance program participation and therapeutic benefit. The following section is a
reflective discussion of the literature review, program development, limitations to this project,
and opportunities for future research.

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Section V: Discussion
In this section, a summary of the literature review, program development, limitations to
this project, and opportunities for future research are discussed. This discussion also includes a
reflection of the “provider’s perspective” example featured in the program guide.
Summary of Research
This research sought to provide a framework for the inclusion of 3D printing as an
intervention method for medical art therapists working in clinical settings with cancer survivors.
Inspired by the story of “Bashing Boris” (Michigan Medicine, 2016), this investigation and
program guide development brought together the medical utility of 3D printing with the theories
and methods of digital art therapy. The theoretical stance of this resource guide built upon
Winnicott's (1953) theory of transitional objects and used a dialectical approach to narrative
therapy. Within this framework, patients have opportunities for self-expression, externalization
of feelings, reconceptualization of challenges and personal narrative, fostering of
hope/empowerment, and emergence of self-determination.
The four-stage program presented in the resource guide was inspired by the work of
Arthern & Madill (1999) and is designed to promote maximal therapeutic benefit while honoring
the fluidity of the cancer experience.
Stage 1
Early Stage, Physical. Exploration of media, materials, and methods. Introductory
therapeutic dialogue and case conceptualization.
Stage 2
Middle Stage, Process. Early designs and first prints. Deconstruction of experiences,
elicitation of stories, and promotion of externalization.

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Stage 3
Late Stage, Context. Finalization of designs and completion of printing. Identify
resolutions and deepen exploration of meaning. Promotion of externalization.
Stage 4
Concluding Stage, Concept. Completion of artwork, processing of experiences, and
reaching resolution. Revision of personal narrative.
Discussion
A cancer diagnosis can be a deeply disruptive and profoundly difficult experience for
patients, families, and caregivers. Chronic, life-threatening illness can have both acute and longlasting physical, psychological, and spiritual impacts across a person’s lifespan. Meeting the
psychosocial needs of cancer patients in clinical settings can be challenging due to the barriers of
the medical environment and limitations to the access of services.
Ensuring patient and family access to mental health resources requires hospital-based
practitioners to seek innovative methods rooted in evidence-based practice. Art therapists
providing services in oncology centers are especially impacted by the limitations of the hospital
environment, wherein traditional art media may pose safety risks to medically fragile patients or
are otherwise unwelcome in the clinical setting. Therefore, medical art therapists have the added
responsibility of creatively innovating their intervention methods to bridge accessibility gaps,
including integrating digital media and technology. Arguably, 3D printing is an acceptable tool
for this purpose, not only because it is often already used in medical settings, but also because it
supports the theoretical foundations of contemporary art therapy practice.
Medical art therapists working with cancer populations typically use trauma-informed
interventions structured around creating a sense of safety, addressing psychosomatic symptoms,

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providing opportunities for choice and control, and building resilience. These might include
theoretical frameworks such as Cognitive-Behavioral Therapy (CBT), Dialectical Behavioral
Therapy (DBT), or Solution-Focused Brief Therapy (SFBT). Further, emotional processing of
cancer-related psychosocial challenges and one’s relationship to them might include a Narrative
Therapy approach. Combined with the art therapy concept of transitional objects, cancer
survivors can benefit from the powerful treatment potential of actively reconceptualizing their
disease, processing their experiences, and redefining their self-concepts. The design for this
program guide sought to balance the nuance of the hospital environment and fluidity of the
cancer experience with evidence-based interventions. The goal of this innovative approach is to
bypass many of the barriers to access of art therapy services in hospital settings while providing
a unique intervention method for meaning making for patients, families, and caregivers –
including providers.
Most of my professional career has been dedicated to bringing creative arts programming
to a pediatric oncology hospital. My role is to ensure access to the arts for patients, families, and
staff. In the near-decade that I have been in this position, I have learned how to hold space for
the weight of bereavement, pain of chronic illness and treatment, and elation of a remission bellringing celebration. Cancer care is something that has deeply shaped who I am, both as a person
and as a professional. It is the reason I chose to become an art therapist. The “provider’s
perspective” in the program guide is an example of the methods of this project told from my own
perspective. It is my hope that this guide provides a foundation for meaningful and
therapeutically beneficial work and serves as inspiration for future research on the use of digital
media in art therapy.
Limitations

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Three-dimensional printing is an emerging technology that is growing increasingly
accessible to everyday users, but financial costs continue to pose great limitations on
accessibility. Though commercial and professional-grade printing machines have their own
industrial standards for quality and costs, consumer-grade printing machines, materials, and tools
can vary widely. According to Formlabs.com (2024), the average costs for privately owning 3D
printing machines and filaments can range from $350 USD to over $4000 USD (found at
https://formlabs.com/blog/how-to-calculate-3d-printer-cost/), not including the cost of a
computer/laptop, software, or any software-related membership fees. Clinicians considering
integration of 3D printing to their work must be aware of the layered costs of materials,
maintenance, and memberships. Suggestions for alternative, lower cost materials are included in
the appendix of the resource guide.
A challenge for implementing technologies in art therapy is safe storage of digital
protected healthcare information (PHI). Artwork produced by clients is considered PHI in art
therapy practice. As such, confidentiality standards that safeguard client PHI apply to media
produced in art therapy (ATCB, 2021, Section 2). Digital storage methods must be HIPAA
compliant. All points of the creative process using 3D printing (including the CAD software,
transference to the printer, and digital archiving of files) must have safeguards in place to protect
patient confidentiality. Meaning, that software cannot be internet-based, flash drives or other
external storage devices must be encrypted, and all devices must be “wiped” of patient data
between uses. It might also be necessary to use a virtual private network (VPN) to protect any
online activity, such as cloud storage or wireless connections to printers.
Perhaps one of the most critical limitations of this project is the refinement of its context.
This project focuses on niche intervention methods with a niche population: 3D printing and

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specific theories for work with cancer populations. It is entirely theoretical based on limited
existing data and anecdotal support. Though the intended design of the program guide was to
avoid rigidity and prescript methods, there is still an opportunity to expand its concepts to a wide
range of populations and settings. 3D printing is a novel tool that can arguably be integrated into
the “art therapist’s toolbox” in diverse contexts. Overall, there is limited research on the use of
3D printing, especially in mental health contexts, so the theories and methods proposed in this
project have yet to be tested.
Suggestions for Future Research
The development of this resource guide revealed opportunities for future research
surrounding the utility of 3D printing in art therapy. It is necessary to collect data on the current
proposed framework and refine its methods based on those outcomes. Importantly, future studies
would include exploration across the diversity in cancer diagnoses (types), stages, and patient
population, including developmental age, gender/sex, race, and ethnicity. Future studies might
also include other, non-cancer medical situations. To grow the body of literature on the utility of
3D printing in art therapy, broader exploration of diverse populations and settings is needed.
More refined methods of the proposed framework in this resource guide are also encouraged. Art
therapists might consider evaluating variations in materials, including use of different filament
types, CAD software, or 3D printing alternatives like 3D doodle pens. Adaptations in methods
could also be explored. For example, some CAD software have pre-constructed objects that can
be assembled or manipulated, whereas others are fully user-driven and reflect a virtual sculpting
experience. The levels of active creative engagement relative to therapeutic outcomes could be
investigated. Further, exploration of 3D printing as it relates to the art therapy ETC is imperative
to better understanding its therapeutic benefit.

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Conclusion
The story of “Bashing Boris” provided an anecdotal foundation for how the tenets of art
therapy theories, combined with novel intervention tools like 3D printing, can shape personal
narratives for cancer survivors. Existing literature on the contextual topics surrounding the
integrative, theoretical intervention methods presented in this project is limited. However, as the
landscape of digital and technology-based interventions in art therapy continuously evolves,
there is a greater opportunity to investigate the therapeutic benefits of non-traditional methods
and media, particularly with diverse populations and settings. This project began with the
intention of understanding the therapeutic underpinnings of “Bashing Boris,” and resulted in a
theoretical model preliminarily tested from the perspective of a provider with experience
working in oncology. In its entirety, the process of developing this theoretical model and
resource guide demonstrates that not only is more research on the therapeutic applications of 3D
printing in art therapy needed, but it is also attainable.

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