Introduction

The experience of living with cancer can reduce quality of life of patients [1]. Interventions aiming to support patients in enhancing quality of life could include art, for instance as art therapy [2,3,4,5,6,7], or, more recently, as co-creative processes [8,9,10,11]. Art therapy tends to have a more therapeutic focus [12] compared to co-creation [8]. In co-creation, an artist supports patients to express aspects of the patient’s life narrative, culminating into a work of art [8,9,10,11]. Co-creation is characterised by the use of multiple senses and imagination, supporting various ways of expression in patients [9, 12, 13]. The experiences that are addressed could include a sense of loss, uncontrollability, uncertainty or despair, all related to an inability to control the circumstances patients are facing [8, 9, 14]. An example of co-creation is creative writing where a patient, together with an artist, expresses her feelings of being overwhelmed by her cancer and its treatment.

In previous studies on co-creation, artists indicated that the relation between patient and both artist and material is of a reciprocal nature and forms an important factor facilitating the co-creation process. Artists suggested that the co-creation process only becomes meaningful when patients become engaged [8, 11]. Another factor in co-creation processes with patients seems to include a confrontation with circumstances beyond one’s control which affect the patient and create a meaningful action perspective for placing the experience within their life narrative [8, 11, 15].

The reciprocal nature of relations which actors have with their worlds is acknowledged by theories on resonance [16, 17], as well as by certain orientations within psychotherapy [18, 19]. Yet, the factor of uncertainty due to experiences beyond one’s control is either not well described, as in general theories on resonance [16], or viewed as unfavourable, when the aim of self-efficacy [19] or coping [20] partly lies in regaining a sense of control over one’s existence. Contrary to the above [16, 19, 20], resonance theory by Rosa [21] describes that the core of a resonance relationship lies in its indefinite quality and attuned appeal which creates an immediate, intense, embodied, sounding relationship between the person, the other(s) and the tangible world. Uncontrollability is an ever present characteristic of these relationships. Rosa’s theoretical assumptions seem particularly important for co-creation processes as resonance theory describes how people are affected by others or by the world, how they respond and how they are subsequently changed, and, as such, could deepen our understanding of how patients are affected and changed during co-creation processes.

A resonance process may unfold when one is sufficiently responsive to others, oneself and the world. An open attitude, the ability to be affected and the flexibility to change one’s perspective are prerequisites to experience resonance [21]. Resonance has been described to have four main characteristics.

(1) Being affected, touched or moved by the world is the first experience of a subject, which may stimulate an intrinsic interest in that which affects him or her. This intrinsic interest comes forth when one’s core values are affected in contact with the world, which becomes evident through bodily sensations, emotions and thoughts. (2) Self-efficacy unfolds when the person is able to actively reciprocate the call of that which affected him or her. (3) Uncontrollability is the element that is ingrained in the full experience of resonance. We cannot know when and how the world is going to affect us, nor do we know beforehand how to relate to being affected by the world. If one does not have the ability to be open to new experiences or to the unexpected, there is no possibility for resonance. (4) Adaptive transformation takes place when the person who is affected is able to respond effectively, which in turn changes both the person’s experience in the encounter with the unexpected as well as the person him or her-self.

According to Rosa, relations that contain these four main characteristics of resonance affect and change those who have these relations [21, 22]. In line with Rosa, here we will call these relations ‘resonance relationships’. As far as we know, no studies have been published yet that further investigate the nature of these relations in a co-creation setting.

In this study, we will first investigate, if and if so, how resonance relationships, as defined by their four main characteristics, occur within co-creation processes, from the perspective of the artist. Secondly, we will investigate how artists use these resonance relationships within co-creation.

Methods

Participants

For the current study, we interviewed professional artists who are participating in the In Search Of Stories project (ISOS) [23]. ISOS, funded by the Dutch Cancer Society, is an ongoing project evaluating a narrative multimodal intervention aimed at enhancing quality of life in palliative cancer patients recruited from four Dutch hospitals [23]. Within ISOS, a spiritual counsellor supports patients with a life review interview, drawing of a rich picture [24] and reading selected literature [23], followed by a co-creation process supported by a professional artists [11]. The artists involved in ISOS meet two inclusion criteria: extensive experience in co-creation processes with patients and the ability to work with a broad repertoire of art modalities in addition to their main art modality, thereby enhancing their possibilities to support patients during the co-creation processes. The ISOS project includes 11 artists with experience in a variety of primary art forms who are all eligible for the current study, for further details see [11]. Within the ISOS project, individual artists reflect on their ongoing co-creation processes with patients, together with two supervisors. Both supervisors are senior faculty members of the HKU University of the Arts Utrecht. Supervision sessions with the artist and both supervisors take place one to three times during a co-creation process. Supervision sessions can focus on the process and patient, but also on logistics and provision of the artistic material used in the co-creation process, or on future presentations. Supervision sessions are intended to support the artist during co-creation processes and all supervision sessions are audio recorded.

Study design and data collection

We used a qualitative study design in which we audio recorded supervision sessions between professional artists and their supervisors as they reflected on co-creation processes with palliative cancer patients within the ISOS project. Artists and supervisors were not trained in, or familiar with resonance theory, nor were the supervision sessions based on resonance theory.

Data analyses

We have first used template analysis to search for the presence and content of characteristics of resonance relationships within our study material. Secondly, we have used directed content analysis of specific sections of our study material to investigate how artists use resonance relationships within co-creation. All presented quotations and constructs were translated from Dutch into English by YW.

To investigate our first research question—if and if so, how resonance relationships occur within co-creation processes—we looked for the presence and content of the four main characteristics of resonance by means of template analysis [25, 26]. Template analyses offer steps of analyses which clarify how a conceptual model can be developed and deepened by a comparison and elaboration of the collected empirical data. Template analyses entail several rounds of familiarising oneself with the data, identification, labelling and coding of themes and categories, organising emerging themes into larger wholes of meaningful clusters and categories, until all data are integrated in the emerging template, culminating in a final template. The main procedural steps of the analyses of our audio recordings are shown in Table 1. The audio recordings of the supervision sessions were imported in AtlasTi [25]. AtlasTi offers a possibility to directly analyse audio recordings, instead of plain text, which adds details of tonality and intonation of the spoken words into the analyses. The audio recordings were primarily analysed by YW (MA, MSc, MSc, female), who has a professional background in art therapy, clinical psychology and spiritual care. Within template analyses, so-called a priori themes can be identified based on literature, current knowledge or experience [26, 27]. These a priori themes serve as a preliminary template. During the data analyses, the preliminary template can be adjusted or changed to fit all relevant data until saturation is reached, culminating in the final template [26, 27]. Our preliminary template was based on the four main characteristics of the theoretical concept of resonance (see Table 2) [21]. Results of the data analyses were discussed with MSR (Associate professor, PhD, male), who has a professional background in religious studies, theology, spiritual care, template analyses and qualitative research. The final template was discussed with MSR and HvL (Professor, MD, PhD, PhD, female), who has a professional background in medical oncology and theology.

Table 1 Main procedural steps of the data analyses
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Table 2 Characteristics of resonance and their descriptions as used in the preliminary template
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Case descriptions

To investigate our second research question, how artists use resonance relationships within co-creation, and to deepen our insights from investigating our initial research question, completed co-creation processes were selected. Co-creation processes from start to finish illustrate the full temporal developments within resonance relationships. The audio recordings of the supervision sessions of these cases were analysed by means of directed content analysis [28, 29]. Directed content analysis is a deductive approach suitable to analyse a text for an already established framework of concepts [28, 29]. Here we used the framework which had been established in our analyses of the characteristics of resonance relationships. YW analysed the data focussing on the presence of the themes of the final template in combination with temporal developments in both the main characteristics of resonance relationships and, more importantly, on how artists use these resonance relationships within co-creation. All analyses were conducted in AtlasTi and discussed with MSR and HvL.

Ethics

The study was performed in line with the principles of the Declaration of Helsinki. This study was exempted from ethical approval by the Medical Ethics Review Committee of the Academic Medical Centre, since the Medical Research Involving Human Subjects Act was not applicable (reference number: W20_436 # 20.483). Written informed consent from every participating patient was obtained at the start of their enrolment. The professional artists interviewed for the current study were employed within the ISOS project and therefore informed consent from them was not applicable.

Results

Participants and setting

In total, ten supervision sessions focussing on the co-creation process with the patient, involving eight of the eleven artists and two supervisors, were available at the time of the study. The other three artists were not yet involved in a co-creation process within the ISOS project. The eight participating artists were musicians, visual artists, scenographers, a theatre composer and a creative writer (see Table 3). The supervision sessions were held at the HKU University of the Arts Utrecht. Supervision sessions took place between April 2021 and August 2021. The duration of the supervision sessions varied between 30 and 60 min, with a median duration of 45 min.

Table 3 Participating artists involved in the co-creation processes
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Characteristics of resonance relationships

To investigate our first research question—if and if so, how resonance relationships occur within co-creation processes—we first looked for the presence of the characteristics of resonance, which are described in the final template (see Fig. 1), and secondly, these characteristics are described in more detail, including artist’s quotations, in Table 4.

Fig. 1
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Final template of the characteristics of resonance

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Table 4 Characteristics of resonance relationships in the process of co-creation, with artist’s quotations
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Final template

The final template mainly resembled the preliminary template; however, uncontrollability showed to be multi-layered and included several distinct dynamics and mechanisms. Therefore, the characteristic Moments of uncontrollability was further subdivided into Expressions in a sequence, Making space to be surprised, Looking for the field of constant tension, Exposing the sting of the experience of uncontrollability and Attunement. Some labels of the characteristics were slightly extended to better encompass their content. The final template is shown in Fig. 1.

Characteristics of resonance relationships in the process of co-creation

The characteristics of resonance relationships are described in detail and illustrated with artist’s quotations in Table 4. Artists are referred to with a capital letter, corresponding to Table 3.

Case descriptions

Two cases are described to illustrate the temporal aspect of our findings on the second part of our first research question, how resonance relationships, as defined by their four main characteristics, occur within co-creation, and, more importantly, to answer our second research question, how artists use these resonance relationships within co-creation. These two cases are examples of different approaches in resonance relations that can be used by artists in co-creation processes. During the co-creation process, resonance relationships can provide a point of focus to alternate with moments of uncontrollability. Artists kept the patient interested and connected to the co-creation process during moments of uncontrollability by focussing on either or both resonance relationships. In case one, the artist puts more emphasis on the resonance relationship between patient and artist, whereas in case two, the artist puts more emphasis the resonance relationship between patient and material (Table 5).

Table 5 Case descriptions of resonance relationships, with artist’s quotations
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Discussion

To the best of our knowledge, this is the first study describing that within co-creation, from the perspective of the artist, uncontrollability has a central role and showed to be multi-layered and included several distinct dynamics and mechanisms. Also, artists both actively use attunement and keep the patient interested and connected to the co-creation process during moments of uncontrollability by focussing on either or both resonance relationships. Furthermore, resonance relationships, as defined by their four characteristics, are shown to be present in co-creation.

One of the main characteristics of resonance theory, uncontrollability, plays a central role in co-creation as it affects the patient and invites responses from within the patient which can be expressed in subsequent stages of the work of art. Also, the encounters with uncontrollability can influence the perspective of the patient which can change over time. Uncontrollability also shows similarities to the element of uncontrollability in life events. These experiences of uncontrollability are sometimes referred to as experiences of contingency, which are described as having a nature to befall us unexpectedly [30]. Contingency refers to the idea that everything—including one’s own life—could have been different, one’s plans and expectations could have developed otherwise [15, 31, 32]. An experience of contingency is understood as the experience of a life event that introduces an undesired future, which threatens one’s existence, life goals and sense of meaning [1, 30, 33]. Living with cancer could be an experience of contingency which could include a high level of uncontrollability [34]. According to Zirfas [35], art is a solidification of uncontrollability, and the effect art has on the observer is uncontrollable and can differ at each subsequent encounter with the work of art. Possibly, for a patient, practising with the uncontrollability of creating art within resonance relationships in a co-creation setting could have a positive effect on the patient’s ability to successfully deal with the uncontrollability of the experience of contingency that is focussed on.

Attunement is the word artists use to describe the level of resonance within resonance relationships. Artists consciously and actively attune to the patient to establish a high intensity of resonance. Attunement illustrates that resonance not only automatically emerges but that artists consciously support the establishment of a high intensity of resonance. In addition to this, artists also actively modulate the level of attunement and subsequently the intensity of resonance in the resonance relationship between patient and both material and artist. In this way, both the intensity of the patient’s experience of working with the material and the patient’s own emotions can be influenced. In attunement, there is conscious and active participation from the part of the artist in reaching out to the patient and adapting or adjusting to the patient. Our findings on attunement connect to a larger field of research where attunement is described as a factor influencing content and outcomes of various processes, as for instance in looking at art [36], art therapy [12], counselling [37] and psychology [38]. Previously, in resonance theory, a more unconscious process of an unfolding relationship between patient and both artist and material was supposed. Our finding is in line with more recent work of Rosa in which he describes that in a classroom situation the teacher also has to actively connect with the pupils to make them interested and become affected by the world of the subject that is taught by the teacher [39]. Based on our case descriptions, it could be hypothesised that in resonance relationships between artists and patients both the level of attunement and fluctuations in these levels influence the way the patients resonate with the work of art, or can identify with the work of art. A patient’s perspective on attunement could deepen our understanding of how the resonance relationships between patient and artist, and patient and material, affect reworking experiences of uncontrollability within one’s life narrative.

Also, we found that during the co-creation process resonance relationships can provide a point of focus to alternate with moments of uncontrollability. Artists keep the patient interested and connected to the co-creation process during moments of uncontrollability by focussing on either or both resonance relationships, i.e. between patient and material, between patient and artist, or both.

Finally, within co-creation, resonance relationships between patient and both artist and material occur. These resonance relationships are defined by the four main characteristics of resonance theory: being affected, self-efficacy, uncontrollability and adaptive transformation. In our research, we found uncontrollability to be multi-layered encompassing five distinct modes of operation within co-creation. Also, artists consciously stimulate the emergence of resonance relationships. If these modes of operation and conscious creation of resonance relationships are also present in resonance relationships in other settings, this would be a further elaboration of resonance theory. As artists and their supervisors were not trained in, or familiar with resonance theory, the finding of the four main characteristics of resonance within co-creation could be seen as some form of confirmation of resonance theory as described by Rosa [21].

The total of the above-described findings could be used as a template to further unravel and understand the intricate process of co-creation.

Strengths of the study include that the artists were very experienced in their field of expertise, had previous experience in working with co-creation and had a high level of reflection on processes within themselves and in relation to the patient. Also, the involvement of artists with different fields of expertise and their ability to work with hybrid art forms contributed to creativity in the art making processes and as such positively affected artist-patient dynamics. A limitation of the study is that only the perspective of the artists is used while the perspective of the patients might be different. Thus, findings of the current study need to be confirmed by studies on the patients’ perspective.

Conclusion

This study showed uncontrollability and attunement to be important factors in co-creation. The study confirmed the presence of resonance relationships within co-creation and showed how these resonance relationships can be used within co-creation. Focus on elements of resonance relationships within co-creation, specifically attunement and practising with uncontrollability while working with art, could strengthen interventions targeting integration of life events, i.e. experiences of contingency. Interventions using art, specifically the joint creation of a work of art, may contribute to supportive care for survivors with advanced cancer. Yet, further research to confirm this in patients and to evaluate effects on quality of life is needed.