research on art as therapy

The Future of Mental Health

Dispatches on the latest efforts in psychological and psychiatric treatment

How Making Art Helps Improve Mental Health

With depression and anxiety on the rise during the pandemic, more professionals may adopt art therapy as a treatment

Daily Correspondent

Like many, Andrea Cooper felt increasingly isolated and lonely during the coronavirus pandemic. Cooper, a retired graphic designer and amateur folk musician who leads a grant-funded art program for cancer patients at Baltimore’s Mercy Medical Center, is a highly social person. So when the pandemic led to the cancellation of many of her activities and events, and caused others to be switched to Zoom, she missed her usual face-to-face connections with others.

As the pandemic dragged on, her mental health began to suffer even more. Eventually, Cooper’s depression got so bad that she had to be hospitalized. As part of her recovery, she participated in a ten-day inpatient program and began working with an art therapist.

Even though she’s an artist herself, Cooper was at first skeptical of the therapist’s prompts, which were meant to inspire Cooper and other patients to draw and paint as a means of working through their pain. But as Cooper spent more time thinking about her mental health, she began to deeply contemplate the therapist’s questions, including one about growth. “I thought about it and knew I was going to have to make some hard decisions in order to grow, that if I kept on the same track, things were not going to get any better,” says Cooper, who is 66.

In the end, she drew pair of pruning sheers cutting one of the stems of a rose bush. On her drawing, she wrote: “Sometimes you have to prune the flower to encourage growth.”

Cooper is one of the many individuals who have experienced the benefits of art therapy, an integrative treatment that uses artistic self-expression as a means of improving mental health and well-being. And as individuals continue to work through the mental health challenges brought on by the pandemic—which triggered a 25 percent increase in depression and anxiety around the globe, according to the World Health Organization —this niche therapy is poised to become even more popular. The pandemic brought up many difficult-to-define feelings and emotions, and making art in the presence of a licensed therapist can be a mindful, low-tech way to work through them.

Making art as a form of mental health treatment dates back to the mid-20th century, when soldiers returning from the battlefields of World War II were left with a condition that was known as “ shell shock ,” but is now called post-traumatic stress disorder . Veterans painted, drew, sculpted and made other forms of art to help process what they’d witnessed and experienced at war. “They struggled with traditional forms of medical and therapeutical intervention,” says Girija Kaimal , an art therapist at Drexel University and the president of the American Art Therapy Association (AATA). “Experiences like trauma are very difficult to articulate into words, so therapies that can support and connect patients with nonverbal expression are really the foundation of the creative arts therapies.”

The practice has been growing ever since. Today, around 5,000 art therapists practice in the United States, plus more around the world. They use the treatment to help patients in myriad situations. Children in schools have worked with art therapists to deal with social and emotional difficulties, behavioral disorders, ADHD, low self-esteem and other issues. Adults who have experienced some kind of trauma have tried it as well. Therapists have brought art to cancer patients undergoing chemotherapy, teens facing mental health issues, veterans , aging seniors , patients with eating disorders , prisoners and many other groups experiencing physical and mental health challenges.

Therapists offer treatment in groups or in one-on-one settings, and the therapy itself can take on many forms—from unstructured doodling to more specific prompts and activities designed to help patients make sense of their emotions. Patients can initially be reluctant to engage—often because they don’t consider themselves to be artistic or they haven’t made art since childhood—so therapists sometimes have to get creative. “I might ask them to make a gesture or even try to make a sound like a sigh, and then use colors, shapes and lines to show me what that looks like,” Cathy Malchiodi, an art therapist and the director of the Trauma-Informed Practices and Expressive Arts Therapy Institute, told Art in America magazine’s Jacoba Urist in October 2021.

Of course, humans—and our prehistoric ancestors—have been making art since long before art therapy became an established field. Though archaeologists disagree about exactly what constitutes art, they believe the practice dates back to at least the Paleolithic, tens of thousands of years ago . And though no one knows exactly why prehistoric individuals felt compelled to paint on and carve up the walls of caves, based on the amount and geographic reach of prehistoric art, they likely got some enjoyment out of this artistic expression. “Art-making for health and well-being is as old as the hills—it’s not anything new,” says Kaimal. “Every community has creative practices that we’ve engaged in for as long as we’ve been around.”

But why art? When patients have a hard time putting feelings into words, drawing, painting, sculpting, making collages, creating personalized papier-maché masks and engaging in other practices can help them unlock their emotions and translate them into something real. In the process, they’re able to share a bit of what they’re going through with the folks around them. Like other forms of therapy, art is also a safer, healthier way to channel stress and other negative emotions into action compared to destructive or harmful choices, says Kaimal. “Engaging in the artistic practice helps concretize and externalize these difficult inner experiences,” she says. “When we limit ourselves to just words, we’re losing a significant part of our lived experiences. Some people can put their feelings into words beautifully, but most of us cannot. To have additional expressive forms is really just allowing the whole person to present themselves.”

Research has found that making art can activate reward pathways in the brain, reduce stress , lower anxiety levels and improve mood . Various studies have also looked at its benefits among specific populations: It’s been linked with reduced post-traumatic stress disorder and depression among Syrian refugee children and lower levels of anxiety, PTSD and dissociation among children who were victims of sexual abuse, for example. Art therapy can help reduce pain and improve patients’ sense of control over their lives.

Because art therapy can be particularly helpful when folks don’t have the words to describe their experience or challenges, it’s ideally suited for improving mental health and well-being in the wake of the pandemic, which gave rise to abstract emotions like languishing and burnout . In AATA’s May 2020 coronavirus impact report , therapists pointed out that individuals are simply tired of talking about the pandemic and such feelings—and, because of all-day meetings on Zoom, talking in general. During art therapy, they don’t have to say a word if they don’t want to—but they can still work through their emotions. As one therapist noted in the survey, many clients “welcome expressing themselves using art materials, giving their brains a new task and their mouths a break.”

Making art is a hands-on process that requires total focus, which means it also offers a break from screentime , which surged during the pandemic. As Mallory Braus and Brenda Morton wrote in the journal Psychological Trauma: Theory, Research, Practice, and Policy in 2020, “In art therapy, mindfulness is what allows an individual to receive the therapeutic benefit of ‘tuning out’ the daily stress and anxiety and to focus on a single task while also focusing on the materials employed for self-expression.”

Art therapy isn’t a cure-all and it may not be the right approach for everyone—it often works well as a complement to other traditional therapies, Kaimal says—but it can have definite benefits. Still, researchers need to do more to fully understand how, why and when art therapy works. Much of the research draws on the anecdotal experiences of clinicians and patients, and many studies have had small sample sizes, Kaimal notes. Experts need to conduct more randomized control trials and larger-scale quantitative studies to help sway health insurance companies to recognize art therapy as a form of treatment—and pay for it. The field could also benefit from additional evidence around how art therapy affects different populations. “Compared to other mental health professions, we have a long way to go,” she says.

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Sarah Kuta is a writer and editor based in Longmont, Colorado. She covers history, science, travel, food and beverage, sustainability, economics and other topics.

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Review: systematic review of effectiveness of art psychotherapy in children with mental health disorders

• Review Article
• Open access
• Published: 06 July 2021
• Volume 191 , pages 1369–1383, ( 2022 )

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• Irene Braito   ORCID: orcid.org/0000-0002-3695-6464 1 , 2 ,
• Tara Rudd 3 ,
• Dicle Buyuktaskin   ORCID: orcid.org/0000-0003-4679-3846 1 , 4 ,
• Mohammad Ahmed 1 ,
• Caoimhe Glancy 1 &
• Aisling Mulligan   ORCID: orcid.org/0000-0001-7708-1177 3 , 5  

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Art therapy and art psychotherapy are often offered in Child and Adolescent Mental Health services (CAMHS). We aimed to review the evidence regarding art therapy and art psychotherapy in children attending mental health services. We searched PubMed, Web of Science, and EBSCO (CINHAL®Complete) following PRISMA guidelines, using the search terms (“creative therapy” OR “art therapy”) AND (child* OR adolescent OR teen*). We excluded review articles, articles which included adults, articles which were not written in English and articles without outcome measures. We identified 17 articles which are included in our review synthesis. We described these in two groups—ten articles regarding the treatment of children with a psychiatric diagnosis and seven regarding the treatment of children with psychiatric symptoms, but no formal diagnosis. The studies varied in terms of the type of art therapy/psychotherapy delivered, underlying conditions and outcome measures. Many were case studies/case series or small quasi-experimental studies; there were few randomised controlled trials and no replication studies. However, there was some evidence that art therapy or art psychotherapy may benefit children who have experienced trauma or who have post-traumatic stress disorder (PTSD) symptoms. There is extensive literature regarding art therapy/psychotherapy in children but limited empirical papers regarding its use in children attending mental health services. There is some evidence that art therapy or art psychotherapy may benefit children who have experienced trauma. Further research is required, and it may be beneficial if studies could be replicated in different locations.

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Art Therapy

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Introduction

Child and Adolescent Mental Health Services (CAMHS) often offer art therapy, as well as many other therapeutic approaches; we wished to review the literature regarding art therapy in CAMHS. Previous systematic reviews of art therapy were not specifically focused on the effectiveness in children [ 1 , 2 , 3 , 4 , 5 ] or were focused on the use of art therapy in children with physical conditions rather than with mental health conditions [ 6 ]. The use of art or doodling as a communication tool in CAMHS is long established—Donald Winnicott famously used “the Squiggle Game” to break boundaries between a patient and professional to narrate a story through a simple squiggle [ 7 ]. Art is particularly useful to build a rapport with a child who presents with an issue that is too difficult to verbalise or if the child does not have words to express a difficulty. The term art therapy was coined by the artist Adrian Hill in 1942 following admission to a sanatorium for the treatment of tuberculosis, where artwork eased his suffering. “Art psychotherapy” expands on this concept by incorporating psychoanalytic processes, seeking to access the unconscious. Jung influenced the development of art psychotherapy as a means to access the unconscious and stated that “by painting himself he gives shape to himself” [ 8 ]. Art psychotherapy often focuses on externalising the problem, reflecting on it and analysing it which may then give way to seeing a resolution.

The UK Joint Commissioning Panel for Mental Health 2013 recommends that psychotherapists and creative therapists are part of the CAMHS teams [ 9 ]. There is a specific UK recommendation that art therapy may be used in the treatment of children and young people recovering from psychosis, particularly those with negative symptoms [ 10 ], but no similar recommendation in the Irish HSE National Clinical Programme for Early Intervention in Psychosis [ 11 ]. There is less clarity about the use of art therapy in the treatment of depression in young people—arts therapies were previously recommended [ 12 ], but more recent NICE guidelines appear to have dropped this advice, though the recommendation for psychodynamic psychotherapy has remained [ 13 ]. Art therapy is often offered to treat traumatised children, but we note that current NICE guidelines on the management of PTSD do not include a recommendation for art therapy [ 14 ]. The Irish document “Vision for Change” did not include a recommendation regarding art psychotherapy or creative therapies [ 15 ]. Similarly, the document “Sharing the Vision” does not make any recommendation regarding creative or art therapies, though it recommends psychotherapy for adults and recommends arts activities as part of social prescribing for adults [ 16 ]. Meanwhile, it is not uncommon for there to be an art therapist in CAMHS inpatient units, working with those with the highest mental healthcare needs. We wished to find out more about the evidence for, or indeed against, the use of art therapy in CAMHS. We performed a systematic review which aimed to clarify if art psychotherapy is effective for use in children with mental health disorders. This review aimed to address the following questions: (1) Is art therapy/psychotherapy an effective treatment for children with mental health disorders? (2) What are the various methods of art therapy or art psychotherapy which have been used to treat children with mental health disorders and how do they differ in terms of (i) setting and duration, (ii) procedure of the sessions, and (iii) art activities details?

The Preferred Reporting Items for Systematic Reviews (PRISMA) statement for systematic reviews was followed. Searches and analysis were conducted between September 2016 and April 2020 using the following databases: PubMed, Web of Science and EBSCO (CINHAL®Complete). The following “medical subject terms” were utilized for searches: (“creative therapy” OR “art therapy”) AND (child* OR adolescent OR teen*). Review publications were excluded. Studies in the English language meeting the following inclusion criteria were selected: (i) use of art therapy/art psychotherapy, (ii) psychiatric disorder/diagnosis and/or mood disturbances and/or psychological symptoms, (iii) human participants aged 0–17 years inclusive. Articles investigating the efficiency of art therapy in children with medical conditions were included only if the measured outcome related to psychological well-being/symptoms. Exclusion criteria included: (i) application of therapies which do not involve art activities, (ii) application of a combination of therapies without individual results for art therapy, (iii) not clinical studies (review, meta-analysis, reports, others), (iv) studies which focused on the artwork itself/art therapy procedure and did not measure and publish any clinical outcomes, (v) absence of any pre psychiatric symptoms or comorbidity in the participant sample prior to art intervention. All articles were screened for inclusion by the authors (MA, TR, IB, AM, DB), unblinded to manuscript authorship.

Data extraction

The authors (IB, TR, AM, MA, DB) extracted all data independently (unblinded). Data were extracted and recorded in three tables with specific information from each study on (i) the study details, (ii) art therapy details and outcome measures and (iii) art therapy results. The following specific study details were extracted: author/journal, country, year of publication, study type (i.e. study design), study aims, study setting, participant details (number, age and gender), disease/disorder studied and inclusion criteria and exclusion criteria of the study. The following details were extracted regarding the art therapy provided and outcome measures : type of art therapy provided (individual or group therapy), the art therapy procedure and/or techniques used, the art therapy setting, therapy duration (including frequency and duration of each art therapy session), the type of outcome measure used, the investigated domains, the time points (for outcome measures) and the presence or absence of pre-/post-test statistical analysis. Finally, we extracted specific information on the art therapy results , including therapy group results, control group results, the number and percentage of who completed therapy, whether or not a pre-/post-test statistical difference was found and the general outcome of each study. Following the extraction of all data, studies included were divided into two groups: (1) children with psychiatric disorder diagnosis and (2) children with psychiatric symptoms. Finally, the QUADAS-2 tool was used to assess the risk of bias for each study, and a summary of the risk of bias for all data was calculated [ 17 ]. The QUADAS-2 is designed to assess and record selection bias, performance bias, detection bias, attrition bias, reporting bias and any other bias [ 17 ].

Study inclusion and assessment

A total of 1273 articles were initially identified (Fig.  1 ). After repeats and duplicates were removed, 1186 possible articles were identified and screened for inclusion/exclusion according to the title and abstract, which resulted in 1000 articles being excluded. The remaining 186 full articles were retrieved and full text considered. Following review of the full text, 70 articles were selected and further analysed. Fifty-three of them did not meet our criteria for review. Reasons for exclusion were grouped into four main categories: (1) not art therapy [ n  = 2]; (2) not mental health [ n  = 5]; (3) no outcome measured [ n  = 18]; (4) other reasons (i.e. descriptive texts, full article not available) [ n  = 28]. In conclusion, there were 17 articles remaining that met the full inclusion criteria, and further descriptive analysis was performed on these 17 studies. All the considered articles were produced in the twenty-first century, between 2001 and 2020, most in the USA (60%), followed by Canada (30%) and Italy (10%). The characteristics of studies included in our final synthesis are reported in Tables 1 and 2 .

PRISMA 2009 flow diagram

Participant characteristics

Participants in the 17 studies ranged from 2 to 17 years old inclusive. In ten articles, children with an established psychiatric diagnosis were included (Group 1, see Table 1 ). The type of psychiatric disorders as (i) PTSD, (ii) mood disorders (bipolar affective disorder, depressive disorders, anxiety disorder), (iii) self-harm behaviour, (iv) attachment disorder, (v) personality disorder and (vi) adjustment disorder. In seven articles, children with psychiatric symptoms were enrolled, usually referred by practitioners and school counsellors (Group 2, see Table 2 ). Participants had a wide variety of conditions including (i) symptoms of depression, anxiety, low mood, dysthymic features; (ii) attention and concentration disorder symptoms; (iii) socialisation problems and (iv) self-concept and self-image difficulties. Some children had medical conditions such as leukaemia requiring painful procedures, or glaucoma, cancer, seizures, acute surgery; others had experienced adversity such as parental divorce, physical, emotional and/or sexual abuse or had developed dangerous and promiscuous social habits (drugs, prostitution and gang involvement).

Study design: children with an established psychiatric diagnosis (Table 1 )

A summary of the ten studies on art therapy in children with a psychiatric diagnosis can be seen in Table 1 , with further information about each study. There are just two randomised controlled in this category, both treating PTSD in children [ 18 , 19 ]. Chapman et al. [ 18 ] provided individual art therapy to young children who had experienced trauma and assessed symptom response using the PTSD-I assessment of symptoms 1 week after injury and 1 month after hospital admission [ 18 ]. Their study included 85 children; 31 children received individual art therapy, 27 children received treatment as usual and 27 children did not meet criteria for PTSD on the initial PTSD-I assessment [ 18 ]. The art therapy group had a reduction in acute stress symptoms, but there was no significant difference in PTSD scores [ 18 ]. The second randomised controlled trial provided trauma-focused group art therapy in an inpatient setting and showed a significant reduction in PTSD symptoms in adolescents who attended art therapy in comparison to a control group who attended arts-and-crafts. However, this study had a high drop-out rate, with 142 patients referred to the study and just 29 patients who completed the study [ 19 ].

The remaining studies regarding art therapy or art psychotherapy in children with psychiatric disorders are case studies, case series or quasi experimental studies, most with less than five participants. All these studies reported positive effects of art therapy; we did not find any published negative studies. We can summarise that the studies differed greatly in the type of therapy delivered, in the setting (group or individual therapy) and in the types of disorders treated (Table 1 ).

Forms of art therapy intervention and assessment (Table 1 )

The various modalities and duration of art therapy described in the ten studies with children with psychiatric diagnoses are summarised in Table 1 . The treatment of PTSD was described in two studies, but each described a different art therapy protocol, and the studies varied in terms of setting and duration [ 18 , 19 ]. The Trauma Focused Art Therapy (TF-ART) study described 16 weekly in-patient group sessions [ 19 ], whereas the Chapman Art Therapy Treatment Intervention (CATTI) is a short-term individual therapy, lasting 1 h at the bedside of hospital inpatients [ 18 ]. Despite the differences, the methods have some common aspects. Both therapy methods focused on helping the individual express a narrative of his/her life story, supporting the individual to reflect on trauma-related experiences and to describe coping responses. Relaxation techniques were used, such as kinaesthetic activities [ 18 ] and “feelings check-ins” [ 19 ]. In the TF-ART protocol, each participant completed at least 13 collages or drawings and compiled in a hand-made book to describe his/her “life story” [ 19 ]. The use of art therapy in a traumatised child has also been described in a single case study [ 20 ].

Group art therapy has been described in the treatment of adolescent personality disorder, in an intervention where adolescents met weekly in two separate periods of 18 sessions over 6 months, with each session lasting 90 min, facilitated by a psychotherapist [ 21 ]. Sessions consisted of a short group conversation regarding events/issues during the previous week followed by a brief relaxing activity (e.g. listening to music), a period of art-making and an opportunity to explain their work, guided by the psychotherapist.

A long course of art psychotherapy over 3 years with a vulnerable female adolescent who presented with self-harm and later disclosed being a victim of a sexual assault has been described [ 22 ]. The young person described an “enemy” inside her which she had overcome in her testimony to her improvement, which was included in the published case study [ 22 ]. The approach of “art as therapy” has been described with children with bipolar disorder and other potential comorbidities, such as Asperger syndrome and attention deficit disorder, using the “naming the enemy” and “naming the friend” approaches [ 23 ].

The concept of the “transitional object”—a coping device for periods of separation in the mother–child dyad during infancy—has been considered in art therapy [ 24 ]. It was proposed that “transitional objects” could be used as bridging objects between a scary reality and the weak inner-self. Children brought their transitional objects to therapy sessions, and the therapy process aimed to detach the participant from his/her transitional object, giving him/her the strength to face life situations with his/her own capabilities [ 24 ].

Two studies of art therapy in children with adjustment disorders were included in our systematic review [ 25 , 26 ]. Children attended two or three video-recorded sessions and were encouraged to use art materials to explore daily life events. The child and therapist then watched the video-recorded session and participated in a semi-structured interview that employed video-stimulated recall. The therapy aimed to transport the participant to a comfortable imaginary world, giving the child the possibility to create powerful, strong characters in his/her story, thus enhancing the ability to cope with life’s challenges [ 25 , 26 ].

Outcome measures and statistical analysis (Table 1 )

Three articles on psychiatric disorders evaluated potential changes in outcome using an objective measure [ 18 , 19 , 22 ]. Two studies used the “The University of California at Los Angeles Children’s PTSD Index” (UCLA PTSD-I), which is a 20-item self-report tool [ 18 , 19 ]. Statistical differences were evaluated by calculating the mean percentage change [ 18 ] and the ANOVA [ 19 ]. The 12-item “MacKenzie’s Group Climate Questionnaire” was used to measure the outcome of group art therapy in adolescents with personality disorder, and a significant reduction in conflict in the group was found [ 21 ]. However, the sample size was small, and there was no control group [ 21 ]. Many studies did not use highly recognised measures of outcome but relied instead on a comprehensive description of outcome or change after art therapy/psychotherapy, in case studies or case series [ 20 , 22 , 23 , 24 , 25 , 26 , 27 ].

Study design: children with psychiatric symptoms (Table 2 )

We included seven studies in our review synthesis where art therapy or art psychotherapy was used as an intervention for psychiatric symptoms—many of these studies occurred in paediatric hospitals, where children were being treated for other conditions. Two of these studies were non-randomised controlled trials, one of which was waitlist controlled [ 28 , 29 ], and the other five were quasi-experimental studies [ 30 , 31 , 32 , 33 , 34 ].

Forms of intervention and assessment (Table 2 )

Three articles described art therapy in paediatric hospital patients but varied in terms of therapy and underlying condition [ 28 , 29 , 33 ]. The effectiveness of art therapy on self-esteem and symptoms of depression in children with glaucoma has been investigated; a number of sensory-stimulating art materials were introduced during six individual 1-h sessions [ 33 ]. Short-term or single individual art therapy sessions have also been used in hospital aiming to improve quality of life [ 28 , 29 ]. Art therapy has been provided to children with leukaemia; the children transformed unused socks into puppets called “healing sock creatures” [ 29 ]. Short-term art therapy prior to painful procedures, such as lumbar puncture or bone marrow aspiration, has also been described, using “visual imagination” and “medical play” with age-appropriate explanations about the procedure, with a cloth doll and medical instruments [ 28 ].

The remaining articles described the provision of art therapy to vulnerable patients, where the therapy aimed to increase self-confidence or address worries. Two studies focused on female self-esteem and self-concept, both using group activities [ 31 , 32 ]. Hartz and Thick [ 32 ] compared two different art therapy protocols: art psychotherapy, which employed a brief psychoeducational presentation and encouraged abstraction, symbolization and verbalization and an art as therapy approach, which highlighted design potentials, technique and the creative problem-solving process, trying to evoke artistic experimentation and accomplishment rather than different strengths and aspects of personality [ 32 ]. Participants completed a known questionnaire about self-esteem as well as a study-specific questionnaire.

Coholic and Eys [ 34 ] described the use of a 12-week arts-based mindfulness group programme with vulnerable children referred by mental health or child welfare services, with a combination of group work and individual sessions [ 34 ]. Children were given tasks which included the “thought jar” (filling an empty glass jar with water and various-shaped and coloured beads representing thoughts and feelings), the “me as a tree” activity, during which the participant drew him/herself as a tree, enabling the participant to introduce him/herself, the “emotion listen and draw” activity which provided the opportunity to draw/paint feelings while listening to five different songs and the “bad day better” activity which involved painting what a “bad day” looked like, and then to decorate it to turn it into a “good day”. The research included quantitative analysis and qualitative assessment using self-report Piers-Harris Children’s Self-Concept Scale and the Resiliency Scales for Children and Adolescents [ 37 , 38 ].

Kearns [ 30 ] described a single case study of art therapy with a child with a sensory integration difficulty, comparing teacher-reported behaviour patterns after art therapy sessions using kinaesthetic stimulation and visual stimulation with behaviour after 12 control sessions of non-art therapy; a greater improvement was reported with art therapy [ 30 ].

Outcome measures and statistical analysis (Table 2 )

Most of the studies on art therapy in children with psychiatric symptoms (but not confirmed disorders) used widely accepted outcome measures [ 29 , 30 , 31 , 32 , 33 , 34 ] (Table 2 ), such as self-report measurements including the 27-item symptom-orientated Children’s Depression Inventory or the Tennessee Self Concept Scale: Short Form [ 33 , 35 , 36 ]. The 60-item Piers-Harris Children’s Self-Concept Scale (2nd edition) and the Resiliency Scales for Children and Adolescents (RSCA) were used in a study on vulnerable children [ 34 , 37 , 38 ]. The Piers-Harris Children’s Self-Concept Scale is a widely used self-report measure of psychological health and self-concept in children and teens and consists of three global self-report scales presented in a 5-point Likert-type scale: sense of mastery (20 items), sense of relatedness (24 items) and emotional reactivity (20 items) [ 37 ]. A modified version of the Daley and Lecroy’s Go Grrrls Questionnaire was administered at group intake and follow-up, to rank various self-concept items including body image and self-esteem along a four-point ordinal scale in group therapy with young females [ 31 , 39 ].

Some researchers created their own outcome measures [ 28 , 29 , 30 , 33 ]. One study group created a mood questionnaire for young children—this was administered by a research assistant to patients before and after each therapy session, in their small wait-list controlled study [ 29 ]. Another group evaluated classroom performance using an observational system rated by the teacher for each 30-min block of time every day during the study [ 30 ]. The classroom study also used the “person picking an apple from a tree” (PPAT) drawing task—this was the only measurement tool in the studies we reviewed which assessed the features of the artworks themselves [ 30 , 40 ]. Pre- and post-test drawings were evaluated for evidence of changes in various qualities over the course of the research period [ 30 ].

Hartz and Thick [ 32 ] used both the 45-items Self-Perception Profile for Adolescents (SPPA) [ 41 ] which is widely used and considered reliable, as well as the Hartz Art Therapy Self-Esteem Questionnaire (Hartz AT-SEQ) [ 32 ], which is a 20-question post-treatment questionnaire designed by the author, to understand how specific aspects of art therapy treatment affect self-esteem in a quasi-experimental study with group art therapy. Four of the seven articles performed statistical analysis of the data collected, using the Wilcoxon signed-rank test [ 31 ], Fisher’s t [ 32 ], MANOVA [ 34 ], and two-tailed Student’s t test [ 29 ].

Assessment of bias

The QUADAS-2 assessment of bias for each study included in our systematic review synthesis can be seen in Table 3 , with a summary of the results of the QUADAS-2 assessment for all included studies in our review in Table 4 . Studies marked in green had a low risk of bias; those marked in red had a high risk of bias while those in yellow had an unclear risk of bias. Just two studies were found to have a low risk of bias [ 19 , 29 ].

We found extensive literature regarding the use of art therapy in children with mental health difficulties ( N  = 1273), with a large number of descriptive qualitative studies and cases studies, but a limited number of quantitative studies which we could include in our review synthesis ( N  = 17). The predominance of descriptive studies is not surprising considering that the field of art therapy and art psychotherapy has developed from the descriptive writings of Freud, Jung, Winnicott and others, and for many years, academic psychotherapy focused on detailed case descriptions rather than quantitative outcome studies. The numerous descriptive and qualitative publications generally described positive changes in participants undergoing art therapy, which may represent publication bias. Our aim was however to describe the quantitative evidence regarding the use of art therapy or art psychotherapy in children and adolescents with mental health difficulties, and we found a limited number of studies to include in our review synthesis. There were just two randomised controlled trials, no replication studies and insufficient information to allow for a meta-analysis. However, the articles in our review synthesis suggested that art therapy may have a positive outcome in various groups of patients, especially if the therapy lasts at least 8 weeks.

There is some evidence from controlled trials to support the use of art therapy in children who have experienced trauma [ 18 , 19 ]. It should be noted that art therapy or art psychotherapy was delivered as individual sessions in most of the studies in our review, especially for children with a psychiatric diagnosis. A group approach to art therapy was used in some studies with vulnerable children such as children in need, female adolescents with self-esteem issues and female offenders [ 22 , 31 , 34 ]. However, the studies on group art therapy or psychotherapy are quasi-experimental studies of limited size, and it would be useful if larger, more robust studies such as randomised controlled trials could study the efficacy of group art therapy or group art psychotherapy.

Many of the studies included in our review synthesis ranked low in the Cochrane Risk of Bias criteria, with a high risk of bias. Our review synthesis highlights the heterogeneity of the studies—various methods of individual or group art therapy were delivered, with some studies delivering psychoanalytic-type interventions while others delivered interventions resembling cognitive behaviour therapy, delivered via art. The literature also showed a general lack of standardisation with regard to the duration of art therapy and outcome measures used. Despite this, the authors of many of the studies described common themes and hypothesised about the value of art therapy or art psychotherapy in improving self-esteem, communication and integration. The interventions often encouraged the child to re-enact or to process trauma, and the authors described improved integration, and therapeutic change or transformation of the young person. It appears that there were varied interventions in the studies in the review synthesis but that many studies had theoretical similarities.

Strengths and limitations

We used clearly defined aims and followed PRISMA guidelines to perform this systematic review. However, we did not incorporate unpublished studies into our review and did not examine trial websites. By following strict exclusion criteria, we excluded studies on art psychotherapy and mental health where one or more participant commenced treatment before his/her eighteenth birthday and completed after the eighteenth birthday such as that by Lock et al. [ 42 ]. The Lock et al. [ 42 ] study may be of interest to those who are considering commissioning art therapy services for CAMHS, as it is a randomised controlled trial and suggests that art therapy may be a useful adjunct to Family-Based Treatment for adolescent anorexia nervosa in those with obsessive symptoms [ 42 ]. Our strict criteria also led us to exclude many studies where the primary focus was on educational issues including school behaviour or educational achievement—this is both a strength and limitation of our study. By excluding these studies, our systematic review can give useful information to CAMHS staff regarding the suitability of art therapy or art psychotherapy for children and adolescents with mental health difficulties. However, we note that a complete assessment of the effectiveness of art therapy or art psychotherapy in children would also include studies on the use of art therapy or art psychotherapy with children who have educational difficulties [ 43 , 44 ], those with physical illness or disability, as well as describing the many studies on art therapy or art psychotherapy in children who are refugees or living in emergency accommodation. We focused our review on quantitative research, but there are many mixed-methods studies in art therapy and art psychotherapy, where qualitative studies analysis may be used to generate hypotheses, and quantitative methods are used to test the hypothesis. A complete analysis of the effectiveness of art therapy or art psychotherapy in children could include summaries of qualitative or mixed-methods studies as well as quantitative studies.

Meanwhile, it should be noted that there is considerable evidence for the effectiveness of psychotherapy in general [ 45 , 46 ]. It has long been established that the common factors of alliance, empathy, expectations, cultural adaptation and therapist differences are important in the provision of effective psychotherapy [ 47 ]. Art therapy and art psychotherapy are more likely than the traditional talking therapies to provide these factors for those working with children.

Conclusions and future perspectives

There is extensive literature which suggests that art therapy or art psychotherapy provide a non-invasive therapeutic space for young children to work through and process their fears, trauma and difficulties. Art has been used to enhance the therapeutic relationship and provide a non-verbal means of communication for those unable to verbally describe their feelings or past experiences. We noted that there is considerably more qualitative and case description research than quantitative research regarding art therapy and art psychotherapy in children. We found some quantitative evidence that art therapy may be of benefit in the treatment of children who were exposed to trauma. However, while there are positive outcomes in many studies regarding art therapy for children with mental health difficulties, further robust research and randomised controlled trials are needed in order to define new and stronger evidence-based guidelines and to establish the true efficacy of art psychotherapy in this population. It would be helpful if there were studies with standardised outcome measures to facilitate cross comparison of results.

Availability of data and material

Data can be made available to reviewers if required.

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Acknowledgements

However we would like to acknowledge the support of the European Erasmus mobility scheme which allowed Dr. Irene Braito and Dr. Dicle Buyuktaskin to join the Department of Child and Adolescent Psychiatry, University College Dublin for placements. We would also like to acknowledge the summer student research scheme in University College Dublin which supported Mohammad Ahmed.

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Braito, I., Rudd, T., Buyuktaskin, D. et al. Review: systematic review of effectiveness of art psychotherapy in children with mental health disorders. Ir J Med Sci 191 , 1369–1383 (2022). https://doi.org/10.1007/s11845-021-02688-y

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Research Article

The effectiveness of art therapy for anxiety in adults: A systematic review of randomised and non-randomised controlled trials

Roles Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Faculty of Health, University of Applied Sciences Leiden, Leiden, The Netherlands, Clinical Neurodevelopmental Sciences, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands

Roles Conceptualization, Formal analysis, Investigation, Writing – review & editing

Affiliations Faculty of Health, University of Applied Sciences Leiden, Leiden, The Netherlands, KenVak, Research Centre for the Arts Therapies, Heerlen, The Netherlands

Roles Conceptualization, Writing – review & editing

Affiliations KenVak, Research Centre for the Arts Therapies, Heerlen, The Netherlands, Centre for the Arts Therapies, Zuyd University of Applied Sciences, Heerlen, The Netherlands, Faculty of Psychology and Educational Sciences, Open University, Heerlen, The Netherlands

Roles Writing – review & editing

Affiliation Clinical Neurodevelopmental Sciences, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands

Roles Conceptualization, Supervision, Writing – review & editing

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliation Faculty of Health, University of Applied Sciences Leiden, Leiden, The Netherlands

• Annemarie Abbing, 
• Anne Ponstein, 
• Susan van Hooren, 
• Leo de Sonneville, 
• Hanna Swaab, 

• Published: December 17, 2018
• https://doi.org/10.1371/journal.pone.0208716
• Reader Comments

Anxiety disorders are one of the most diagnosed mental health disorders. Common treatment consists of cognitive behavioral therapy and pharmacotherapy. In clinical practice, also art therapy is additionally provided to patients with anxiety (disorders), among others because treatment as usual is not sufficiently effective for a large group of patients. There is no clarity on the effectiveness of art therapy (AT) on the reduction of anxiety symptoms in adults and there is no overview of the intervention characteristics and working mechanisms.

A systematic review of (non-)randomised controlled trials on AT for anxiety in adults to evaluate the effects on anxiety symptom severity and to explore intervention characteristics, benefitting populations and working mechanisms. Thirteen databases and two journals were searched for the period 1997 –October 2017. The study was registered at PROSPERO (CRD42017080733) and performed according to the Cochrane recommendations. PRISMA Guidelines were used for reporting.

Only three publications out of 776 hits from the search fulfilled the inclusion criteria: three RCTs with 162 patients in total. All studies have a high risk of bias. Study populations were: students with PTSD symptoms, students with exam anxiety and prisoners with prelease anxiety. Visual art techniques varied: trauma-related mandala design, collage making, free painting, clay work, still life drawing and house-tree-person drawing. There is some evidence of effectiveness of AT for pre-exam anxiety in undergraduate students. AT is possibly effective in reducing pre-release anxiety in prisoners. The AT characteristics varied and narrative synthesis led to hypothesized working mechanisms of AT: induce relaxation; gain access to unconscious traumatic memories, thereby creating possibilities to investigate cognitions; and improve emotion regulation.

Conclusions

Effectiveness of AT on anxiety has hardly been studied, so no strong conclusions can be drawn. This emphasizes the need for high quality trials studying the effectiveness of AT on anxiety.

Citation: Abbing A, Ponstein A, van Hooren S, de Sonneville L, Swaab H, Baars E (2018) The effectiveness of art therapy for anxiety in adults: A systematic review of randomised and non-randomised controlled trials. PLoS ONE 13(12): e0208716. https://doi.org/10.1371/journal.pone.0208716

Editor: Vance W. Berger, NIH/NCI/DCP/BRG, UNITED STATES

Received: July 15, 2018; Accepted: November 22, 2018; Published: December 17, 2018

Copyright: © 2018 Abbing et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All files are available from https://tinyurl.com/yamju5x5 .

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Anxiety disorders are disorders with an ‘abnormal’ experience of fear, which gives rise to sustained distress and/ or obstacles in social functioning [ 1 ]. Among these disorders are panic disorder, social phobia, agoraphobia, specific phobia, obsessive-compulsive disorder (OCD) and generalized anxiety disorder (GAD). The prevalence of anxiety disorders is high: 12.0% in European adults [ 2 ] and 10.1% in the Dutch population [ 3 ]. Lifetime prevalence for women ranges from 16.3% [ 2 , 4 ] to 23.4% [ 3 ] and for men from 7.8% to 15.9% [ 2 , 3 ] in Europe. It is the most diagnosed mental health disorder in the US [ 5 ] and incidence levels have increased over the last half of the 20 th century [ 6 ].

Anxiety disorders rank high in the list of burden of diseases. According to the Global Burden of Disease study [ 7 ], anxiety disorders are the sixth leading cause of disability, in terms of years lived with disability (YLDs), in low-, middle- and high-income countries in 2010. They lead to reduced quality of life [ 8 ] and functional impairment, not only in personal life but also at work [ 4 , 9 , 10 ] and are associated with substantial personal and societal costs [ 11 ].

The most common treatments of anxiety disorders are cognitive behavioral therapy (CBT) and/ or pharmacotherapy with benzodiazepines, tricyclic antidepressants, monoamine oxidase inhibitors and selective serotonin reuptake inhibitors [ 1 ]. These treatments appear to be only moderately effective. Pharmacological treatment causes side effects and a significant percentage of patients (between 20–50% [ 12 – 15 ] is unresponsive or has a contra-indication. Combination with CBT is recommended [ 16 ] but around 50% of patients with anxiety disorders do not benefit from CBT [ 17 ].

To increase the effectiveness of treatment of anxiety disorders, additional therapies are used in clinical practice. An example is art therapy (AT), which is integrated in several mental health care programs for people with anxiety (e.g. [ 18 , 19 ]) and is also provided as a stand-alone therapy. AT is considered an important supportive intervention in mental illnesses [ 20 – 22 ], but clarity on the effectiveness of AT is currently lacking.

AT uses fine arts as a medium, like painting, drawing, sculpting and clay modelling. The focus is on the process of creating and (associated) experiencing, aiming for facilitating the expression of memories, feelings and emotions, improvement of self-reflection and the development and practice of new coping skills [ 21 , 23 , 24 ].

AT is believed to support patients with anxiety in coping with their symptoms and to improve their quality of life [ 20 ]. Based on long-term experience with treatment of anxiety in practice, AT experts describe that AT can improve emotion regulation and self-structuring skills [ 25 – 27 ] and can increase self-awareness and reflective abilities [ 28 , 29 ]. According to Haeyen, van Hooren & Hutschemakers [ 30 ], patients experience a more direct and easier access to their emotions through the art therapies, compared to verbal approaches. As a result of these experiences, AT is believed to reduce symptoms in patients with anxiety.

Although AT is often indicated in anxiety, its effectiveness has hardly been studied yet. In the last decade some systematic reviews on AT were published. These reviews covered several areas. Some of the reviews focussed on PTSD [ 31 – 34 ], or have a broader focus and include several (mental) health conditions [ 35 – 39 ]. Other reviews included AT in a broader definition of psychodynamic therapies [ 40 ] or deal with several therapies (CBTs, expressive art therapies (e.g., guided imagery and music therapy), exposure therapies (e.g., systematic desensitization) and pharmacological treatments within one treatment program) [ 41 ].

No review specifically aimed at the effectiveness of AT on anxiety or on specific anxiety disorders. For anxiety as the primary condition, thus not related to another primary disease or condition (e.g. cancer or autism), there is no clarity on the evidence nor of the employed therapeutic methods of AT for anxiety in adults. Furthermore, clearly scientifically substantiated working mechanism(s), explaining the anticipated effectiveness of the therapy, are lacking.

The primary objective is to examine the effectiveness of AT in reducing anxiety symptoms.

The secondary objective is to get an overview of (1) the characteristics of patient populations for which art therapy is or may be beneficial, (2) the specific form of ATs employed and (3) reported and hypothesized working mechanisms.

Protocol and registration

The systematic review was performed according to the recommendations of the Cochrane Collaboration for study identification, selection, data extraction, quality appraisal and analysis of the data [ 42 ]. The PRISMA Guidelines [ 43 ] were followed for reporting ( S1 Checklist ). The review protocol was registered at PROSPERO, number CRD42017080733 [ 44 ]. The AMSTAR 2 checklist was used to assess and improve the quality of the review [ 45 ].

Eligibility criteria

Types of study designs..

The review included peer reviewed published randomised controlled trials (RCTs) and non-randomised controlled trials (nRCTs) on the treatment of anxiety symptoms. nRCTs were also included because it was hypothesized that nRCTs are more executed than RCTs, for the research field of AT is still in its infancy.

Only publications in English, Dutch or German were included. These language restrictions were set because the reviewers were only fluent in these three languages.

Types of participants.

Studies of adults (18–65 years), from any ethnicity or gender were included.

Types of interventions.

AT provided to individuals or groups, without limitations on duration and number of sessions were included.

Types of comparisons.

The following control groups were included: 1) inactive treatment (no treatment, waiting list, sham treatment) and 2) active treatment (standard care or any other treatment). Co-interventions were allowed, but only if the additional effect of AT on anxiety symptom severity was measured.

Types of outcome measures.

Included were studies that had reduction of anxiety symptoms as the primary outcome measure. Excluded were studies where reduction of anxiety symptoms was assessed in non-anxiety disorders or diseases and studies where anxiety symptoms were artificially induced in healthy populations. Populations with PTSD were not excluded, since this used to be an anxiety disorder until 2013 [ 46 ].

The following 13 databases and two journals were searched: PUBMED, Embase (Ovid), EMCare (Ovid), PsychINFO (EBSCO), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Review of Effects, Web of Science, Art Index, Central, Academic Search Premier, Merkurstab, ArtheData, Reliëf, Tijdschrift voor Vaktherapie.

A search strategy was developed using keywords (art therapy, anxiety) for the electronic databases according to their specific subject headings or structure. For each database, search terms were adapted according to the search capabilities of that database ( S1 File Full list of search terms).

The search covered a period of twenty years: 1997 until October 9, 2017. The reference lists of systematic reviews—found in the search—were hand searched for supplementing titles, to ensure that all possible eligible studies would be detected.

Study selection

A single endnote file of all references identified through the search processes was produced. Duplicates were removed.

The following selection process was independently carried out by two researchers (AA and AP). In the first phase, titles were screened for eligibility. The abstracts of the remaining entries were screened and only those that met the inclusion criteria were selected for full text appraisal. These full texts were subsequently assessed according to the eligibility criteria. Any disagreement in study selection between the two independent reviewers was resolved through discussion or by consultation of a third reviewer (EB).

Data collection process

The data were extracted by using a data extraction spreadsheet, based on the Cochrane Collaboration Data Collection Form for intervention reviews ( S1 Table Data collection form).

The form concerned the following data: aim of the study, study type, population, number of treated subjects, number of controlled subjects, AT description, duration, frequency, co-intervention(s), control description, outcome domains and outcome measures, time points, outcomes and statistics.

After separate extraction of the data, the results of the two independent assessors were compared and discussed to reach consensus.

Risk of bias in individual studies

The risk of bias (RoB) was independently assessed by the two reviewers with the Cochrane Collaboration’s tool for assessing RoB [ 47 ]. Bias was assessed over the domains: selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of researchers conducting outcome assessments), attrition bias (incomplete outcome data), reporting bias (selective reporting). A judgement of ‘low’, ‘high’ or ‘unclear’ risk of bias was provided for each domain. Since the RoB tool was developed for use in pharmacological studies, we followed the recommendations of Munder & Barth [ 48 ] that placed the RoB tool in the context of psychotherapy outcome research. Performance bias is defined here as "studies that did not use active control groups or did not assess patient expectancies or treatment credibility", instead of only 'blinding of participants and personnel'.

A summary assessment of RoB for each study was based on the approach of Higgins & Green [ 47 ]: overall low RoB (low risk of bias in all domains), unclear RoB (unclear RoB in at least one domain) and high RoB (unclear RoB in more than one domain or high RoB in at least one domain).

The primary outcome measure was anxiety symptoms reduction (pre-post treatment). The outcomes are presented in terms of differences between intervention and control groups (e.g., risk ratios or odds ratios). Within-group outcomes are also presented, to identify promising outcomes and hypotheses for future research.

Data from studies were combined in a meta-analyses to estimate overall effect sizes, if at least two studies with comparable study populations and treatment were available that assessed the same specific outcomes. Heterogeneity was examined by calculating the I 2 statistic and performing the Chi 2 test. If heterogeneity was considered relevant, e.g. I 2 statistic greater than 0.50 and p<0.10, sources of heterogeneity were investigated, subanalyses were performed as deemed clinically relevant, and subtotals only, or single trial results were reported. In case of a meta-analysis, publication bias was assessed by drawing a funnel plot based on the primary outcome from all trials and statistical analysis of risk ratios or odds ratios as the measure of treatment effect.

A content analysis was conducted on the characteristics of the employed ATs, the target populations and the reported or hypothesized working mechanisms.

Quality of evicence

Quality (or certainty) of evidence of the studies with significant outcomes only was was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) [ 49 ]. Evidence can be scored as high, moderate, low or very low, according to a set of criteria.

The search yielded 776 unique citations. Based on title and abstract, 760 citations were excluded because the language was not English, Dutch or German (n = 23), were not about anxiety (n = 164), or it concerned anxiety related to another primary disease or condition (n = 175), didn’t concern adults (18–65 years) (n = 152), were not about AT (n = 94), were not a controlled trial (n = 131), or were lacking a control group (n = 22) or anxiety symptoms were not used as outcome measure (n = 1).

Of the remaining 16 full text articles, 13 articles were excluded. Reasons were: lack of a control group [ 50 – 54 ], anxiety was related to another primary disease or condition [ 55 , 56 ], or the study population consisted of healthy subjects [ 57 , 58 ], did not concern subjects in the age between 18–65 years [ 59 ], or was not peer-reviewed [ 60 ] or did not have pre-post measures of anxiety symptom severity [ 61 , 62 ]. A list of all potentially relevant studies that were excluded from the review after reading full-texts, is presented in S2 Table Excluded studies with reasons for exclusion . Finally, three studies were included for the systematic review ( Fig 1 ).

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https://doi.org/10.1371/journal.pone.0208716.g001

Screening of references from systematic reviews.

The systematic literature search yielded 15 systematic reviews. All titles from the reference lists of these reviews were screened (n = 999), of which 27 publications were eligible for abstract screening and were other than the 938 citations found in the search described above (see Study selection). From these abstracts, 18 were excluded because they were not peer reviewed (n = 3), not in English, Dutch or German (n = 1), not about anxiety (n = 2), or were about anxiety related to cancer (n = 2), were not about AT (n = 2) or were not a controlled trial (n = 8). Nine full texts were screened for eligibility and were all excluded. Six full texts were excluded because these concerned psychodynamic therapies and did not include AT [ 63 – 68 ]. Two full texts were excluded because they concerned multidisciplinary treatment and no separate effects of AT were measured [ 18 , 19 ]. The final full text was excluded because it concerned induced worry in a healthy population [ 69 ]. No studies remained for quality appraisal and full review. The justified reasons for exclusion of all potentially relevant studies that were read in full-text form, is presented in S2 Table Excluded studies with reasons for exclusion .

Study characteristics

The review includes three RCTs. The study populations of the included studies are: students with PTSD symptoms and two groups of adults with fear for a specific situation: students prior to exams and prisoners prior to release. The trials have small to moderate sample sizes, ranging from 36 to 69. The total number of patients in the included studies is 162 ( Table 1 ).

https://doi.org/10.1371/journal.pone.0208716.t001

In one study, AT is combined with another treatment: a group interview [ 72 ]. The other two studies solely concern AT ( Table 2 ) [ 70 , 71 ].

https://doi.org/10.1371/journal.pone.0208716.t002

The provided AT varies considerably: mandala creation in which the trauma is represented [ 70 ] or colouring a pre-designed mandala, free clay work, free form painting, collage making, still life drawing [ 71 ], and house-tree-person drawings (HTP) [ 72 ]. Session duration differs from 20 minutes to 75 minutes. The therapy period ranges from only once to eight weeks, with one to ten sessions in total ( Table 2 ). In one study, the control group receives the co-intervention only: group interview in Yu et al. [ 72 ]. Henderson et al. [ 70 ] use three specific drawing assignments as control condition, which are not focussed on trauma, opposed to the provided art therapy in the experimental group. Sandmire et al. [ 71 ] used inactive treatment. Here, AT is compared to comfortably sitting. Study settings were outpatient: universities (US) and prison (China). None of the RCTs reported on sources of funding for the studies.

See S3 Table for an extensive overview of characteristics and outcomes of the included studies.

Risk of bias within studies

Based on the Cochrane Collaboration’s tool for assessing risk of bias, estimations of bias were made. Table 3 shows that the risk of bias (RoB) is high in all studies.

https://doi.org/10.1371/journal.pone.0208716.t003

Selection bias : overall, methods of randomization were not always described and selection bias can therefore not be ruled out, which leads to unclear RoB. Henderson et al. [ 70 ] described the randomisation of participants over experimental and control groups. However, it is unclear how gender and type of trauma are distributed. Sandmire et al. [ 71 ] did not describe the randomization method but there was no baseline imbalance. Also Yu et al. [ 72 ] did not decribe the randomisation method, but two comparable groups were formed as concluded on baseline measures. Nevertheless it is unclear whether psychopathology of control and experimental groups are comparable.

Performance bias : Sandmire’s RCT had inactive control, which gives a high risk on performance bias [ 48 ]. Like in psychotherapy outcome research, blinding of patients and therapists is not feasible in AT [ 48 , 73 ]. It is not possible to judge whether the lack of blinding influenced the outcomes and also none of the studies assessed treatment expectancies or credibility prior to or early in treatment, so all studies were scored as ‘high risk’ on performance bias.

Detection bias : in all studies only self-report questionnaires were used. The questionnaires used are all validated, which allows a low risk score of response bias. However, the exact circumstances under which measures are used are not described [ 70 , 71 ] and may have given rise to bias. Presence of the therapist and or fear for lack of anonymity may have influenced scores and may have led to confirmation bias (e.g.[ 74 ]), which results in a ‘unclear’ risk of detection bias.

Attrition bias : in the study of Henderson it is not clear whether the outcome dataset is complete.

Reporting bias : there are no reasons to expect that there has been selective reporting in the studies.

Other issues : in Sandmire et al. [ 71 ] it was noted that the study population constists of liberal arts students, who are likely to have positive feelings towards art making and might expericence more positive effects (reduction of anxiety) than students from other disciplines.

Overall risk of bias : since all studies had one or more domains with high RoB, the overall RoB was high.

Outcomes of individual studies

The measures used in the studies are shown in Table 4 . The outcome measures for anxiety differ and include the State-Trait Anxiety Inventory (STAI) (used in two studies), the Hamilton Anxiety Rating Scale (HAM-A) and the Zung Self-rating Anxiety Scale (SAS) (used in one study). Quality of life was not measured in any of the included studies.

https://doi.org/10.1371/journal.pone.0208716.t004

Anxiety–in study with inactive control.

Sandmire et al. [ 71 ] showed significant between-group effects of art making on state anxiety (tested with ANOVA: experimental group (mean (SD)): 39.3 (9.4) - 29.5 (8.6); control group (mean (SD)): 36.2 (8.8) - 36.0 (10.9)\; p = 0.001) and on trait anxiety (experimental group (mean (SD)): 39.1 (5.8) - 33.3 (6.1); control group (mean (SD)): 38.2 (10.2) - 37.3 (11.2); p = 0.004) There were no significant differences in effectiveness between the five types of art making activities.

Anxiety–in studies with active control.

Henderson et al. [ 70 ] reported no significant effect of creating mandalas (trauma-related art making) versus random art making on anxiety symptoms (tested with ANCOVA: experimental group (mean (SD)): 45.05 (10.75) - 41.16 (11.30); control group (mean (SD): 49.05 (12.29) - 44.05 (10.12), p -value: not reported) immediately after treatment. At follow-up after one month there was also no significant effect of creating mandalas on anxiety symptoms: experimental group (mean (SD): 40.95 (11.54); control group (mean (SD): 42.0 (13.26)), but there was significant improvement of PTSD symptom severity at one-month follow-up ( p = 0.015).

Yu et al. (2016) did not report analyses of between-group effects. Only the experimental group, who made HTP drawings followed by group interview, showed a significant pre- versus post-treatment reduction of anxiety symptoms (two-tailed paired sample t-tests: HAM-A (mean (SD): 24.36 (9.11) - 17.42 (10.42), p = 0.001; SAS (mean (SD): 62.63 (9.46) - 56.78 (11.64,) p = 0.004). The anxiety level in the control group on the other hand, who received only group interview, increased between pre- and post-treatment (HAM-A (mean (SD): 24.75 (6.14) - 25.22 (7.37), not significant; SAS (mean (SD): 62.57 (7.36) - 66.11 (10.41), p = 0.33).

Summary of outcomes and quality.

Of three included RCTs studying the effects of AT on reducing anxiety symptoms, one RCT [ 71 ] showed a significant anxiety reduction, one RCT [ 72 ] was inconclusive because no between-group outcomes were provided, and one RCT [ 70 ] found no significant anxiety reduction, but did find signifcant reduction of PTSD symptoms at follow-up.

Regarding within-group differences, two studies [ 71 , 72 ] showed significant pre-posttreatment reduction of anxiety levels in the AT groups and one did not [ 70 ].

The quality of the evidence in Sandmire [ 71 ] as assessed with the GRADE classification is low to very low (due to limited information the exact classification could not be determined). The crucial risk of bias, which is likely to serious alter the results [ 49 ], combined the with small sample size (imprecision [ 75 ]) led to downgrading of at least two levels.

Meta-analysis.

Because data were insufficiently comparable between the included studies due to variation in study populations, control treatments, the type of AT employed and the use of different measures, a meta-analysis was not performed.

Narrative synthesis

Benefiting populations..

AT seems to be effective in the treatment of pre-exam anxiety (for final exams) in adult liberal art students [ 71 ], although the quality of evidence is low due to high RoB. Based on pre-posttreatment anxiety reduction (within-group analysis) AT may be effective for adult prisoners with pre-release anxiety [ 72 ].

Characteristics of AT for anxiety.

Sandmire et al. [ 71 ] gave students with pre-exam stress one choice out of five art-making activities: mandala design, free painting, collage making, free clay work or still life drawing. The activity was limited to one session of 30 minutes. This was done in a setting simulating an art center where students could use art materials to relieve stress. The mandala design activity consisted of a pre-designed mandala which could be completed by using pencils, tempera paints, watercolors, crayons or markers. The free form painting activity was carried out on a sheet of white paper using tempera or water color paints which were used to create an image from imagination. Participants could also use fine-tip permanent makers, crayons, colored pencils and pastels to add detailed design work upon completion of the initial painting. Collage making was also one of the five options. This was done with precut images and text, by further cutting out the images and additonal images from provided magazins and gluing them on a white piece of paper. Participants could also choose for a clay activity to make a ‘pleasing form’. Examples were a pinch pot, coil pot and small animal figures. The final option for art-making was a still life drawing, by arranging objects into a pleasing assembly and drafting with pencil. Additionally, diluted sepia ink could be used to paint in tonal values.

Yu et al. [ 72 ] used the HTP drawings in combination with group interviews about the drawings, to treat pre-release anxiety in male prisoners. The procedure consists of drawing a house, a tree and a person as well as some other objects on a sheet of paper. Yu follows the following interpretation: the house is regarded as the projection of family, the tree represents the environment and the person represents self-identification [ 76 ]. The HTP drawing is usually used as a diagnostic tool, but is used in this study as an intervention to enable prisoners to become more aware of their emotional issues and cognitions in relation to their upcoming release. A counselor gives helpful guidance based on the drawing and reflects on informal or missing content, so that the drawings can be enriched and completed. After completion of the drawings, prisoners participated in a group interview in which the unique attributes of the drawings are related to their personal situation and upcoming release.

Henderson et al. [ 70 ] treated traumatised students with mandala creation, aiming for the expression and representation of feelings. The participants were asked to draw a large circle and to fill the circle with feelings or emotions related to their personal trauma. They could use symbols, patterns, designs and colors, but no words. One session lasted 20 minutes and the total intervention consisted of three sessions, on three consecutive days. One month after the intervention, the participants were asked about the symbolic meaning of the mandala drawings.

Working mechanisms of AT.

Sandmire used a single administration of art making to treat the handling of stressful situations (final exams) of undergraduate liberal art students. The art intervention did not explicitly expose students to the source of stress, hence a general working mechanism of AT is expected. The authors claim that art making offers a bottom-up approach to reduce anxiety. Art making, in a non-verbal, tactile and visual manner, helps entering a flow-like-state of mind that can reduce anxiety [ 77 ], comparable to mindfulness.

Yu reports that nonverbal symbolic methods, like HTP-drawing, are thought to reflect subconscious self-relevant information. The process of art making and reflection upon the art may lead to insights in emotions and (wrong) cognitions that can be addressed during counseling. The authors state that “HTP-drawing is a natural, easy mental intervention technique through which counselors can guide prisoners to form helpful cognitions and behaviors within a relative relaxing and well-protected psychological environment”. In this case the artwork is seen as a form of unconscious self-expression that opens up possibilities for verbal reflections and counseling. In the process of drawing, the counselor gives guidance so the drawing becomes more complete and enriched, what possibly entails a positive change in the prisoners’ cognitive patters and behavior.

Henderson treated PTSD symptoms in students and expected the therapy to work on anxiety symptoms as well. The AT intervention focussed on the creative expression of traumatic memories, which can been seen as an indirect approach to exposure, with active engagement. The authors indicate that mandala creation (related to trauma) leads to changes in cognition, facilitating increasing gains. Exposure, recall and emotional distancing may be important attributes to recovery.

Summarizing, three different types of AT can be distinguised: 1) using art-making as a pleasant and relaxing activity; 2) using art-making for expression of (unconsious) cognitive patterns, as an insightful tool; and 3) using the art-making process as a consious expression of difficult emotions and (traumatic) memories.

Based on these findings, we can hypothesize that AT may contribute to reducing anxiety symptom severity, because AT may:

• induce relaxation, by stimulating a flow-like state of mind, presumably leading to a reduction of cortisol levels and hence stress and anxiety reduction (stress regulation) [ 71 ];
• make the unconscious visible and thereby creating possibilities to investigate emotions and cognitions, contributing to cognitive regulation [ 70 , 72 ].
• create a safe environment for the conscious expression of (difficult) emotions and memories, what is similar to exposure, recall and emotional distancing, possibly leading to better emotion regulation [ 70 ].

Currently there is no overview of evidence of effectiveness of AT on the reduction of anxiety symptoms and no overview of the intervention characteristics, the populations that might benefit from this treatment and the described and/ or hypothesized working mechanisms. Therefore, a systematic review was performed on RCTs and nRCTs, focusing on the effectiveness of AT in the treatment of anxiety in adults.

Summary of evidence and limitations at study level

Three publications out of 776 hits of the search met all inclusion and exclusion criteria. No supplemented publications from the reference lists (999 titles) of 15 systematic reviews on AT could be included. Considering the small amount of studies, we can conclude that effectiveness research on AT for anxiety in adults is in a beginning state and is developing.

The included studies have a high risk of bias, small to moderate sample sizes and in total a very small number of patients (n = 162). As a result, there is no moderate or high quality evidence of the effectiveness of AT on reducing anxiety symptom severity. Low to very low-quality of evidence is shown for AT for pre-exam anxiety in undergraduate students [ 71 ]. One RCT on prelease anxiety in prisoners [ 72 ] was inconclusive because no between-group outcome analyses were provided, and one RCT on PTSD and anxiety symptoms in students [ 70 ] found significant reduction of PTSD symtoms at follow-up, but no significant anxiety reduction. Regarding within-group differences, two studies [ 71 , 72 ] showed significant pre-posttreatment reduction of anxiety levels in the AT groups and one did not [ 70 ]. Intervention characteristics, populations that might benefit from this treatment and working mechanisms were described. In conclusion, these findings lead us to expect that art therapy may be effective in the treatment of anxiety in adults as it may improve stress regulation, cognitive regulation and emotion regulation.

Strengths and limitations of this review

The strength of this review is firstly that it is the first systematic review on AT for primary anxiety symptoms. Secondly, its quality, because the Cochrane systematic review methodology was followed, the study protocol was registered before start of the review at PROSPERO, the AMSTAR 2 checklist was used to assess and improve the quality of the review and the results were reported according to the PRISMA guidelines. A third strength is that the search strategy covers a long period of 20 years and a large number of databases (13) and two journals.

A first limitation, according to assessment with the AMSTAR 2 checklist, is that only peer reviewed publications were included, which entails that many but not all data sources were included in the searches. Not included were searches in trial/study registries and in grey literature, since peer reviewed publication was an inclusion criterion. Content experts in the field were also not consulted. Secondly, only three RCTs met the inclusion criteria, each with a different target population: students with moderate PTSD, students with pre-exam anxiety and prisoners with pre-release anxiety. This means that only a small part of the populations of adults with anxiety (disorders) could be studied in this review. A third (possible) limitation concerns the restrictions regarding the included languages and search period applied (1997- October 2017). With respect to the latter it can be said that all included studies are published after 2006, making it likely that the restriction in search period has not influenced the outcome of this review. No studies from 1997 to 2007 met the inclusion and exclusion criteria. This might indicate that (n)RCTs in the field of AT, aimed at anxiety, are relatively new. A fourth limitation is the definition of AT that was used. There are many definitions for AT and discussions about the nature of AT (e.g. [ 78 ]). We considered an intervention to be art therapy in case the visual arts were used to promote health/wellbeing and/or the author called it art therapy. Thus, only art making as an artistic activity was excluded. This may have led to unwanted exclusion of interesting papers.

A fifth limitation is the use of the GRADE approach to assess the quality of evidence of art therapy studies. This tool is developed for judging quality of evidence of studies on pharmacological treatments, in which blinding is feasible and larger sample sizes are accustomed. However the assessed study was a RCT on art therapy [ 71 ], in which blinding of patients and therapists was not possible. Because the GRADE approach is not fully tailored for these type of studies, it was difficult to decide whether the the exact classification of the available evidence was low or very low.

Comparison to the AT literature

The results of the review are in agreement with other findings in the scientific literature on AT demonstrating on the one hand promising results of AT and on the other hand showing many methodological weaknesses of AT trials. For example, other systematic reviews on AT also report on promising results for art therapy for PTSD [ 31 – 34 , 37 ] and for a broader range of (mental) health conditions [ 35 – 39 ], but since these reviews also included lower quality study designs next to RCTs and nRCTs, the quality of this evidence is likely to be low to very low as well. These reviews also conclude on methodological shortcomings of art therapy effectiveness studies.

Three approaches in AT were identified in this review: 1) using art-making as a relaxing activity, leading to stress reduction; 2) using the art-making process as a consious pathway to difficult emotions and (traumatic) memories; leading to better emotion regulation; and 3) using art-making for expression, to gain insight in (unconscious) cognitive patterns; leading to better cognitive regulation.

These three approaches can be linked to two major directions in art therapy, identified by Holmqvist & Persson [ 74 ]: “art-as-therapy” and “art-in-psychotherapy”. Art-as-therapy focuses on the healing ability and relaxing qualities of the art process itself and was first described by Kramer in 1971 [ 79 ]. This can be linked to the findings in the study of Sandmire [ 71 ], where it is suggested that art making led to lower stress levels. Art making is already associated with lower cortisol levels [ 80 ]. A possible explanation for this finding can be that a trance-like state (in flow) occurs during art-making [ 81 ] due to the tactile and visual experience as well as the repetitive muscular activity inherent to art making.

Art-in-psychotherapy , first described by Naumberg [ 82 ] encompasses both the unconscious and the conscious (or semi-conscious) expression of inner feelings and experiences in apparently free and explicit exercises respectively. The art work helps a patient to open up towards their therapist [ 74 ], so what the patient experienced during the process of creating the art work, can be deepened in conversation. In practice, these approaches often overlap and interweave with one another [ 83 ], which is probably why it is combined in one direction ‘art-in-psychotherapy’. It might be beneficial to consider these ways of conscious and unconscious expression separately, because it is a fundamental different view on the importance of art making.

The overall picture of the described and hypothesized working mechanisms that emerged in this review lead to the hypotheses that anxiety symptoms may decrease because AT may support stress regulation (by inducing relaxation, presumably comparable to mindfulness [ 64 , 84 ], emotion regulation (by creating the safe condition for expression and examination of emotions) and cognitive regulation (as art work opens up possibilities to investigate (unconscious) cognitions). These types of regulation all contribute to better self-regulation [ 85 ]. The hypothesis with respect to stress regulation is further supported by results from other studies. The process of creating art can promote a state of mindfulness [ 57 ]. Mindfulness can increase self-regulation [ 84 ] which is a moderator between coping strength and mental symptomatology [ 86 ]. Improving patient’s self-regulation leads, amongst others, to improvement of coping with disease conditions like anxiety [ 85 , 86 ]. Our findings are in accordance with the findings of Haeyen [ 30 ], stating that patients learn to express emotions more effectively, because AT enables them to “examine feelings without words, pre-verbally and sometimes less consciously”, (p.2). The connection between art therapy and emotion regulation is also supported by the recently published narrative review of Gruber & Oepen [ 87 ], who found significant effective short-term mood repair through art making, based on two emotion regulation strategies: venting of negative feelings and distraction strategy: attentional deployment that focuses on positive or neutral emotions to distract from negative emotions.

Future perspectives

Even though this review cannot conclude effectiveness of AT for anxiety in adults, that does not mean that AT does not work. Art therapists and other care professionals do experience the high potential of AT in clinical practice. It is challenging to find ways to objectify these practical experiences.

The results of the systematic review demonstrate that high quality trials studying effectiveness and working mechanisms of AT for anxiety disorders in general and specifically, and for people with anxiety in specific situations are still lacking. To get high quality evidence of effectiveness of AT on anxiety (disorders), more robust studies are needed.

Besides anxiety symptoms, the effectiveness of AT on aspects of self-regulation like emotion regulation, cognitive regulation and stress regulation should be further studied as well. By evaluating the changes that may occur in the different areas of self-regulation, better hypotheses can be generated with respect to the working mechanisms of AT in the treatment of anxiety.

A key point for AT researchers in developing, executing and reporting on RCTs, is the issue of risk of bias. It is recommended to address more specifically how RoB was minimalized in the design and execution of the study. This can lower the RoB and therefor enhance the quality of the evidence, as judged by reviewers. One of the scientific challenges here is how to assess performance bias in AT reviews. Since blinding of therapists and patients in AT is impossible, and if performance bias is only considered by ‘lack of blinding of patients and personnel’, every trial on art therapy will have a high risk on performance bias, making the overall RoB high. This implies that high or even medium quality of evidence can never be reached for this intervention, even when all other aspects of the study are of high quality. Behavioral interventions, like psychotherapy and other complex interventions, face the same challenge. In 2017, Munder & Barth [ 48 ] published considerations on how to use the Cochrane's risk of bias tool in psychotherapy outcome research. We fully support the recommendations of Grant and colleagues [ 73 ] and would like to emphasize that tools for assessing risk of bias and quality of evidence need to be tailored to art therapy and (other) complex interventions where blinding is not possible.

The effectiveness of AT on reducing anxiety symptoms severity has hardly been studied in RCTs and nRCTs. There is low-quality to very low-quality evidence of effectiveness of AT for pre-exam anxiety in undergraduate students. AT may also be effective in reducing pre-release anxiety in prisoners.

The included RCTs demonstrate a wide variety in AT characteristics (AT types, numbers and duration of sessions). The described or hypothesized working mechanisms of art making are: induction of relaxation; working on emotion regulation by creating the safe condition for conscious expression and exploration of difficult emotions, memories and trauma; and working on cognitive regulation by using the art process to open up possibilities to investigate and (positively) change (unconscious) cognitions, beliefs and thoughts.

High quality trials studying effectiveness on anxiety and mediating working mechanisms of AT are currently lacking for all anxiety disorders and for people with anxiety in specific situations.

Supporting information

S1 checklist. prisma checklist..

https://doi.org/10.1371/journal.pone.0208716.s001

S1 File. Full list of search terms and databases.

https://doi.org/10.1371/journal.pone.0208716.s002

S1 Table. Data extraction form.

https://doi.org/10.1371/journal.pone.0208716.s003

S2 Table. Excluded studies with reasons for exclusion.

https://doi.org/10.1371/journal.pone.0208716.s004

S3 Table. Background characteristics of the included studies.

https://doi.org/10.1371/journal.pone.0208716.s005

Acknowledgments

We would like to thank Drs. J.W. Schoones, information specialist and collection advisor of the Warlaeus Library of Leiden University Medical Center (LUMC), for assisting in the searches.

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• Open access
• Published: 16 May 2022

The effect of active visual art therapy on health outcomes: protocol of a systematic review of randomised controlled trials

• Ronja Joschko   ORCID: orcid.org/0000-0003-4450-254X 1 ,
• Stephanie Roll   ORCID: orcid.org/0000-0003-1191-3289 1 ,
• Stefan N. Willich 1 &
• Anne Berghöfer   ORCID: orcid.org/0000-0002-7897-6500 1  

Systematic Reviews volume  11 , Article number:  96 ( 2022 ) Cite this article

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Art therapy is a form of complementary therapy to treat a wide variety of health problems. Existing studies examining the effects of art therapy differ substantially regarding content and setting of the intervention, as well as their included populations, outcomes, and methodology. The aim of this review is to evaluate the overall effectiveness of active visual art therapy, used across different treatment indications and settings, on various patient outcomes.

We will include randomised controlled studies with an active art therapy intervention, defined as any form of creative expression involving a medium (such as paint etc.) to be actively applied or shaped by the patient in an artistic or expressive form, compared to any type of control. Any treatment indication and patient group will be included. A systematic literature search of the Cochrane Library, EMBASE (via Ovid), MEDLINE (via Ovid), CINAHL, ERIC, APA PsycArticles, APA PsycInfo, and PSYNDEX (all via EBSCOHost), ClinicalTrials.gov and the WHO’s International Clinical Trials Registry Platform (ICTRP) will be conducted. Psychological, cognitive, somatic and economic outcomes will be used. Based on the number, quality and outcome heterogeneity of the selected studies, a meta-analysis might be conducted, or the data synthesis will be performed narratively only. Heterogeneity will be assessed by calculating the p-value for the chi 2 test and the I 2 statistic. Subgroup analyses and meta-regressions are planned.

This systematic review will provide a concise overview of current knowledge of the effectiveness of art therapy. Results have the potential to (1) inform existing treatment guidelines and clinical practice decisions, (2) provide insights to the therapy’s mechanism of change, and (3) generate hypothesis that can serve as a starting point for future randomised controlled studies.

Systematic review registration

PROSPERO ID CRD42021233272

Peer Review reports

Complementary and integrative treatment methods can play an important role when treating various chronic conditions. Complementary medicine describes treatment methods that are added to the standard therapy regiment, thereby creating an integrative health approach, in the anticipation of better treatment effects and improved health outcomes [ 1 ]. Within a broad field of therapeutic approaches that are used complementarily, art therapy has long occupied a wide space. After an extensive sighting of the literature, we decided to differentiate between five clusters of art that are used in combination with standard therapies: visual arts, performing arts, music, literature, and architecture (Fig. 1 ). Each cluster can either be used actively or receptively.

The five clusters of art used in medicine for therapeutic purposes, with examples of active visual art forms (figure created by the authors)

Active visual art therapy (AVAT) is often used as a complementary therapy method, both in acute medicine and in rehabilitation. The use of AVAT is frequently associated with the treatment of psychiatric, psychosomatic, psychological, or neurological disorders, such as anxiety [ 2 ], depression [ 3 ], eating disorders [ 4 ], trauma [ 5 , 6 ], cognitive impairment, or dementia [ 7 ]. However, the application of AVAT extends beyond that, thereby broadening its potential benefits: it is also used to complement the treatment of cystic fibrosis [ 8 ] or cancer [ 9 , 10 ], to build up resilience and well-being [ 11 , 12 ], or to stop adolescents from smoking [ 13 ].

As a complementary intervention, AVAT aims at reducing symptom burden beyond the effect of the standard treatment alone. Since AVAT is thought to be side effect free [ 14 ] it could be a valuable addition to the standard treatment, offering symptom reduction with no increased risk of adverse events, as well as an potential improvement in quality of life [ 15 , 16 , 17 ].

The existing literature examining the effectiveness of art therapy has shown some positive results across a wide variety of treatment indications, such as the treatment of depression [ 3 , 18 ], anxiety [ 19 , 20 ], psychosis [ 21 ], the enhancement of mental wellbeing [ 22 ], and the complementary treatment of cancer [ 15 , 23 ]. However, the existing evidence is characterised by conflicting results. While some studies report favourable results and treatment successes through AVAT [ 17 , 24 , 25 , 26 ], many studies report mixed results [ 3 , 15 , 16 , 27 , 28 ]. There is a substantial number of systematic reviews which examine the effectiveness of art therapy regarding individual outcomes, such as trauma [ 29 , 30 , 31 , 32 , 33 ], anxiety [ 19 ] mental health in people who have cancer [ 23 , 34 , 35 ] dementia [ 7 ], and potential harms and benefits of the intervention [ 36 ]. The limited number of published studies, however, can make the creation of a systematic review difficult, especially when narrowing down additional factors, such as the desired study design [ 7 ].

Therefore, it might be helpful to combine all existing evidence on the therapeutic effects of AVAT in one review, to generate evidence regarding its overall effectiveness. To our knowledge, there is no systematic review that accumulates the data of all published RCTs on the topic of AVAT, while abiding to strict methodological standards, such as the Cochrane handbook [ 37 ] and the PRISMA statement [ 38 ]. We thus aim to establish and strengthen the existing evidence basis for AVAT, reflecting the clinical reality by including a wide variety of settings, populations, and treatment indications. Furthermore, we will try to identify characteristics of the setting and the intervention that may increase AVAT’s effectiveness, as well as differences in treatment success for different conditions or reasons for treatment.

Methods/Design

Registration and reporting.

We have submitted the protocol to PROSPERO (the International Prospective Register of Systematic Reviews) on February 9, 2021 (PROSPERO ID: CRD42021233272). In the writing of this protocol we have adhered to the adapted PRISMA-P (Preferred reporting items for systematic review and meta-analysis protocols, see Additional file 1 ) [ 39 ]. Important protocol amendments will be submitted to PROSPERO.

Eligibility criteria

Type of study.

We will include randomised controlled trials to minimise the sources of bias possibly arising from observational study designs.

Types of participants

As AVAT is used across many patient populations and settings, we will include patients across all treatment indications. Thus, we will include populations receiving curative, palliative, rehabilitative, or preventive care for a variety of reasons. Patients of all ages (including seniors, children and adolescents), all cultural backgrounds, and all living situations (inpatients, outpatients, prison, nursing homes etc.) will be included without further restrictions. The resulting diversity reflects the current treatment reality. Heterogeneity of included studies will be accounted for by subgroup analyses at the stage of data synthesis. Differences in treatment success depending on population characteristics are furthermore of special interest in this review.

Types of interventions

As the therapeutic mechanisms of AVAT are not yet unanimously agreed upon, we want to reduce the heterogeneity of treatment methods included by focusing on only one cluster of art activities (active visual art).

We define AVAT as any form of creative expression involving a medium such as paint, wax, charcoal, graphite, or any other form of colour pigments, clay, sand, or other materials that are applied or shaped by the individual in an artistic or expressive form.

The interventions must include a therapeutic element, such as the targeted guidance from an art therapist or a reflective element. Both, group and individual treatment in any setting are included.

Purely occupational activities not intended to have a therapeutic effect will not be considered.

All forms of music, dance, and performing art therapies, as well as poetry therapy and (expressive) writing interventions which focus on the content rather than appearance (like journal therapy) will not be included. Studies with mixed interventions will be included only if the effects of the AVAT can be separated from the effects of the other treatments. Furthermore, all passive forms of visual art therapy will be excluded, such as receptive viewings of paintings or pictures.

Comparison interventions

Depending on the treatment indication and setting, the control group design will likely vary. We will include studies with any type of control group, because art therapy research, just like psychotherapy research, must face the problem that there are usually no standard controls like, e.g. a placebo [ 40 ]. Therefore, we will include all control groups using treatment as usual (including usual care, standard of care etc.), no treatment (with or without waitlist control design), or any active control other than AVAT (such as attention placebo controls) as potential comparators.

Stakeholder involvement

Stakeholders will be involved to increase the relevance of the study design. Patients, art therapists, and physicians prescribing art therapy, all from a centre that uses AVAT regularly, will be interviewed using a semi structured questionnaire that captures the expert’s perspective on meaningful outcomes. Particularly, we are interested in the stakeholders’ opinions about which outcomes might be most affected by AVAT, which individual differences might be expected, and which other factors could affect the effectiveness of AVAT.

A second session might be held at the stage of result interpretation as the stakeholders’ perspective could be a valuable tool to make sense of the data.

As there is no universal standard regarding the outcomes of AVAT, we have based our choice of outcome measures on selected, high quality work on the subject [ 7 ], and on theoretical considerations.

Outcome measures will include general and disease specific quality of life, anxiety, depression, treatment satisfaction, adverse effects, health economic factors, and other disorder specific outcomes. The latter are of special relevance for the patients and have the potential to reflect the effectiveness of the therapy. The disorder specific outcomes will be further clustered into groups, such as treatment success, mental state, affect and psychological wellbeing, cognitive function, pain (medication), somatic effects, therapy compliance, and motivation/agency/autonomy regarding the underlying disease or its consequences. Depending on the included studies, we might re-evaluate these categories and modify the clusters if necessary.

Outcomes will be grouped into short-term and long-term outcomes, based on the available data. The same approach will be taken for dividing the treatment groups according to intensity, with the aim of observing the dose-response relationship.

Grouping for primary analysis comparisons

AVAT interventions and their comparison groups can be highly divers; therefore, we might group them into roughly similar intervention and comparison groups for the primary analysis, as indicated above. This will be done after the data extraction, but before data analysis, in order to minimise bias.

Search strategy

Based on the recommendations from the Cochrane Handbook we will systematically search the Cochrane Library, EMBASE (via Ovid), and MEDLINE (via Ovid) [ 41 ]. Furthermore, we will search CINAHL, ERIC, APA PsycArticles, APA PsycInfo, and PSYNDEX (all via EBSCOHost), as well as the ClinicalTrials.gov and the WHO’s International Clinical Trials Registry Platform (ICTRP), which includes various smaller and national registries, such as the EU Clinical Trials Register and the German Clinical Trials Register (DRKS).

The search strategy is comprised of three search components; one concerning the art component, one the therapy component and the last consists of a recommended RCT filter for EMBASE, optimised for sensitivity and specificity [ 42 , 43 , 44 ]. See Additional file 2 for the complete search strategy, exemplified for the Cochrane Library search interface. In addition, relevant hand selected articles from individual databank searches, or studies identified through the screening of reference lists will be included in the review. A handsearch of The Journal of Creative Arts Therapies will be conducted.

Results of all languages will be considered, and efforts undertaken to translate articles wherever necessary. There will be no limitation regarding the date of publication of the studies.

Data collection and data management

Study selection process.

Two reviewers will independently scan and select the studies, first by title screening, second by abstract screening, and in a third step by full text reading. The two sets of identified studies will then be compared between the two researchers. In case of disagreement that cannot be resolved through discussion, a third researcher will be consulted to decide whether the study in question is eligible for inclusion. The Covidence software will be used for the study selection process [ 45 ].

Data extraction

All relevant data concerning the outcomes, the participants, their condition, the intervention, the control group, the method of imputation of missing data, and the study design will be extracted by two researchers independently and then cross-checked, using a customised and piloted data extraction form. The chosen method of imputation for missing data (due to participant dropout or similar) will be extracted per outcome. Both, intention to treat (ITT) and per protocol (PP) data will be collected and analysed.

If crucial information will be missing from a study and its protocol, authors will be contacted for further details.

Risk of bias assessment for included studies

In line with the revised Cochrane risk of bias tool for randomised trials (RoB 2) [ 46 ], we will examine the internal bias in the included studies regarding their bias arising from the randomisation process, bias due to deviations from intended interventions, due to missing outcome data, bias in measurement of the outcome, and in selection of the reported result [ 47 ].

The risk will be assessed by two people independently from each other, only in cases of persisting disagreement a third person will be consulted.

If the final sample size allows, we will conduct an additional analysis in which the included studies are analysed separately by bias risk category.

Measures of treatment effect

If possible, we will conduct our main analyses using intention-to-treat data (ITT), but we will collect ITT and per-protocol (PP) data [ 48 ]. If for some studies ITT data is not reported, we will use the available PP data instead and perform a sensitivity analysis to see if that affects the results. Dichotomous data will be analysed using risk ratios with 95% confidence intervals, as they have been shown to be more intuitive to interpret than odds ratio for most people [ 49 ]. We will analyse continuous data using mean differences or standardised mean differences.

Unit of analysis issues

Cluster trials.

If original studies did not account for a cluster design, a unit of analysis error may be present. In this case, we will use appropriate techniques to account for the cluster design. Studies in which the authors have adjusted the analysis for cluster-randomisation will be used directly.

Cross-over trials

An inherent risk to cross-over trials is the carry-over effect.

This design is also problematic when measuring unstable conditions such as psychotic episodes, as the timing could account more for the treatment success than the treatment itself (period effect).

As art therapy is used frequently in the treatment of unstable conditions, such as mental health problems or neurodegenerative disorders (i.e. Alzheimer’s), we will include full cross-over trials only if chronic and stable concepts are measured (such as permanent physical disabilities or epilepsy) [ 50 ].

When including cross-over studies measuring stable conditions, we will include both periods of the study. To incorporate the results into a meta-analysis we will combine means, SD or SE from both study periods and analyse them like a parallel group trial [ 51 ]. For bias assessment we will use the risk of bias tool for crossover trials [ 47 ].

For cross-over studies that measure unstable or degenerative conditions of interest, we will only include the first phase of the study as parallel group comparison to minimise the risk of carry-over or period effects. We will evaluate the risk of bias for those cross-over trials using the same standard risk of bias tool as for the parallel group randomised trials [ 52 ]. We will critically evaluate studies that analyse first period data separately, as this might be a form of selective reporting and the inclusion of this data might result in bias due to baseline differences. We might exclude studies that use this kind of two-stage analysis if we suspect selective reporting or high risk for baseline differences [ 47 ].

Missing data

Studies with a total dropout rate of over 50% will be excluded. To account for attrition bias, studies will be downrated in the risk of bias assessment (RoB 2 tool) if the dropout rate is more than half for either the control or the intervention group. An overall dropout rate of 25–50% we will also be downrated.

Assessment of clinical, methodological, and statistical heterogeneity

We will discuss the included studies before calculating statistical comparisons and group them into subgroups to assess their clinical and methodological heterogeneity. Statistical heterogeneity will be assessed by calculating the p value for the chi 2 test. As few included studies may lead to insensitivity of the p value, we may adjust the cut-off of the p value if we only included a small amount of studies [ 49 ]. In addition, we will calculate the I 2 statistic and its confidence interval, based on the chi 2 statistic to assess statistical heterogeneity. We will explore possible reasons for observed heterogeneity, e.g. by conducting the planned subgroup analyses. Based on the amount and quality of included studies and their outcome heterogeneity, we will decide if a meta-analysis can be conducted. In case of high statistical heterogeneity, we first check for any potential errors during the data input stage of the review. In a second step, we evaluate if choosing a different effect measure, or if the justified removal of outliers will reduce heterogeneity. If the outcome heterogeneity of the selected studies is still too high, we will not conduct a meta-analysis. If clinical heterogeneity is high but can be reduced by adjusting our planned comparisons, we will do so.

Reporting bias

Funnel plot.

Funnel plots can be a useful tool in detecting a possible publication bias. However, we are aware, that asymmetrical funnel plots can potentially have other causes than an underlying publication bias. As a certain number of studies is needed in order to create a meaningful funnel plot, we will only create those plots, if more than about 10 studies are included in the review.

Data analysis and synthesis

Based on the amount and quality of included studies and their heterogeneity, we will decide if a meta-analysis is feasible.

If a meta-analysis can be conducted, we will be using the inverse variance method with random effects (to increase compatibility with the different identified effect measures and to account for the diversity of the included interventions). We would expect each study to measure a slightly different effect based on differing circumstances and differing intervention characteristics. Therefore, a random effects model is the most suitable option.

A disadvantage of the random effects model is that it does not give studies with large sample sizes enough weight when compared to studies with small sample sizes and therefore could lead to a small study effect. However, we expect to find studies with comparable study sizes with an N of 10–50, as very large trials are uncommon for art therapy research. If we include studies with a very large sample size, we might calculate a fixed effects model additionally, as sensitivity analysis, to assess if this would affect the results.

If the calculation of a meta-analysis is not advisable due to difficulties (such as a low number of included studies, low quality of included studies, high heterogeneity, incompletely reported outcome or effect estimates, differing effect measures that cannot be converted), we will choose the most appropriate method of narrative synthesis for our data, such as the ones described in the Cochrane Handbook (i.e. summarising effect estimates, combining p values or vote counting based on direction of effect) [ 53 ].

Subgroup analysis

If the number of included studies is large enough (around 10 or more [ 54 ]) and subgroups have an adequate size, we plan to compare subgroups based on the therapy setting (inpatient, outpatient, kind of institution), the intervention characteristics (the kind of AVAT, intensity of treatment, staff training, group size), the population (treatment indication, age, gender, country), or other study characteristics (e.g. bias category, publication date). If possible, we will also examine these factors by calculating meta-regressions.

Sensitivity analysis

Where possible, sensitivity analyses will be conducted using different methods to establish robustness of the overall results. Specifically, we will assess the robustness of the results regarding cluster randomisation and high risk of bias (RoB 2 tool).

AVAT encompasses a wide array of highly diverse treatment options for a multitude of treatment indications. Even though AVAT is a popular treatment method, the empirical base for its effectiveness is rather fragmented; many (often smaller) studies examined the effect of very specific kinds of AVATs, with a narrow focus on certain conditions [ 2 , 7 , 55 , 56 ]. Our review will give a current overview over the entire field, with the hope of estimating the magnitude of its effectiveness. Several clinical guidelines recommend art therapy based solely on clinical consensus [ 57 ]. By accumulating all empirical evidence, this systematic review could inform the creation of future guidelines and thereby facilitate clinical decision-making.

Understanding the benefits, limits, and mechanisms of change of AVAT is crucial to optimally apply and tailor it to different contexts and settings. Consequently, by better understanding this intervention, we could potentially increase its effectiveness and optimise its application, which would lead to improved patient outcomes. This would not only benefit each individual who is treated with AVAT, but also the health care provider, who could apply the intervention in its most efficient way, thereby using their resources optimally.

Furthermore, explorative findings regarding the characteristics of the treatment could generate new hypotheses for future RCTs, for example regarding the effectiveness of certain types of AVAT for specific treatment indications. Moreover, the emergence of certain patterns in effectiveness could inspire further research about possible mechanisms of change of AVAT.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

• Active visual art therapy

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols

Randomised controlled trial

Risk of Bias tool

Intention to treat

Per protocol

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Ronja Joschko, Stephanie Roll, Stefan N. Willich & Anne Berghöfer

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RJ was responsible for the search strategy development and study protocol and manuscript preparation. SW, AB, and SR gave advice and feedback on the study planning and design, and the protocol, manuscript and search strategy development throughout the planning process. SR also assisted with selecting the appropriate statistical methods. RJ is the guarantor of the review. All authors read and approved the final manuscript.

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Additional file 1..

PRISMA-P checklist.

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Search strategy.

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Joschko, R., Roll, S., Willich, S.N. et al. The effect of active visual art therapy on health outcomes: protocol of a systematic review of randomised controlled trials. Syst Rev 11 , 96 (2022). https://doi.org/10.1186/s13643-022-01976-7

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What Is Art Therapy?

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Effectiveness

Things to consider, how to get started.

The use of artistic methods to treat psychological disorders and enhance mental health is known as art therapy. Art therapy is a technique rooted in the idea that creative expression can foster healing and mental well-being.

People have been relying on the arts for communication, self-expression, and healing for thousands of years. But art therapy didn't start to become a formal program until the 1940s.

Doctors noted that individuals living with mental illness often expressed themselves in drawings and other artworks, which led many to explore the use of art as a healing strategy. Since then, art has become an important part of the therapeutic field and is used in some assessment and treatment techniques.

Types of Creative Therapies

Art therapy is not the only type of creative art used in the treatment of mental illness. Other types of creative therapies include:

• Dance therapy
• Drama therapy
• Expressive therapy
• Music therapy
• Writing therapy

The goal of art therapy is to utilize the creative process to help people explore self-expression and, in doing so, find new ways to gain personal insight and develop new coping skills.

The creation or appreciation of art is used to help people explore emotions, develop self-awareness, cope with stress, boost self-esteem, and work on social skills.

Techniques used in art therapy can include:

• Doodling and scribbling
• Finger painting
• Photography
• Working with clay

As clients create art, they may analyze what they have made and how it makes them feel. Through exploring their art, people can look for themes and conflicts that may be affecting their thoughts, emotions, and behaviors.

What Art Therapy Can Help With

Art therapy can be used to treat a wide range of mental disorders and psychological distress . In many cases, it might be used in conjunction with other psychotherapy techniques such as group therapy or cognitive-behavioral therapy (CBT) .

Some conditions that art therapy may be used to treat include:

• Aging-related issues
• Eating disorders
• Emotional difficulties
• Family or relationship problems
• Medical conditions
• Psychological symptoms associated with other medical issues
• Post-traumatic stress disorder (PTSD)
• Psychosocial issues
• Substance use disorder

Benefits of Art Therapy

According to a 2016 study published in the  Journal of the American Art Therapy Association, less than an hour of creative activity can reduce your stress and have a positive effect on your mental health, regardless of artistic experience or talent.

An art therapist may use a variety of art methods, including drawing, painting, sculpture, and collage with clients ranging from young children to older adults.

Clients who have experienced emotional trauma, physical violence, domestic abuse, anxiety, depression, and other psychological issues can benefit from expressing themselves creatively.

Some situations in which art therapy might be utilized include:

• Adults experiencing severe stress
• Children experiencing behavioral or social problems at school or at home
• Children or adults who have experienced a traumatic event
• Children with learning disabilities
• Individuals living with a brain injury
• People experiencing mental health problems

While research suggests that art therapy may be beneficial, some of the findings on its effectiveness are mixed. Studies are often small and inconclusive, so further research is needed to explore how and when art therapy may be most beneficial.  

• In studies of adults who experienced trauma, art therapy was found to significantly reduce trauma symptoms and decrease levels of depression.
• One review of the effectiveness of art therapy found that this technique helped patients undergoing medical treatment for cancer improve their quality of life and alleviated a variety of psychological symptoms.
• One study found that art therapy reduced depression and increased self-esteem in older adults living in nursing homes.

If you or someone you love is thinking about art therapy, there are some common misconceptions and facts you should know.

You Don't Have to Be Artistic

People do not need to have artistic ability or special talent to participate in art therapy, and people of all ages including children, teens , and adults can benefit from it. Some research suggests that just the presence of art can play a part in boosting mental health.

A 2017 study found that art displayed in hospital settings contributed to an environment where patients felt safe. It also played a role in improving socialization and maintaining an identity outside of the hospital.

It's Not the Same as an Art Class

People often wonder how an art therapy session differs from an art class. Where an art class is focused on teaching technique or creating a specific finished product, art therapy is more about letting clients focus on their inner experience.

In creating art, people are able to focus on their own perceptions, imagination, and feelings. Clients are encouraged to create art that expresses their inner world more than making something that is an expression of the outer world.

Art Therapy Can Take Place in a Variety of Settings

Inpatient offices, private mental health offices, schools, and community organizations are all possible settings for art therapy services. Additionally, art therapy may be available in other settings such as:

• Art studios
• Colleges and universities
• Community centers
• Correctional facilities
• Elementary schools and high schools
• Group homes
• Homeless shelters
• Private therapy offices
• Residential treatment centers
• Senior centers
• Wellness center
• Women's shelters

If specialized media or equipment is required, however, finding a suitable setting may become challenging.

Art Therapy Is Not for Everyone

Art therapy isn’t for everyone. While high levels of creativity or artistic ability aren't necessary for art therapy to be successful, many adults who believe they are not creative or artistic might be resistant or skeptical of the process.

In addition, art therapy has not been found effective for all types of mental health conditions. For example, one meta-analysis found that art therapy is not effective in reducing positive or negative symptoms of schizophrenia.

If you think you or someone you love would benefit from art therapy, consider the following steps:

• Seek out a trained professional . Qualified art therapists will hold at least a master’s degree in psychotherapy with an additional art therapy credential. To find a qualified art therapist, consider searching the Art Therapy Credentials Board website .
• Call your health insurance . While art therapy may not be covered by your health insurance, there may be certain medical waivers to help fund part of the sessions. Your insurance may also be more likely to cover the sessions if your therapist is a certified psychologist or psychiatrist who offers creative therapies.
• Ask about their specialty . Not all art therapists specialize in all mental health conditions. Many specialize in working with people who have experienced trauma or individuals with substance use disorders, for example.
• Know what to expect . During the first few sessions, your art therapist will likely ask you about your health background as well as your current concerns and goals. They may also suggest a few themes to begin exploring via drawing, painting, sculpting, or another medium.
• Be prepared to answer questions about your art-making process . As the sessions progress, you'll likely be expected to answer questions about your art and how it makes you feel. For example: What were you thinking while doing the art? Did you notice a change of mood from when you started to when you finished? Did the artwork stir any memories?

Becoming an Art Therapist

If you are interested in becoming an art therapist, start by checking with your state to learn more about the education, training, and professional credentials you will need to practice. In most cases, you may need to first become a licensed clinical psychologist , professional counselor, or social worker in order to offer psychotherapy services.

In the United States, the Art Therapy Credentials Board, Inc. (ATCB) offers credentialing programs that allow art therapists to become registered, board-certified, or licensed depending upon the state in which they live and work.

According to the American Art Therapy Association, the minimum requirements:

• A master's degree in art therapy, or
• A master's degree in counseling or a related field with additional coursework in art therapy

Additional post-graduate supervised experience is also required. You can learn more about the training and educational requirements to become an art therapist on the AATA website .

Van Lith T. Art therapy in mental health: A systematic review of approaches and practices . The Arts in Psychotherapy . 2016;47:9-22. doi:10.1016/j.aip.2015.09.003

Junge MB. History of Art Therapy . The Wiley Handbook of Art Therapy . Published online November 6, 2015:7-16. doi:10.1002/9781118306543.ch1

Farokhi M. Art therapy in humanistic psychiatry . Procedia - Social and Behavioral Sciences . 2011;30:2088-2092. doi:10.1016/j.sbspro.2011.10.406

Haen C, Nancy Boyd Webb. Creative Arts-Based Group Therapy with Adolescents: Theory and Practice . 1st ed. (Haen C, Webb NB, eds.). Routledge; 2019. doi:10.4324/9780203702000

Schouten KA, de Niet GJ, Knipscheer JW, Kleber RJ, Hutschemaekers GJM. The effectiveness of art therapy in the treatment of traumatized adults . Trauma, Violence, & Abuse . 2014;16(2):220-228. doi:10.1177/1524838014555032

Gall DJ, Jordan Z, Stern C. Effectiveness and meaningfulness of art therapy as a tool for healthy aging: a comprehensive systematic review protocol . JBI Evidence Synthesis . 2015;13(3):3-17. doi:10.11124/jbisrir-2015-1840

Lefèvre C, Ledoux M, Filbet M. Art therapy among palliative cancer patients: Aesthetic dimensions and impacts on symptoms . Palliative and Supportive Care . 2015;14(4):376-380. doi:10.1017/s1478951515001017

Hunter M. Art therapy and eating disorders . In: Gussak DE, Rosal ML, eds.  The Wiley Handbook of Art Therapy . John Wiley & Sons, Ltd; 2015:387-396. https://doi.org/10.1002/9781118306543.ch37

Schmanke L. Art therapy and substance abuse . The Wiley Handbook of Art Therapy . Published online November 6, 2015:361-374. doi:10.1002/9781118306543.ch35

Kaimal G, Ray K, Muniz J. Reduction of cortisol levels and participants’ responses following art making . Art Therapy . 2016;33(2):74-80. doi:10.1080/07421656.2016.1166832

Gussak DE, Rosal ML, eds. The Wiley Handbook of Art Therapy . 1st ed. John Wiley & Sons, Ltd; 2015. doi:10.1002/9781118306543

Regev D, Cohen-Yatziv L. Effectiveness of art therapy with adult clients in 2018—what progress has been made?   Front Psychol . 2018;9. doi:10.3389%2Ffpsyg.2018.01531

Regev D, Cohen-Yatziv L. Effectiveness of art therapy with adult clients in 2018—what progress has been made? .  Front Psychol . 2018;9:1531. doi:10.3389/fpsyg.2018.01531

Ching-Teng Y, Ya-Ping Y, Yu-Chia C. Positive effects of art therapy on depression and self-esteem of older adults in nursing homes .  Social Work in Health Care . 2019;58(3):324-338. doi:10.1080/00981389.2018.1564108

Nielsen SL, Fich LB, Roessler KK, Mullins MF. How do patients actually experience and use art in hospitals? The significance of interaction: a user-oriented experimental case study .  International Journal of Qualitative Studies on Health and Well-being . 2017;12(1):1267343. doi:10.1080/17482631.2016.1267343

Gussak DE. Art therapy in the prison milieu . In: Gussak DE, Rosal ML, eds.  The Wiley Handbook of Art Therapy . John Wiley & Sons, Ltd; 2015:478-486. doi:10.1002/9781118306543.ch46

Stuckey HL, Nobel J. The connection between art, healing, and public health: A review of current literature . Am J Public Health . 2010;100(2):254-63. doi:10.2105/AJPH.2008.156497

Bird J. Art therapy, arts-based research and transitional stories of domestic violence and abuse . International Journal of Art Therapy . 2018;23(1):14-24.  doi:10.1080/17454832.2017.1317004

Laws KR, Conway W. Do adjunctive art therapies reduce symptomatology in schizophrenia? A meta-analysis .  WJP . 2019;9(8):107-120. doi:10.5498/wjp.v9.i8.107

About The Credentials | Art Therapy Credentials Board, Inc. ATCB. https://www.atcb.org/about-the-credentials/

Bureau of Labor Statistics. Occupational Employment and Wages, May 2018: 29-1125 Recreational Therapists .

Nielsen SL, Fich LB, Roessler KK, Mullins MF. How do patients actually experience and use art in hospitals? The significance of interaction: a user-oriented experimental case study. Int J Qual Stud Health Well-being. 2017;12(1):1267343. doi:10.1080/17482631.2016.1267343

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Lost for words? Research shows art therapy brings benefits for mental health

Academic, Master of Art Therapy Program, Western Sydney University

Senior Lecturer, Child and Adolescent Psychiatry, UNSW Sydney

Disclosure statement

Sarah Versitano is a PhD Candidate at Western Sydney University and works for the Sydney Children's Hospitals Network, which is part of NSW Health. She has received funding from the Health Education and Training Institute (HETI) for the Mental Health Research Award. She is a Registered Art Therapist with the Australia, New Zealand and Asian Creative Arts Therapies Association (ANZACATA) and Registered Clinical Counsellor with the Psychotherapists and Counsellors Federation of Australia (PACFA). She has delivered art therapy and psychotherapy in public and private hospital settings.

Iain Perkes works for the University of New South Wales and the Sydney Children's Hospitals Network which is part of NSW Health. He has previously worked for numerous health services throughout NSW Health. He has received funding or awards from the Australian National Health and Medical Research Council (NHMRC), the International Association of Child and Adolescent and Allied Professions, (IACAPAP), the World Psychiatric Association (WPA), the Tourette's Association of America (TAA), Tourette Syndrome Association (TSA), the NSW Institute of Psychiatry, The University of Sydney, and the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE). He is affiliated with Neuroscience Research Australia (NeuRA) and the Health Education and Training Institute (HETI, NSW Health).

Western Sydney University and UNSW Sydney provide funding as members of The Conversation AU.

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Creating art for healing purposes dates back tens of thousands of years , to the practices of First Nations people around the world. Art therapy uses creative processes, primarily visual art such as painting, drawing or sculpture, with a view to improving physical health and emotional wellbeing .

When people face significant physical or mental ill-health, it can be challenging to put their experiences into words . Art therapists support people to explore and process overwhelming thoughts, feelings and experiences through a reflective art-making process. This is distinct from art classes , which often focus on technical aspects of the artwork, or the aesthetics of the final product.

Art therapy can be used to support treatment for a wide range of physical and mental health conditions. It has been linked to benefits including improved self-awareness, social connection and emotional regulation, while lowering levels of distress, anxiety and even pain scores.

In a study published this week in the Journal of Mental Health , we found art therapy was associated with positive outcomes for children and adolescents in a hospital-based mental health unit.

An option for those who can’t find the words

While a person’s engagement in talk therapies may sometimes be affected by the nature of their illness, verbal reflection is optional in art therapy.

Where possible, after finishing an artwork, a person can explore the meaning of their work with the art therapist, translating unspoken symbolic material into verbal reflection.

However, as the talking component is less central to the therapeutic process, art therapy is an accessible option for people who may not be able to find the words to describe their experiences.

Read more: Creative arts therapies can help people with dementia socialise and express their grief

Art therapy has supported improved mental health outcomes for people who have experienced trauma , people with eating disorders , schizophrenia and dementia , as well as children with autism .

Art therapy has also been linked to improved outcomes for people with a range of physical health conditions . These include lower levels of anxiety, depression and fatigue among people with cancer , enhanced psychological stability for patients with heart disease , and improved social connection among people who have experienced a traumatic brain injury .

Art therapy has been associated with improved mood and anxiety levels for patients in hospital , and lower pain, tiredness and depression among palliative care patients .

Our research

Mental ill-health, including among children and young people , presents a major challenge for our society. While most care takes place in the community , a small proportion of young people require care in hospital to ensure their safety.

In this environment, practices that place even greater restriction, such as seclusion or physical restraint, may be used briefly as a last resort to ensure immediate physical safety. However, these “restrictive practices” are associated with negative effects such as post-traumatic stress for patients and health professionals .

Worryingly, staff report a lack of alternatives to keep patients safe . However, the elimination of restrictive practices is a major aim of mental health services in Australia and internationally.

Read more: 'An arts engagement that's changed their life': the magic of arts and health

Our research looked at more than six years of data from a child and adolescent mental health hospital ward in Australia. We sought to determine whether there was a reduction in restrictive practices during the periods when art therapy was offered on the unit, compared to times when it was absent.

We found a clear association between the provision of art therapy and reduced frequency of seclusion, physical restraint and injection of sedatives on the unit.

We don’t know the precise reason for this. However, art therapy may have lessened levels of severe distress among patients, thereby reducing the risk they would harm themselves or others, and the likelihood of staff using restrictive practices to prevent this.

That said, hospital admission involves multiple therapeutic interventions including talk-based therapies and medications. Confirming the effect of a therapeutic intervention requires controlled clinical trials where people are randomly assigned one treatment or another.

Although ours was an observational study, randomised controlled trials support the benefits of art therapy in youth mental health services. For instance, a 2011 hospital-based study showed reduced symptoms of post-traumatic stress disorder among adolescents randomised to trauma-focussed art therapy compared to a “control” arts and crafts group.

What do young people think?

In previous research we found art therapy was considered by adolescents in hospital-based mental health care to be the most helpful group therapy intervention compared to other talk-based therapy groups and creative activities.

In research not yet published, we’re speaking with young people to better understand their experiences of art therapy, and why it might reduce distress. One young person accessing art therapy in an acute mental health service shared:

[Art therapy] is a way of sort of letting out your emotions in a way that doesn’t involve being judged […] It let me release a lot of stuff that was bottling up and stuff that I couldn’t explain through words.

A promising area

The burgeoning research showing the benefits of art therapy for both physical and especially mental health highlights the value of creative and innovative approaches to treatment in health care .

There are opportunities to expand art therapy services in a range of health-care settings. Doing so would enable greater access to art therapy for people with a variety of physical and mental health conditions.

• Mental health
• Mental illness
• Art therapy
• Youth mental health

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Lecturer / senior lecturer in construction and project management.

ORIGINAL RESEARCH article

Trends in research on art therapy indexed in the web of science: a bibliometric analysis.

• 1 Departamento de Enfermeria, Universidad de la Laguna, San Cristóbal de La Laguna, Spain
• 2 Instituto de Investigación en Cuidados del Colegio Oficial de Enfermeros de Santa Cruz de Tenerife, Santa Cruz de Tenerife, Spain

Aim: Despite the increase in international research in art therapy, few studies have been developed with a bibliometric approach which describe the situation regarding this area of knowledge. Thus, the aim of this study is to describe and contextualize international scientific production in the visual arts modality in the context of artistic therapies, to offer a broader and more in-depth vision of the structure of this area of knowledge through of a bibliometric analysis of the publications indexed in the core collection of the Web of Science.

Methods: This is a retrospective, exploratory and descriptive, cross-sectional study to analyze the bibliographic data retrieved from the databases of the core collection. The analysis parameters included the data corresponding to the production according to type of document, country, journal, and institution. In addition, the main lines of research were located and classified and the subject matter of the most cited articles in each of them was summarized. Four periods were selected, between 1994 and 2020, to facilitate the thematic analysis and offer an evolutionary perspective of art therapy research.

Results: A total of 563 works were published, in 250 journals, in the 63 years between 1958, when the first document was published, and April 2021. The annual growth rate was 7.3% with a mean average of 8.7 publications per year, and 83.13% of the published works were articles. A total of 1,269 authors from 56 countries were counted. The mean number of citations per document was 5.6 and the mean number of citations per document and year was 0.6. The main research domains were psychology and/or rehabilitation and the highest production on this topic was concentrated in only three journals. In general, a high degree of variability was observed in the study topics and numerous theoretical and methodological articles. The most used visual arts modalities were in the main drawing, painting and photography.

Conclusion: This work did not find previous existence of any bibliometric analysis on the international scientific production in art therapy. In general terms, there has been a substantial growth in the number of publications on the subject over the last decade. However, this research area does not appear to have peaked, but, on the contrary, is still growing and progressing despite its long history in clinical practice.

Introduction

As a result of international research in art therapies, they are increasingly being accepted as a health promoting practice ( Stuckey and Nobel, 2010 ; Jensen and Bonde, 2018 ). Scientific evidence in this regard shows that these types of interventions positively influence both physical and psychological health, while improving social relationships ( Stuckey and Nobel, 2010 ; Jensen and Bonde, 2018 ). In general terms, art therapy is a type of intervention that uses the creative process as a way to meet a therapeutic objective where different artistic disciplines can come together, as an instrument at the service of the healing process ( Gacto and Gacto, 2012 ).

According to the Spanish Professional Association of Art Therapists, “Art therapy is a form of therapy that uses visual and artistic languages to facilitate the containment, exploration and resolution of conflicts. It is a healthcare profession, characterized by the use of artistic means and processes, to help contain and solve people’s emotional or psychological conflicts. In art therapy, the artistic creation process and the resulting objects act as intermediaries in the therapeutic relationship, allowing certain conflicting feelings or emotions to find complementary or alternative ways of expression to the word. The fields of application of art therapy extend to health, education and social assistance.”

On the other hand, the American Art Therapy Association (AATA) ( American Art Therapy Association, 2021 ), defines art therapy as follows: “Art therapy provides the opportunity for non-verbal expression and communication, on the one hand, through involvement to solve emotional conflicts as well as to promote self-awareness and personal development.” It is about using art as a vehicle for psychotherapy, helping the individual to find a more compatible relationship between their inner and outer world.

Therefore, art therapy is understood to be a means by which an individual to know themselves, it requires an accompaniment of the person (in their process of inner growth) and a help for the person with social, educational, personal difficulties, through their artistic production, in such a way that the work carried out generates a process of transformation of the individual him or herself.

Different clinical guidelines of the National Institute for Health and Care Excellence (NICE) include art therapy as an indication with recommended evidence. Similarly, since the beginning of the 21st century, art therapy has been recognized in the Nursing Interventions Classification (NIC), as a Nursing intervention. Butcher et al. (2018) , call it “Art Therapy” (4330), and it is defined as “the facilitation of communication through drawings or other forms of art.”

As complementary therapies, the different modalities of art therapy, among which are the visual arts, music therapy, dance therapy and drama therapy, are used to treat different psychological or cognitive behavioral disorders such as depression, stress, anxiety or neurological symptoms such as those caused by strokes ( Wallace et al., 2004 ; Ozdemir and Akdemir, 2009 ; Hughes and da Silva, 2011 ; Eum and Yim, 2015 ; Sarid et al., 2017 ; Jang et al., 2018 ) or disorders derived from chronic diseases such as diabetes ( Tang et al., 2021 ). These therapies provide benefits not only in the treatment or rehabilitation of the disease but also in the prevention of both certain disorders and the complications derived from them. Thus, different government agencies worldwide have drawn up evidence-based public policy documents that not only recognize the value of these interventions as alternative therapies, but also include their use in their recommendations ( Galletly et al., 2016 ; Scottish Intercollegiate Guidelines Network, 2016 ; Sall et al., 2019 ).

In the specific case of the visual arts modality (drawing, illustration, painting, collage, photography and sculpture), art therapy not only prevails as a clinical intervention tool ( Cheng et al., 2021 ; Hass-Cohen et al., 2021 ; Tang et al., 2021 ) but also as a diagnostic tool ( Akhavan Tafti et al., 2021 ; Goldner et al., 2021 ; Grenimann Bauch and Bat Or, 2021 ), which gives it a versatile and innovative character, and which distinguishes it from the other art therapy modalities. Bearing in mind the above, and given the variety of studies and publications in this regard, it is of interest to have a more in-depth view of the scope and characteristics of the existing research; bibliometrics is the ideal instrument for this objective since by using bibliometric indicators, it is possible to evaluate scientific activity in any discipline or area of knowledge, and thus determine different basic categories that define who the producing people, institutions or countries are, how much they produce, what the impact of their publications is and how they collaborate with each other ( Rodríguez Gutiérrez and Gómez Velasco, 2017 ).

After a thorough search of the literature, no research was found that involved a bibliometric study on scientific production in the visual arts modality within art therapy, therefore, this study could provide valuable information regarding the state of the question at hand in world research on the subject. Thus, the objective of the authors was to describe and contextualize international scientific production in the visual arts modality in the context of artistic therapies, to offer a broader and in-depth vision of the structure of this area of knowledge through a bibliometric analysis of the publications indexed in the core collection of the Web of Science (WoS), owned by Clarivate Analytics.

Materials and Methods

This is a retrospective, exploratory and descriptive, cross-sectional study.

Bibliographic data retrieved through a search strategy from databases including the core collection of the WoS were analyzed for the study. The data set included a total of 563 references.

Data Source

After a selection process and subsequent decision-making, it was agreed that the WoS would be the most appropriate platform for data extraction, since it is a fundamental source of information for the evaluation of the research ( Archambault et al., 2009 ). On the other hand, there is access to it, which from an operational point of view is essential to be able to obtain the necessary data. In addition, from a content point of view, its complete bibliographic data is available to develop a bibliometric analysis, and as such it is a widely used resource for this end ( Archambault et al., 2009 ).

Search Strategy

In order to define the search strategy, different preliminary tests were conducted using the advanced PubMed search, until a balance was achieved between the sensitivity and specificity of the results. The first step was to test the combination (art-therapy OR “Art Therapy”), once the first 100 results had been reviewed, it was concluded that it was necessary to add specific terms on visual arts to the strategy since the aim of the search was to identify publications on interventions with artistic therapies using visual techniques.

Finally, a search strategy was designed to obtain the corpus of information using the following combination of keywords: (art-therapy OR “Art Therapy”) AND (picture OR artwork OR illustrate OR photography OR painting OR paint OR “art galleries” OR “plastic arts” OR sculpture OR drawing OR draw).

Selection criterio:

Inclusion: as the present work is a type of analysis that aims to describe the state of the art in research in this domain, the objective of the search was to retrieve publications on the use of the visual arts as an art therapy technique, whether or not it is combined with another type of treatment, in any age group, within the health, educational or community sphere, without limits of year, country, etc.

Exclusion: any publication that does not refer to fine arts as an art therapy technique.

The search was conducted in the subject and title fields, with no date limit. The final execution date of the search was April 13, 2021.

Data Extraction

As the database only allows the exportation of references in batches of 500, the results were downloaded twice and later, with the help of the Notepad++ for Windows text editing program, both downloads were merged into a single file for subsequent analysis. On the one hand, an Excel database was created in which the different fields of each record were categorized as follows: author names, title, source journal, abstract, organization, keywords, references, and page numbers.

Analysis Methods

The analysis was performed by importing the data in txt format into an Excel spreadsheet using the function of obtaining external data. The analysis parameters included the data corresponding to the production by type of document, country, journal and institution. In addition, the main lines of research were identified and classified and the subject matter of the most cited articles in each of them was summarized.

The research lines were identified by dividing the corpus of analysis into different periods of 5 or 6 years, according to the publication dates of the articles. Keywords were identified and grouped by year, starting with 1994, the year when the first keywords were reported within the data retrieved for the analysis. After the periods had been defined, the main characteristics of the publications were identified through text mining in terms of the subject matter they address, the target population, the intervention environment, the pathologies treated and the type of art technique used.

Validity, Reliability, and Rigor

Two researchers developed the selection process independently, with the aim of ruling out duplicate or incomplete references or those that did not exactly fit the study objective. In the case of differences, the investigators tried to reach an agreement with each other or requested arbitration from a third party.

Descriptive Analysis

A total of 563 works were published, in 250 journals, in the 63 years between 1958, when the first document was published, and April 2021. The annual growth rate was 7.3% with a mean average of 8.7 publications per year and 83.13% of the published works were articles. The first article indexed in the reference database was published in the International Journal of Group Psychotherapy in 1958 ( Potts, 1958 ). English with 507 (90.05%) publications was the main language of the publications, followed in second place by Spanish with 15 (2.66%), German was third with 14 (2.49%), and French was fourth with 11 (1.1%). A total of 1,269 authors from 56 countries were counted. The mean average number of citations per document was 5.6 and the mean average number of citations per document and year was 0.6. The description of the type of publication and search characteristics is shown in Table 1 .

Table 1. Description, search characteristics, and results found in art therapy.

Evolution Over Time

Between 1958, when the first work was published, and 1977, only two articles were published. As of 1978, production fluctuated which lasted until 2005, when a clear upward trend began ( Quinn et al., 2013 ), which accelerated in 2012. The most productive year was 2018 when 61 papers were published. The evolution of the publications can be seen in Figure 1 .

Figure 1. Evolution of the frequency of publications in art therapy over time.

Distribution by Countries

An analysis was conducted by countries regarding the state of publications on art therapy. The results showed that, in the 63-year time window, from 1958 to 2021, authors from 53 countries participated with the United States, with 316 publications, leading the ranking of the most productive countries, followed by Israel (99) and the United Kingdom (69), in second and third place, respectively. Table 2 shows the countries with a minimum of 10 publications on the subject of study. In general terms, the United States was at the forefront in art therapy research, not only in terms of the volume of publications but also in terms of the number of citations received.

Table 2. Scientific production in art therapy, by country, with a minimum frequency of 10 publications.

Distribution by Journals

Regarding the 250 journals that published works on art therapy, only three, belonging to the psychology and/or rehabilitation research domains, concentrated the largest production on this topic. Table 3 shows detailed information on the most productive journals in Art therapy.

Table 3. Journals with the highest production in art therapy publications.

Figure 2 shows a scatter diagram illustrating the quantitative relationship between the 250 journals and the 563 scientific articles analyzed in the study.

Figure 2. Scatter diagram of journals and articles on art therapy retrieved through the core WoS collection. Total number of journals: 250, total number of articles: 563.

Distribution by Institutions

In total, 639 institutions were recorded, which were classified into three performance levels. Of these, 466 (72.8%) were small producers, with only one published work, 169 (26.41%) were medium producers, with between two and ten works, and only 0.63%, with more than 10 works, were large producers. Of the four most productive institutions, two were from the United States, one from Israel, and one from Korea. Figure 3 is a graph with information on the four most productive institutions.

Figure 3. Most productive institutions in art therapy, based on the data analyzed.

Distribution by Authors

A total of 1,269 authors were counted, of which 181 corresponded to authors of single-author documents and 1,088 were authors of multiple-author documents. Regarding all the analyzed documents, 1,495 signatures were classified with a range of signatures per document from 1 to 12 signatures. The most productive author with nine papers was Seong-in Kim, from Korea University in Seoul, South Korea. Table 4 shows the authors with the highest scientific production in art therapy.

Table 4. Authors and frequency of publications on art therapy.

As can be seen in Figure 4 , almost 90% of the authors are transient authors, with only one publication.

Figure 4. Transience of authors in art therapy publications.

Of the nine papers with a minimum of 50 citations, four were published in psychology journals, three in biomedical journals, and two in interdisciplinary journals. The journals The Arts in Psychotherapy and Psycho-oncology, monopolized 44.44% of the most cited works, with two articles each. Regarding the topic discussed, it was found that four of the most cited works were related to oncological issues, three to mental health, one related to nursing and another to gender violence. Table 5 shows the information related to the authors, topics covered, and citations.

Table 5. Reference of authors, topics covered, and citation of articles related to art therapy.

Distribution by Research Areas

Of the 81 research areas in which works have been published on the art therapy modality that is being analyzed here, clinical psychology and rehabilitation are noteworthy as they account for 70.2% of all publications on the subject. Table 6 shows the results of the areas with a minimum of ten publications.

Table 6. Publications in art therapy, by research area.

Analysis of Keywords

In order to facilitate analysis and provide an evolutionary perspective of art therapy research, four periods were used: 1994–1999; 2000–2005; 2006–2010; 2011–2020. The year 2021 was not included because it is ongoing, and it was decided to report only the full years.

Period 1: 1994–1999

There was talk of creative arts therapies in this period and a high degree of variability is observed in the study topics, ranging from psychiatric disorders, dementia, feminism, speech disorders, palliative care, sexual abuse, disability, grief or infant migraine. Although a defined line of research was not observed, it could be said that the interventions in art therapy which took place in these early years were mainly performed in a hospital or institutional environment, with children and adolescents being the population mostly selected for this type of therapy. The techniques used also vary from drawing, collage, crafts to photography.

Period 2: 2000–2005

There is still a high degree of thematic variability. The first works on interventions in cancer patients appear in this period, as well as several publications on art therapy experiences aimed at healthy people, concerning family relationships, adopted adolescents, pregnant women and battered women. Similarly, intervention experiences in behavioral disorders, learning difficulties, victims of terrorist attacks, epilepsy, grief and psychiatric disorders such as schizophrenia and nervous anorexia and bulimia are addressed. The first publications appear here addressing the use of art therapy as a diagnostic tool, as well as extra-hospital interventions, developed on an outpatient basis in health, community or educational institutions or centers. Although a wide variety of experiences with children and adolescents is published, the adult population takes center stage. As for the techniques, the visual arts are mainly those belonging to modalities such as painting, drawing, photography, etc., but there are also descriptions of experiences of combined therapies integrating two or more types of artistic and psychological therapies such as art therapy, dance therapy, music therapy, and psychotherapy.

Period 3: 2006–2010

Numerous theoretical and methodological articles. Informatics and virtual work environments are introduced, along with digital video as a means of art therapy. Interest in the perspective of the therapist is appreciated, given the impact that their personal experiences in the therapeutic process can have on the results of the therapy. Similarly, vocational training is addressed. The publication of works on patients with serious psychiatric disorders such as schizophrenia and on cancer patients continues. Furthermore, psychopathologies such as trauma and post-traumatic stress in war veterans and in children and child sexual abuse are also addressed. Experiences on art therapy interventions in patients with chronic diseases such as HIV/AIDS, asthma and diabetes are published. Cognitive and behavioral strategies such as coping are worked on, emotional needs are addressed in frail elderly people as well as creativity in patients with dementia. Interest is maintained on the diagnostic use of art therapy through the creation and validation of evaluation tools. Outpatient, community and institutional interventions continue, including intervention experiences with prisoners. The different modalities of artistic therapies are combined with each other through the use of visual arts in all its modalities in combination with dance, music or narration, and alliances are generated with other types of therapies such as occupational therapy, cognitive therapies -behavioral, exercise, other types of complementary or alternative therapies together with healthy life strategies. There is a special interest in this period in research on the use of color, as an important factor in art therapy evaluations.

Period 4: 2011–2020

The use of computers, art materials in digital format, virtual environments and art applications for iPads and mobiles becomes consolidated in this period. Most of the interventions are aimed at adults. Thematic variety is observed in the retrieved results. The topics that generated the most attention were behavioral, psychological and communicative symptoms in patients with dementia, as well as the management of psychosocial difficulties such as fatigue, depression, anxiety and existential and relational concerns in cancer patients. Research continues into serious mental illnesses such as schizophrenia. To a lesser extent, work was published on intellectual disability, special educational needs, improvement of memory and thinking skills to achieve school competencies, socio-emotional problems in adolescents or motivation in children at risk of poverty. There was research on domestic violence and feminism, on epilepsy, childhood trauma, the constructive coping of children who go through experiences of forced relocation due to border changes, wars or natural disasters. Other topics discussed are related to depression, psychosis, as well as the identification of types of attachment in healthy people, as well as intervention in prisoners. In addition, studies aimed at children and adolescents focused on determining the efficacy of art therapy in relation to victims of sexual abuse, orphans, symptoms of separation, anxiety disorder or social adaptation and integration. Cognitive impairment in alcoholics and the development of the identity of the LGTBI community are hardly addressed. The efficacy of the different modalities of combined artistic therapies is addressed and special interest is given to the use of computers in the field of evaluation through art therapy. In general, the modalities of visual arts are drawing, painting, photography, modeling, construction with non-conventional materials, various multimedia techniques, and animation.

The analysis of scientific production, based on bibliometric parameters, is an essential tool for evaluating knowledge and determining the progress of disciplines and their fields. In the present case, given the specificity of the subject, this type of work provides useful information to understand the general properties of the state of knowledge about art therapy ( Capilla-Díaz et al., 2020 ), since it offers a retrospective vision of the scientific production in the world based on the main bibliometric indicators.

Taking into account the annual progression of publications, a particular dynamic is observed with some periods of growth, alternating with others of regression. However, the increase in production from 2012 onward has shown a clear growth trend. This indicates that the topic has been gradually attracting the attention of professionals and researchers.

Regarding the geographical distribution of the publications, the results of the study are equivalent to those of a bibliometric study that analyzed the last 20 years of publications on music therapy ( Li et al., 2021 ) since the 10 countries or regions that these authors identified as the main ones are among the twenty top producing countries in art therapy, with the United States heading the list in both cases.

A high degree of dispersion is observed at the journal level, fulfilling Bradford’s Law, since the scientific production in art therapy presents a highly unequal distribution given that a large number of articles are concentrated in a small population of journals, while the rest of the articles are scattered over a large number of journals. On the other hand, it seems logical that the main sources in this area, Arts in Psychotherapy, Frontiers in Psychology and Art Therapy, would be the journals chosen by the authors to publish their research, considering that they are specialized journals in art therapy. In the case of Frontiers in Psychology, although it is not specific to this area of research, it does belong to the field of psychology, one of the two domains identified in the present study as being main domains. This result is also similar to that of Li et al. (2021) , mentioned above, where the authors found that the leading journals in the field were specialized in music therapy and where one of the main domains was also psychology.

Although two of the four most productive institutions were from the United States, it should be noted that the leading institution in this field is an Israeli university. Most of the institutions had a low performance in the scientific production on art therapy.

The most cited articles have a main interest in addressing symptoms with a psychological component such as anxiety, fatigue, emotional anguish or fear, during the course of serious diseases such as cancer, as well as psychiatric diseases such as schizophrenia or depression. In general, there is a clear line of research that refers to mental health. In addition, the different scientific domains present different citation practices, which for reasons of normalization of the bibliometric indicators are not comparable ( González and González, 2016 ). Therefore, based on the results of this analysis it seems that, in general terms, the research in art therapy may not have an impact maturation speed of more than 5 years. This is probably due to the fact that as an area of research, it is still being development.

Regarding authorship, the most notable result is the high transience of the authors, which also points to the low level of development in research in the area of art therapy.

Art therapy is applied to a wide spectrum of health problems, through a wide variety of artistic modalities. In the last decade of the twentieth century, interventions took place in hospital and institutional settings, in hospitalized or inpatients, and according to the studies analyzed, they were mainly aimed at children. The first outpatient experiences in art therapy appeared in 2000, when it started diversifying out of the health field into educational settings and began to be used as a preventive therapy, applied to healthy people ( Robertson, 2001 ; Swan-Foster et al., 2003 ), and for diagnostic purposes, with drawing or photography being incorporated into the assessment instruments ( Hays and Lyons, 1981 ; Kim et al., 2011 ; Darewych, 2013 ). Experiences of combined therapies integrating two or more types of artistic therapies into psychological and/or pharmacological therapy have been described. As of 2006, with the development of information technology and the internet, the virtual environment and tools in digital format started to gain momentum as a means of artistic therapy. This development in art therapy has been growing stronger since 2010, with the improvement of mobile terminals, applications for digital tablets and mobile phones.

There are no established research lines concerning the thematic variability identified in the analyzed publications. However, the scientific community seems to have been directing its research efforts toward issues related to the improvement of physical symptoms and the psychological well-being in patients with oncological pathologies. Furthermore, there are numerous studies focused on the cognitive behavioral intervention of patients with psychiatric diseases such as schizophrenia or degenerative diseases such as dementias, especially Alzheimer’s. Finally, drawing, painting and photography are the most recurrent visual arts modalities.

Strengths and Limitations

The only information used in the study was retrieved from the core WoS collection. As a quantitative approach was the fundamental approach used in the development of the study, this could lead to a certain bias in the analysis of the results since the qualitative component of the publications in this research area was not taken into account.

The bibliometric approach is a good methodology to map the scientific development of the domain in terms of findings and gaps in research. A systematic review would be necessary to detail the available scientific evidence on the efficacy-effectiveness and efficiency of this type of intervention.

To the best of the authors’ knowledge, this is the first study to describe the evolution of the domain through the development of its lines of research.

This work did not find the previous existence of any bibliometric analysis on the international scientific production in art therapy. The present study shows that the number of publications on the subject has multiplied substantially over the last decade. The results here are similar to those obtained in a similar study ( Li et al., 2021 ) which evaluated the growth of music therapy research over the last 20 years.

The bibliographic data retrieved from the databases of the core WoS collection are analyzed by applying this retrospective, exploratory, descriptive and cross-sectional study, with a bibliometric approach.

In the 63 years between 1958 and April 2021, a total of 563 works on art therapy in the visual arts were found, indexed in the databases selected for the sample of this study, with psychology and rehabilitation being the main domains research.

In addition, the ability of art to broaden personal horizons means that these disciplines are able to transcend the individual aspects present in the disease ( Marxen, 2011 ), bestowing on artistic therapies a polyvalent, multifaceted, multidisciplinary and conceivable character regardless of the application environment, the means and objectives of intervention, as described in this work.

In sum, through the proposed analysis, the authors conclude that, despite verifying a substantial growth in the number of publications on the subject during the last decade, the interest of researchers in visual arts as therapy continues to grow and progress.

The findings may provide useful information for art therapy (visual arts) researchers to identify new research directions and topics.

Data Availability Statement

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Author Contributions

All authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. LC-P and NR: conception and design of the study, acquisition of data and analysis, and interpretation of data. NR, MN, and JR: drafting the manuscript. MN and JR: revising the manuscript critically for important intellectual content. LC-P, NR, MN, and JR: approval of the version of the manuscript to be published.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords : art therapy, bibliometric, trend analysis, visual arts, health

Citation: Rodriguez Novo N, Novo Muñoz MM, Cuellar-Pompa L and Rodriguez Gomez JA (2021) Trends in Research on Art Therapy Indexed in the Web of Science: A Bibliometric Analysis. Front. Psychol. 12:752026. doi: 10.3389/fpsyg.2021.752026

Received: 02 August 2021; Accepted: 27 October 2021; Published: 19 November 2021.

Reviewed by:

Copyright © 2021 Rodriguez Novo, Novo Muñoz, Cuellar-Pompa and Rodriguez Gomez. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Natalia Rodriguez Novo, [email protected] ; Leticia Cuellar-Pompa, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Home / Living Well / The intersection of art and health: How art can help promote well-being

The intersection of art and health: How art can help promote well-being

Art can be helpful in a healthcare setting, whether it's prescribed therapy, something you participate in for fun or part of the environment around you.

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For thousands of years, people have been using arts like singing, painting and dancing for healing purposes. Modern healthcare settings continue to use art to help treat specific conditions, contribute to overall well-being and even help prevent diseases.

You might use art to support your own well-being without even thinking about it. For example, you might doodle when you feel stressed or enjoy playing an instrument at the end of a long day. In fact, artistic expression and appreciation are not only enjoyable but also have the potential to benefit your well-being.

Two approaches commonly used in healthcare settings include:

• Arts in health , which can include artists trained to help patients have positive creative experiences in a healthcare setting. It also can refer to art in the physical spaces where healthcare is delivered — think hospitals, care facilities, etc. This might include art on the wall, musical performances in the lobby and healing gardens.
• Creative arts therapies , which include a licensed professional engaging a patient in arts to address a specific condition or health goal. Therapy can be delivered through visual art, dance, music, poetry or drama and there are corresponding licenses for each type of art specialization.

What are some common creative arts therapy activities?

Music, dance, writing, storytelling, collage-making and painting can all be used in creative arts therapy. Creative arts therapists draw upon their training and the needs and interests of patients to meet clinical goals.

The success of art therapy isn’t measured by the quality of the art produced in a session, but instead by the healing that can happen during the process of making art.

How can creative arts therapy promote healing?

Creative arts therapy is used in treatment for a variety of conditions spanning mental health , cancer , stroke and more. The idea behind creative arts therapy is that artistic expression can help people to feel better and motivated to recover and address clinical needs such as reducing anxiety and blood pressure.

The American Congress of Rehabilitation Medicine says making or even just seeing art can impact the brain. Whether it’s part of a creative arts therapy exercise, or something you experience in your everyday life, art can help:

• Increase serotonin levels.
• Increase blood flow to the part of the brain associated with pleasure.
• Foster new ways of thinking.
• Imagine a more hopeful future.

How is creative arts therapy used for mental health?

In the 1940s, healthcare providers noticed that people with mental illness would express themselves through art. This observation inspired the use of creative arts therapy as a healing technique for conditions including anxiety, depression, mood disorders, schizophrenia and dementia .

Creative arts therapy is used to help treat mental health conditions because it can improve focus, assist with processing emotions, improve communication and increase self-esteem.

What are the benefits of creative arts therapy?

As therapy, research shows that art facilitated by a professional creative arts therapist has the potential to positively impact elements of your physical and mental health, including:

• Overall well-being.
• Quality of life.
• Interpersonal relationships.
• Freedom of expression, when talking about thoughts and feelings is difficult.
• Emotional resilience.

What are the benefits of creative arts therapy for children?

Although creative arts therapy is used with people of all ages, it can have some unique benefits for kids. The American Art Therapy Association shares that art therapy can help kids express themselves and share their feelings without using words, which can be especially helpful when working with younger or nonverbal children. Specifically, it can assist with communication in children with autism, soothe kids with cancer and help improve focus in kids with attention-deficit disorders.

Can art help even if it’s not prescribed therapy?

Yes! In addition to creative arts therapy, the arts also can be beneficial to your physical and mental health when you experience them — as an appreciator or creator. For example, creating visual art like drawings or paintings can provide enjoyment and distraction from things like pain and anxiety. Listening to music might help to improve blood pressure and sleep quality, and can help keep you calm and relaxed during a medical procedure.

In addition to having an impact on overall well-being and specific health outcomes, art can support the overall healthcare experience. Through three humanities-focused centers in Arizona , Florida and Minnesota, Mayo Clinic incorporates arts for enjoyment and creative arts therapy in patient care.

In Minnesota, Sarah Mensink is the program director for the Mayo Clinic Dolores Jean Lavins Center for Humanities in Medicine , which manages a variety of arts programs, including:

• Arts at the Bedside, a program where artists visit with and offer people the opportunity to create art during a hospital stay.
• Mayo Humanities TV Channel, which offers recorded concerts, lectures and other art programs on demand in hospital rooms.
• The “Music is Good Medicine Concert Series” and the “Rosemary and Meredith Wilson Harmony for Mayo Concert Series” that offer live music performances in Mayo Clinic facilities.

“Arts at the Bedside is a nice opportunity to enhance the patient experience. You’re treated as a whole person. Healing is more than a cure. It offers a creative outlet and an opportunity for fun,” says Mensink.

Patients aren’t the only people helped by art in a healthcare setting. It can benefit family members and healthcare providers too. Mensink says that when the patient experience is improved with art, the burden of healthcare providers is lessened.

“When patients are happy and occupied with an art project, staff members are glad to see the person doing well,” she says.

Whether it’s the design of a hospital’s physical space, an impromptu concert to enjoy or a dedicated therapy session that uses art to achieve a clinical goal, each has its place in promoting the well-being of individuals and communities. Art has the potential to go beyond treating symptoms and improve your whole self — including physical, mental and emotional elements.

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Knowledge and use of art therapy for mental health treatment among clinical psychologists

Art therapy allows people to express feelings about any subject through creative work. It is beneficial for people who feel out of touch with their emotions. In Ghana, little is known about art therapy as a therapeutic tool. Herbal treatment, biomedical and faith healing practices are the most common treatment options for mental health. This research aimed to provide new insights into clinical psychologists on their knowledge and use of art therapy in treating clients and identified the enablers and barriers in this therapeutic intervention.

Twenty-one clinical psychologists were sampled using the snowball sampling method. They were interviewed over the phone using a semi-structured interview guide which was developed based on the predefined study objectives. Thematic analysis was employed to analyze the data resulting in three central thematic areas.

Twelve of the clinical psychologists were females and eight were male, with an age range between twenty-five to fifty years. The major themes identified were knowledge of art therapy, the use of art therapy and enablers and barriers in using art therapy. The study revealed that clinical psychologists had limited knowledge of art therapy mainly due to lack of training. With the use of art therapy, the participants revealed that they had used some form of art therapy before and they perceived art therapy to be effective on their clients however, they demonstrated low confidence in using it. Practitioner training and the availability of art therapy-related resources were identified as both facilitators and hindrances to the use of art therapy.

Clinical Psychologists are cognizant of art therapy albeit they have limited knowledge. Therefore, training in how to use art therapy and the availability of resources to facilitate art therapy can be provided for Clinical Psychologists by the Ghana Mental Health Authority.

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Endocytosis as a critical regulator of hematopoietic stem cell fate —implications for hematopoietic stem cell and gene therapy

• Prathibha Babu Chandraprabha 1 , 2 &
• Saravanabhavan Thangavel   ORCID: orcid.org/0000-0001-6760-4106 1  

Stem Cell Research & Therapy volume  15 , Article number:  319 ( 2024 ) Cite this article

Metrics details

Hematopoietic stem cells (HSCs) have emerged as one of the most therapeutically significant adult stem cells, paving way for a range of novel curative regimens over decades. HSCs are transplanted, either directly or post restorative genetic engineering in order to repopulate a healthy hematopoietic homeostasis in patients with disorders affecting the blood and immune cells. Despite being an extensively studied system, the maintenance and expansion of functional HSCs ex vivo remains a major bottleneck. The challenge primarily stems from difficulties in reproducing HSC self-renewal divisions and gradual depletion of stemness characters, in vitro. Refining the in vitro culture can be particularly beneficial in the case of cord blood HSCs (CB-HSCs), as inadequate numbers in a single umbilical cord limits its therapeutic potential. In recent years, molecular dissection of HSC stemness has significantly improved in vitro hematopoietic stem and progenitor cells (HSPCs) culture. Despite such significant progress, lacunae exist in fully understanding all the underlying mechanisms and their interplay active in bona fide HSCs, and how it transforms when cells proliferate in culture. A new groundbreaking study titled “MYCT1 controls environmental sensing in human haematopoietic stem cells”, published in Nature in June 2024, sheds light on this complex field. Through a series of experiments, including knock-down, overexpression, single-cell RNA sequencing, and transplantation, the study identifies a previously unknown role of the MYC target 1 (MYCT1) protein in HSC maintenance. This protein acts as a crucial regulator of human HSCs, with high expression in primitive HSCs and subsequently downregulated during ex vivo culture. The study reveals that MYCT1 plays a vital role in moderating endocytosis and environmental sensing in HSCs, processes thereby essential for maintaining HSC stemness and function. This commentary will discuss the implications of the new findings for cord blood expansion in cell therapies and HSPC culture for gene therapy applications, providing valuable insights for the field of hematopoietic regenerative medicine.

Researchers have long sought to expand hematopoietic stem cells (HSCs) from cord blood to quantities sufficient for transplantation, which could potentially save patients lacking compatible human leukocyte antigens (HLA)-matched donors [ 1 , 2 ]. However, this goal remains elusive despite advanced high-throughput screens identifying factors that support ex vivo culture and expansion of HSPCs [ 3 , 4 ]. Most screens have relied on immunophenotypic markers of HSCs as readouts, which only partially correlate with HSC engraftment potential. New markers like Endothelial protein C receptor (EPCR), Integrin-α3 (ITGA3) and hepatic leukemia factor (HLF) have emerged through the years. These markers enhance the correlation between marker expression, the HSC transcriptome and engraftment potential, aiding in the identification of functional long-term HSCs (LT-HSCs) [ 5 , 6 ]. Yet even these markers fail to fully capture functional HSCs generated ex vivo. The identification of intranuclear factors such as Mixed-Lineage Leukemia Translocated to Chromosome 3 Protein (MLLT3) which regulates H3K79me2 and maintains an open chromatin state of key HSC regulatory genes, including MECOM, HLF, and Musashi-2 (MSI2), has improved our understanding of HSC stemness and self-renewal [ 3 ]. This also signifies the need to elucidate such regulatory programs, which could potentially lead to targeting synergistic pathways that support robust expansion of functional HSCs.

In this pursuit, Aguadé-Gorgorió et al., conducted RNA sequencing analysis to examine the expression of HSC factors in haematopoietic tissues across development and examined the same factors when HSCs were subjected to in vitro culture [ 7 ]. This RNA-seq-based strategy marks a shift from relying solely on surface markers to incorporating transcriptomic data for a more comprehensive understanding of HSC biology. By pinpointing MYCT1 as a key player in HSC regulation, this study opens new avenues for potentially improving ex vivo HSC expansion methods.

Significance of MYCT1 and endocytosis in HSC regulation

Hematopoietic stem cell fate regulation has been widely studied from the angle of transcriptional and epigenetic programs co-ordinating self-renewal and differentiation. Such studies have resulted in the development of aryl hydrocarbon receptor antagonists and compounds preserving epigenetic marks for expanding HSCs during ex vivo culture, and, in turn, CB-HSCs expanded ex vivo with these candidates, have been promising in early clinical studies [ 1 , 8 ]. The study by Aguadé-Gorgorió et al., presents “endocytosis” as another crucial program regulating HSC fate [ 7 ]. Low endocytosis-mediated regulated environmental sensing is key for HSC maintenance, and it suggests that HSCs require stricter control of environmental sensing mechanisms compared to progenitors and differentiated cells. Hence, a tightly controlled endocytosis axis may be crucial for maintaining the unique functional properties of HSCs. The results uncover another layer of complexity in signal sensing programmes in HSCs, with an earlier study reporting an interesting phenomenon of controlled lysosomal activity in phenotypic LT-HSCs, which further alters the cell fate determination trajectories [ 9 ]. Moreover, MYCT1 is highly expressed in MLLT3 and HLF expressing fractions, indicating that MYCT1 expression corroborates with other stemness signatures, and can potentially be a novel HSC hallmark. This insight could lead to new strategies for identifying and isolating high-quality HSCs based on their endocytosis rates or MYCT1 expression levels, in addition, or as an alternative to current LT-HSC immunophenotypic markers; CD34 + CD133 + CD90 + CD49f + cells, potentially improving the efficacy of HSC transplantations and gene therapies.

Implications for ex vivo HSC expansion

Stromal cells or small-molecule compounds like Stemreginin1 and UM171 have been shown to support the in vitro culture of HSCs [ 1 , 10 ], but the new study points that these systems fail to maintain the expression of MYCT1 or the endocytosis rates. This clearly underlines that the existing ex vivo expansion systems are insufficient to fully preserve the functional integrity of HSCs. It would be interesting to screen the expansion supporting small molecule compounds incorporating MYCT1 expression as a readout. Also, current methods using high doses of cytokines or small molecule compounds may inadvertently increase endocytosis rates, potentially compromising HSC quality. It would also be interesting to test whether, the recently proposed, chemically defined cytokine-free HSC culture systems can sustain the MYCT1 expression [ 11 ]. The observation that restoring MYCT1 expression can suppress excessive culture-induced endocytosis in HSPCs can be further explored as a new approach to maintaining HSC function during ex vivo expansion.

This research raises important questions about current HSC culture methods:

Should we re-evaluate the use of high-dose cytokines in HSC culture?

Can we identify upstream regulators of MYCT1 expression to develop more effective expansion protocols?

Should we supplement endocytosis blockers to HSC culture media?

Impact on HSPC gene therapy

The implications of this study extend to the rapidly advancing field of HSPC gene therapy, which encompasses gene editing, retroviral (lentivirus) or adenoviral gene addition techniques. With the recent commercial approval of HSPC gene editing therapies [ 12 ], understanding the factors that maintain HSC quality during manipulation becomes crucial. Homology-directed repair (HDR) gene editing of HSPCs or lentiviral mediated manipulation takes at least 2 days of ex vivo culture. It would be interesting to look at the effect of gene-manipulation stress on the MYCT1 expression. MYCT1 could serve as a valuable quality control indicator for gene-edited HSPCs, potentially improving the outcomes of these therapies.

Moreover, recent findings suggest that shorter culture periods or even culture-free gene editing methods may be beneficial for preserving HSC function [ 13 , 14 ]. This could lead to the development of more efficient and effective protocols for genetic modification of HSCs, enhancing the potential of personalized cell therapies (Fig.  1 ).

Schematic illustration of MYCT1-associated stemness and metabolic programs in ex vivo expanded HSPCs. Potential therapeutic benefits of sustained MYCT1 expression for hematopoietic stem cell and gene therapy are also indicated. Image created with Biorender.com

Future directions and conclusion

This research opens up several avenues for future investigation:

Elucidating the specific endocytic pathways through which MYCT1 exerts its effects on HSC function.

Developing methods to sustain MYCT1 expression during ex vivo culture without relying on viral vectors.

Exploring the potential of MYCT1 and endocytosis rates as markers for HSC quality in clinical applications.

In conclusion, the discovery of MYCT1’s role in regulating HSC fate through the control of endocytosis represents a significant advancement in hematopoietic stem cell biology. By highlighting the importance of controlled environmental sensing in quiescent HSC maintenance, this study not only deepens our understanding of fundamental haematopoietic stem cell biology but also offers new strategies for improving HSC expansion protocols and cell therapies. As research in this area progresses, it has the potential to revolutionize HSC-based regenerative medicine strategies to cure diseases.

Data availability

Not applicable.

Abbreviations

Hematopoietic stem cell

Long-term hematopoietic stem cell

Hematopoietic stem and progenitor cells

MYC target 1

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Acknowledgements

The authors acknowledge the funding support by the DBT/Wellcome Trust India Alliance Fellowship [IA/TSG/22/1/600431] and the Department of Biotechnology, Ministry of Science and Technology, Government of India through the grants ; BT/PR31616/MED/31/408/2019, BT/PR45683/MED/31/465/2022 and BT/PR38267/GET/119/348/2020 awarded to ST. We thank CSIR-JRF fellowship for PB.

DBT/Wellcome Trust India Alliance Fellowship [IA/TSG/22/1/600431] and the Department of Biotechnology, Ministry of Science and Technology, Government of India through the grants; BT/PR45683/MED/31/465/2022, BT/PR38267/GET/119/348/2020 and BT/PR31616/MED/31/408/2019.

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Babu Chandraprabha, P., Thangavel, S. Endocytosis as a critical regulator of hematopoietic stem cell fate —implications for hematopoietic stem cell and gene therapy. Stem Cell Res Ther 15 , 319 (2024). https://doi.org/10.1186/s13287-024-03927-6

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The therapeutic effectiveness of using visual art modalities with the bereaved: a systematic review

Rachel e weiskittle.

Department of Clinical Psychology, Virginia Commonwealth University, Richmond, VA, USA

Sandra E Gramling

Bereaved individuals are increasingly considered at risk for negative psychological and physiological outcomes. Visual art modalities are often incorporated into grief therapy interventions, and clinical application of art therapy techniques with the bereaved has been widely documented. Although clinicians and recipients of these interventions advocate for their helpfulness in adapting to bereavement, research investigating the efficacy of visual art modalities has produced equivocal results and has not yet been synthesized to establish empirical support across settings. Accordingly, this review critically evaluates the existent literature on the effectiveness of visual art modalities with the bereaved and offers suggestions for future avenues of research. A total of 27 studies were included in the current review. Meta-analysis was not possible because of clinical heterogeneity and insufficient comparable data on outcome measures across studies. A narrative synthesis reports that therapeutic application of visual art modalities was associated with positive changes such as continuing bonds with the deceased and meaning making. Modest and conflicting preliminary evidence was found to support treatment effectiveness in alleviating negative grief symptoms such as general distress, functional impairment, and symptoms of depression and anxiety.

Introduction

Bereavement is a ubiquitous human experience that often recurs throughout a lifetime. 1 Coping with the death of a loved one is often challenging and can affect bereaved individuals across multifaceted domains. Along with heightened emotions and longing for the deceased, bereaved individuals may experience symptoms of depression, anxiety, and cognitive disorganization. 2 Those bereaved may also endorse physical manifestations of their distress, such as increased fatigue, greater propensity for developing illness, and overall poorer physical health outcomes than their non-bereaved counterparts. 3 , 4 These symptoms are collectively identified as the negative symptoms of grief and can catalyze a myriad of functional complications, including decreased academic performance, 5 job productivity, and quality of life. 6

Early grief theories, such as those pioneered by Freud 7 and Kubler-Ross, 8 paralleled the universalistic aspect of bereavement by conceptualizing grief as a predictable process of identifiable stages. 9 However, research has increasingly informed a paradigm shift toward a more nuanced understanding of loss. A large body of empirical evidence indicates multiple trajectories of grief rather than one standardized process, and leaders in the field suggest that reactions to loss can be as varied as the bereaved individuals themselves. 10 , 11 Some people demonstrate considerable resilience when faced with loss, 10 others experience significant but temporary impairment, and approximately 10–15% find themselves “stuck” in a persistent state of intense, complicated grief. 12 Characteristics of the bereaved or of their loss can impact these grief trajectories. For example, relationship to the deceased and expectedness of the loss have been found to be particularly salient in influence on the intensity of grief reactions. 12 – 14 As such, contemporary models of grief emphasize that the ways people adapt to loss vary as a function of individual differences.

Theorists and researchers currently embrace a range of empirically validated frameworks that account for the variegated trajectories of bereavement experiences, but two theories have emerged as the most demonstrable in empirical promise. First, the dual-process model of bereavement posits that grieving a loved one entails oscillating between orientation to the loss (i.e., continuing bonds with the deceased by expressing emotion related to the death and reconnecting with the memory of the loved one) and restoration of contact with a changed world (i.e., reengaging relationships and experimenting with new life roles). 15 Second, the meaning reconstruction model of grief views grieving as a process of reaffirming or reforming a world of meaning that has been challenged by loss. 16 In this constructivist-rooted perspective, people create and maintain a system of beliefs that permit them to anticipate and respond to their surroundings. Events’ ascribed meaning must be either assimilated into the existing belief system or the system must be accommodated to make congruent meaning of the event. 17 The death of a loved one is often a challenging event to make meaning of; as such, this model in summary characterizes grief as the process of reconstructing one’s belief system and making meaning of one’s loss. 18 These two predominant bereavement theories are complementary. Both the dual-process model and the meaning reconstruction model view grief as a life-long process of renegotiating continuing bonds with the deceased and formulating meaning into life after the loss. 19 The meaning reconstruction model proposes that the search for meaning is the bereaved individual’s quest following loss, and the dual-process model’s cognitive oscillation of grief helps explain how the meaning is created. 20

Research investigating the applicability of these models demonstrates signs of efficacy, particularly in regard to the ways in which continuing bonds with the deceased and meaning making are important mechanisms of successful adaptation to bereavement. Continuing bonds with the deceased facilitates grief resolution by helping the bereaved to preserve a sense of identity and meaningful connection with the past. 21 , 22 When the bereaved are successful in finding meaning, evidence indicates that they fare better than their counterparts who struggle to make sense of the experience. Specifically, studies have reported that finding meaning is related to higher subjective well-being and more positive immune system functioning. 23 , 24 Research provides empirical support for the processes proposed by the field’s leading bereavement theories and suggests that bereaved people struggling to adjust to their loss could benefit from interventions driven around these two domains. As such, most empirically informed grief therapies aim to provide avenues for patients to explore continued bonds with the deceased, the personalized meaning behind their loss, and a reconstruction of purpose in life without their loved one. 11

As bereavement theory evolved away from ubiquitous stage models toward more contextualized processing of varied individual loss, grief therapy similarly evolved in scope to include a range of treatment modalities. 25 Many practices have made alterations to traditional grief psychotherapy to avoid a “one-size-fits-all” approach to treatment. 26 – 28 An alteration frequently endorsed is the incorporation of expressive art modalities. Expressive art modalities are defined as the use of dance, drama, drawing, music, painting, photography, sculpture, and writing within the context of psychotherapy, counseling, rehabilitation, or medicine. 29 Expressive art therapies are sometimes referred to as integrative or creative art therapies when purposively used in combination with treatment. 30 Many manualized grief interventions incorporate expressive art techniques, such as Shear et al’s 31 , 32 treatment for complicated grief. Thompson and Neimeyer 33 recently published a clinical manual with more than 50 suggested expressive art interventions to use with bereaved clients. The authors encouraged practicing grief therapists to use expressive art modalities to augment their existing clinical bereavement practice and incorporating expressive arts into grief therapy has been hailed as a way for clinicians to take their “game” to the next level. 33 , 34

Not only has the incorporation of expressive arts with traditional grief therapy become increasingly documented but it is also common for those seeking grief therapy to receive care from a certified art therapist. More than 80% of trained art therapists report working with bereaved individuals. Further, bereavement/grief is self-reported as one of the top 10 specialties of practicing art therapists. 35 In fact, peer-reviewed art therapy journals frequently publish educational editorial materials on grief theory in an effort to empirically inform art therapists’ existing practice. 19 Thus, bereaved individuals seeking therapeutic assistance for adjusting to their losses are likely to encounter exposure to expressive art modalities within a therapeutic context.

Theoretical support for the frequent combination of expressive arts and bereavement within a therapeutic setting can be found in the fields’ overlapping treatment goals. Art therapists’ orientation toward externalizing processes and facilitating insight meld naturally with meaning-focused therapeutic practice. 25 The spontaneous creation of art, poetry, and performance offers a way to memorialize the relationship with the deceased and facilitate continuing bonds. 36 Echoing the dual-process model’s oscillating conceptualization of grief, theoretical models of art therapy posit that creativity is both a restorative and assertive act. 37 , 38 Malchiodi 40 noted that therapeutic art making served four purposes, which notably echo the assimilation and accommodation processes of the dual-process model: confronting mortality, meaning making, crisis resolution, and authentic emotional expression. Finally, both the leading theories of grief (i.e., the dual-process model and meaning reconstruction model) and of expressive arts (i.e., the expressive therapies continuum 39 ) argue that creating meaning is the leading mechanism of change.

Although the expressive arts in general have been suggested by many clinicians as useful tools to facilitate adaptation to loss, use of the visual arts has particularly burgeoned within the field in recent years. Visual arts such as drawing, painting, photography, and multimodal forms have been commonplace in grief therapy. 33 Specifically, the creation of mandalas, scrapbooks, and thematic collages are among the most frequently implemented expressive art techniques with the bereaved. For example, photography, ie, the creation of a photographic narrative of the deceased loved one, is one of the core techniques in Shear et al’s 32 manual for complicated grief. Visual arts’ frequent use in the field is congruent with available historical context. Mourning and grief in funeral rituals often employ visual art to express loss, love, and remembrance across cultures. 40 , 41 In addition, visual memorials are often created for remembrance, documentation, and healing for family and community of the decedent. 42 Remarkably, despite the prevalence of implementing expressive art techniques with the bereaved, only recently studies have begun to investigate its efficacy or effectiveness. Given the frequent clinical application of visual art modalities for those bereaved, it is imperative that more investigative work be performed to evaluate this method of treatment, and a thorough review of the literature is warranted.

Materials and methods

Objectives of the empirical review.

This paper reviews and integrates the literature on the therapeutic application of visual art modalities with a bereaved population. Specifically, this review 1) evaluates empirical studies that report findings regarding the clinical effectiveness of visual art modalities as applied to the bereaved population; 2) identifies key mechanisms that may influence outcomes; 3) synthesizes the mechanisms identified across different functional outcomes; and 4) discusses weakness of the current state of the literature as well as promising avenues for future investigation. In addition, the paper discusses methodological considerations for future work examining whether visual arts are effective in promoting adaptation to bereavement when used in a therapeutic context.

Definitions of terms

This review utilizes the dual-process model of bereavement and the meaning reconstruction model to inform its evaluation of treatment effectiveness. This section provides and briefly describes the following terms used to categorize the review’s scope and findings: 1) continuing bonds; 2) meaning making; 3) negative grief symptomatology; and 4) visual art modality.

Continuing bonds

“Continuing bonds” is a term that reflects the “ongoing attachment to the deceased.” 48 Continuing bonds with the deceased can be experienced emotionally, through missing, yearning, and feeling strongly connected to the loved one, 49 and cognitively, by thinking of and remembering the deceased person. 50 Continuing bonds can behaviorally entail talking to the loved one, maintaining his or her belongings post loss, feeling the presence of the loved one, and passing on the deceased’s habits or virtues to others. 51 Importantly, accepting the reality of the death and communicating the narrative of the loved one’s life arc are also manifestations of adaptive continuing bonds with the decedent. 48 “Continuing bonds” is most often measured in quantitative bereavement research with the Continuing Bonds Scale (CBS). 52 In qualitative research, “continuing bonds” is commonly measured by the presence and frequency of the endorsements of the aforementioned characteristics.

Meaning making

Meaning making, according to Thompson and Janigian, 53 is the “ability to develop new goals and purpose, or to construct a sense of self that incorporates the significance of an experience.” Drawing from this definition, researchers propose that meaning making following loss is a cyclical course in which the pain of bereavement (i.e., negative grief symptoms) prompts efforts to find meaning in the challenging event of the loss, with new meanings forming and integrating into a system of beliefs. 18 , 54 , 55 In summary, meaning making during bereavement refers specifically to the reconciliation or reconfiguration of preexisting meanings with the death of a loved one. Meaning making can be manifested in the following documentable ways: sharing views that relate to the philosophical aspects of death and dying such as fairness; 55 questioning, examining, and changing global meaning; 56 discussing topics of religious connotations; 55 expression of lessons learned, new insights gained, or changes in self or family since the death; 55 and expression of strengthened familiar relations following the loss. 57 Qualitative investigation of meaning making during bereavement often prompts participants to describe their loss experience in their own words and codes responses on the presence of the aforementioned documentable manifestations. For example, Lichtenthal et al 58 assessed meaning-making processes in parents who had lost a child with open-ended written prompts (e.g., Have there been any ways in which you have been able to make sense of the loss of your child?). Similarly, Wheeler 59 observed a “crisis in meaning” among bereaved parents in a qualitative study that revealed themes of parents’ struggle to make sense of why the loss occurred, wondering what could have been performed to prevent the loss, preserving the significance of their child’s life, and positive gains related to the loss. Quantitative measurement of meaning making during bereavement is most often assessed by directly asking participants to estimate how much they have been able to “make sense of” a loss on a Likert scale. 60

Negative grief symptoms

Traditional grief theory suggested that bereavement was a one-dimensional experience of suffering, and research has historically focused on the negative outcomes following loss. However, our improved understanding reformulates bereavement as a complex system of experiences that can include positive changes, such as the aforementioned reconstruction of identity, meaning, and purpose. 61 Thus, the negative aspects of bereavement are no longer considered to be the only formulation of grief, but are still viewed as integral and commonly endorsed components of bereavement. 62 These negative grief reactions generally cause distress or impairment to the bereaved. The reactions may be exhibited affectively, emotionally, behaviorally, physiologically, cognitively, or socially. 63 Negative grief symptoms are measured in the literature by endorsement of depressive symptoms, anxiety, poor social/relational functioning, cognitive disorganization, and physical health attributes. 64 Quantitative measures of normative levels of negative grief symptoms are numerous, such as the Core Bereavement Items (CBI) and the Hogan Grief Reaction Checklist (HGRC). 65 , 66 Quantitative measures of complicated grief symptoms include the Inventory of Complicated Grief (ICG) and the Texas Revised Inventory of Grief (TRIG). 67 , 68 The aforementioned measures of negative grief symptoms have the strongest presence in bereavement literature, because they demonstrate strong psychometric properties across a number of bereaved populations.

Visual art modality

The scope of the review focuses on the effectiveness of visual art modalities within the context of bereavement therapy. Treatment parameters within the expressive arts are notoriously opaque. 59 The American Art Therapy Association defines visual art as “drawing, painting, sculpture, and other art forms.” 69 For the purpose of this review, “other art forms” will echo previously published definition of visual art found in cross-disciplinary literature by including the following: printmaking, crafts (e.g., collage and scrapbooking), graffiti, photography, and ceramics. 70 In an effort to replicate existing reviews of the expressive arts as treatment modalities, 43 – 45 this review included studies that utilized visual art as both primary and adjunctive therapies.

Search procedure and review parameters

Pertinent peer-reviewed studies were identified through keyword searches in scientific databases that target the majority of published literature in the social and medical fields (e.g., PsycINFO, PubMed, Wiley Online Library, Web of Knowledge, and Google Scholar). Search terms (or word stems) consisted of (“art therap*” OR “arts psychotherap*” OR “expressive art*” OR “creative arts psychotherap*” OR “creative psycholog*” OR “visual art*”) AND (“bereave*” OR “grief” OR “death”); where * denoted any wild card. After the initial search, specific examples of therapeutic visual art modalities (e.g., mandala and scrapbooking) were searched based on the previous findings to ensure comprehensiveness. Manual searches of prominent relevant journals (e.g., Death Studies, OMEGA, Art Therapy, and Arts in Psychotherapy) were also conducted. The reference sections of identified manuscripts were screened for additional studies. Finally, a separate search was conducted in thesis/dissertation data bases using the same terms.

Studies in the current review satisfied the following inclusion criteria: 1) the study reported original research investigating psychosocial outcomes of therapeutic visual art modalities; 2) the intervention was specific to the modality of visual art (as opposed to music therapy, dance/movement therapy, play therapy, or drama therapy); 3) study participants had experienced bereavement-related loss; and 4) the study was in print or published in English.

The first author screened the abstracts of all identified articles for relevance to the current review, and full-text articles of pertinent studies were obtained. A total of 168 full-text articles were obtained and screened by the first author, of which 141 were excluded for the following reasons: did not examine effectiveness of therapeutic visual art modalities (n = 131); participants had not experienced bereavement-related losses (n = 4) and were not in the context of interventions (n = 6).

A total of 27 studies met all of the inclusion criteria. Table 1 provides details on the research design, sample composition and demographics, outcomes, and key findings of these studies. The subsequent sections first reviews the studies’ research design characteristics. The following design components will be evaluated: study design, intervention characteristics (e.g., group vs. individual intervention, qualifications of individual administering intervention, and length of intervention), and outcome measurement. Subsequently, study results are summarized by the factors central to grief processing, as identified by Stroebe and Schut 15 in the dual-process model of bereavement and by Neimeyer 16 in the meaning reconstruction model: 1) continuing bonds, 2) meaning making, and 3) negative grief symptomatology. The empirical support for each domain is discussed.

Studies examining visual art treatment modalities with bereaved participants

Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CARED, characteristics, attributions, and responses after exposure to death; CBC, Child Behavior Checklist; CPSS, Child PTSD Symptom Scale; FES, Family Environment Scale; GHQ, General Health Questionnaire; IES, Impact of Event Scale; IGTS, Intrusive Grief Thoughts Scale; IPFI, Individual Protective Factors Index; KFD, Kinetic Family Drawing; N/A, not applicable; ns, not significant; PTSD, posttraumatic stress disorder; RCMAS, Revised Measure of Children’s Manifest Anxiety Scale; sig., significant; sx, symptoms; TAU, treatment as usual; T-CRS, Teacher–Child Rating Scale; TRIG, Texas Revised Inventory of Grief; tx, treatment.

Study design

Study samples were heterogeneous across studies. Fifteen (56%) of the studies had a child/adolescent sample, 10 (37%) had an adult sample, and two (7%) had a combined sample with a focus on family systems. Ages ranged from 18 to 94 years in the adult samples and 5 to 17 years in the child/adolescent samples. Average total number of participants was 26 (SD = 24.3). The majority of studies were correlational with no control group (93%). Of the experimental designs, one study used a waitlist control group 71 and one used a treatment as usual control. 72 Approximately 19% of studies were cross-sectional, while 81% were longitudinal; 33% of studies included a follow-up session. The majority of studies were qualitative in nature (62%), while 19% were mixed methods and 19% were quantitative.

Intervention characteristics

Most of the included studies used a group intervention (63%), although individual (30%) and family (7%) approaches were also represented. The interventions included psychotherapy and counseling with adjunct visual art modalities (33%), art therapy support groups (33%), individual art therapy interventions (26%), and interventions using both individual and group formats (8%). The interventions were conducted by certified art therapists (7%), licensed counselors or psychologists (26%), art therapy doctorate students (26%) clinical psychology doctorate students (30%), and co-facilitators of licensed clinicians and certified art therapists (11%). Interventions spanned an average of 9 weeks for an average number of 83-minute sessions, totaling an average of 6.7 intervention hours per participant. Other characteristics of the samples and the studies are presented in Table 2 . These variables were usually coded on the basis of the mean, but the medians or midpoints of the ranges were used when authors failed to report this information.

Study characteristics

Outcome measurement

Outcome measurement varied widely across studies despite similarities in treatment outcome foci. There was insufficient statistical information to obtain a pooled estimate of treatment effect; thus, creating a meta-analysis of the incorporated studies was beyond the remit for the current investigation. Outcomes were assessed using three different reporting methods: participants’ self-report, reports of significant others, and clinician-rated judgment. Instruments that required the participants to respond to questions about themselves on a conventional rating scale or open-ended were considered self-report. Rating scales that involved the evaluation of outward behaviors by other reporters were grouped as other report. Finally, there were instances in which outcomes were determined by a trained professional’s assessment of the participants’ functioning that was usually based on an accepted standard of distress (e.g., severity of depressive symptoms) or the participants’ artwork created during the intervention (e.g., Kinetic Family Drawing [KFD]). Approximately 56% of studies used participants’ self-report, 11% included reports of significant others, and 89% used various formats of clinician-rated judgment as a form of outcome measurement. Approximately 26% of studies used only clinician-rated judgments as reporting methods. Overall, researchers used the three reporting methods to assess outcomes in eight domains: general distress (48%), continuing bonds (44%), meaning making (41%), relational functioning/social adjustment (11%), trauma symptoms (9%), cognitive functioning (6%), anxiety (6%), and depression (3%). Research outcomes of the continuing bonds and meaning making domains are reviewed in more detail in the following sections. The domains of general distress, trauma symptoms, relational functioning/social adjustment, cognitive functioning, anxiety, and depression are subsequently reviewed within the combined context of negative grief symptoms. Some qualitative studies indicated an outcome focus of “grief” or “healing from the loss” but did not delineate specific characteristics of these treatment aims. Upon further review of these studies, it became evident that investigators were looking for signs of general distress secondary to the participants’ bereavement. Thus, these outcome domains were categorized as general distress and were included in the review of negative grief symptomatology. The following sections present a summary of results categorized by the three outcome domains of: 1) continuing bonds, 2) meaning making, and 3) negative grief symptoms. The empirical support for each domain is discussed.

A total of 12 (44%) studies examined continuing bonds as an outcome measure of treatment effectiveness. The majority of studies investigating continuing bonds were qualitative. The aggregate of these findings suggests that visual art modalities facilitated participants’ adaptive preservation of ties with the deceased, and investigators usually argued this finding as an indicator of the treatment thereby aiding the healing process of grief. One important theme that arose across these qualitative studies was acceptance of the death. Maier 72 found that participants who created a scrapbook memorializing their deceased loved ones in a grief support group reported that the scrapbooks helped them with “radical acceptance” of the loss as the creation process helped them “witness the reality” of the decedent’s life arc. Coar 73 found that participants that completed eight 60-minute weekly group therapy sessions incorporating the creation of ceramic mandalas facilitated participants’ adaptation to their loss and cultivated continued ties with the deceased. One study stood out by its singularity in measuring continuing bonds with projective measurement of participant artwork created during the intervention. Carew evaluated continuing bonds in his sample of parentally bereaved children with the KFD test, 74 in which participants are asked to draw a picture of their families. 75 Carew found that his participants’ family drawings incorporated the deceased caregivers more integrally following their individual art therapy sessions than their pre-intervention KFDs, and interpreted this finding as indication of improved continuing bonds with the decedent. 74 Another theme that arose within the domain of continuing bonds was maintaining adaptive attachment to the decedent while coming to terms with the loss, a hallmark of the dual-process model’s oscillating process of grief. For example, narrative theme evaluations conducted by Bates 76 of her bereaved participants revealed endorsement of fondness and storytelling about the deceased that entailed the full life arc of their life story, demonstrating persevering attachment with healthy acknowledgment of the death.

A total of 11 (41%) studies examined meaning making as an outcome measure of treatment effectiveness. Interestingly, no included study evaluated this marker of bereavement adaptation quantitatively, despite available measures. Instead, studies focused on qualitative self-report, often by participants’ evaluation of treatment at follow-up, and clinician-rated judgment. In a study of eight bereaved incarcerated women who completed 60-minute weekly individual therapy sessions, all participants expressed increased understanding of the events surrounding their loss and the ways in which it impacted their emotional health and self-esteem. 77 Clinician-rated judgment was frequently made from inferences about participants’ visual art output. For example, Brodie 78 reported evidence of her case study’s meaning-making processing through painting modalities by her use of the figure emerging from the ground, a motif originally connected to meaning exploration by Simon. 79 Finn 80 reported that incorporating visual art techniques in her group counseling program for bereaved youth helped her clients adjust to their loss and learn new coping skills based on participants’ written evaluation of the group. Finn 80 gathered quantitative data on participants’ rating of how well they met five distinct therapeutic goals on a 4-point scale where higher scores indicated greater achievement of the objective, and reported that participants rated each item with a 3 or 4 (indicating strong endorsement of the objectives) but failed to provide mean and SD of the scores.

A total of 15 (56%) studies examined grief symptomatology as an outcome measure of treatment effectiveness. In the general bereavement literature, assessment of negative grief symptomatology can encompass a myriad of outcomes such as various functional impairments, physical health symptoms, emotional well-being, and psychological concerns. This review’s included studies used the following specific domains to investigate the overall outcome of negative grief symptomatology: general distress, depression, anxiety, cognitive functioning, relational functioning/social adjustment (i.e., social functioning, family functioning, relational functioning, and self-esteem), trauma symptoms, general physical health, academic achievement, aggression, and complicated grief symptoms. This outcome domain entailed the majority of quantitative measures used by the reviewed literature. The included studies quantitatively evaluated the following components of negative grief outcomes: symptoms of anxiety with the Beck Anxiety Inventory (BAI) 81 and the Revised Measure of Children’s Manifest Anxiety Scale (RCMAS); 82 depressive symptoms with the Beck Depression Inventory II (BDI-II); 83 social/familiar functioning with Family Environment Scale (FES); 84 social functioning with the Child Behavior Checklist (CBC) 85 and the Teacher–Child Rating Scale (T-CRS); 86 resiliency with the Individual Protective Factors Index (IPFI); 87 symptoms of posttraumatic stress disorder (PTSD) with the Child PTSD Symptom Scale (CPSS) 88 and Impact of Event Scale (IES); 89 complicated grief symptoms with the Intrusive Grief Thoughts Scale (IGTS) 90 and the TRIG; 68 and physical health with the General Health Questionnaire (GHQ). 91 In addition, Wells 92 recorded grade marks of pediatric participants as a quantitative measure of academic achievement.

Reviewing these results cumulatively, there is modest but conflicting evidence for visual arts’ effectiveness in addressing these syndromes. Schut et al 71 found that both the treatment group receiving weekly group art therapy sessions and the waitlist control group demonstrated general health improvement over the course of the study, but that the treatment group receiving weekly art therapy sessions improved significantly more than the control group. Wells 92 found that in a sample of bereaved children (n = 34) receiving weekly art therapy sessions found a slight overall improvement in the measured outcomes of academic achievement, self-efficacy, and positive outlook, but there was no statistically significant difference between the treatment and control group at follow-up in these domains. Similarly, after traumatically bereaved children completed 12 therapeutic sessions with adjunct visual art modalities, Herring 93 reported results that evidenced significant reductions in cognitive and affective grief reactions and avoidance symptoms similar to those found in randomized controlled trials of grief-focused interventions, as measured by the CPSS and the IGTS. However, reductions in reexperiencing and arousal symptoms were not found. In fact, arousal symptoms appeared to increase throughout treatment for a subgroup of children who reported high levels of anger and fighting by current caregivers. 93 Webb-Ferebee 94 found that younger participants significantly decreased overall anxiety symptoms, while older participants significantly increased anxiety symptoms, as measured by the RCMAS.

The visual art modalities administered by included studies were heterogeneous. Thirteen (48%) studies evaluated interventions that administered multiple modes of therapeutic visual art techniques. For example, one study evaluated grief outcomes following participants’ completion of photographic essays and process-oriented assemblages about their loved one. 76 Another study asked participants to draw an abstract picture depicting the feelings of their grief, create a memory box, and draw a metaphorical bridge of the progress of their grief, among other activities. 117 Nine (33%) studies implemented therapeutic drawing or painting exercises. Specific examples of drawing or painting examples include a family portrait drawing and drawing the feelings of their grief. 92 Two studies (7%) 72 , 121 examined impact of a scrapbooking bereavement group in which bereaved individuals created a scrapbook about their loved one. One study evaluated participants who created ceramic mandala tiles to create a mosaic reflection. 73 Another study assessed making a memorial quilt. 120 Finally, one study investigated the use of Chinese brush strokes in bereavement-related tasks. 122

The purpose of this review was to evaluate the extant literature regarding visual art therapy techniques with a bereaved clinical population. The number of studies that were relevant to this particular review was limited (n = 27), qualifying the strength of conclusions drawn from key results. Further, the heterogeneity of the reviewed studies offers weak external validity and limits their findings’ generalizability to other settings or populations. The variations in the model and content of visual art modalities also lend complication in determining efficacy and replicability. Nevertheless, a number of interesting trends emerged that provide avenues for future research considerations.

When reviewed cumulatively, the included experimental studies documented modest improvements in the facilitation of continuing bonds and meaning making with participants who experienced visual art treatment modalities compared with participants assigned to a control group or who underwent alternative treatments. Nonexperimental studies also provided support for visual art modalities as an effective tool to facilitate continuing bonds and meaning making, although the majority of these findings were qualitative and based on subjective self-report or clinician-rated judgments. There is weaker support for this treatment modality’s efficacy in alleviating negative grief symptoms, as was exemplified by both qualitative and quantitative investigation. Indeed, some studies reported conflicting results within their own participants, as some improved in negative grief symptoms over the course of treatment while others showed no significant improvement or even worsened. This finding provides support for the distinction between these constructs and the movement for conceptualizing grief as a multidimensional experience. Our findings indicate that therapeutic use of visual art modalities with bereaved populations may aid the methods for acquiring positive skills in adapting to bereavement (i.e., sense making, benefit finding, and preservation of the loved one’s legacy) but there is less evidence to support its effectiveness in alleviating the pain of loss. This result is congruent with the existing literature on the investigated domains of grief. For example, meaning making and post-loss have been found to predict the positive outcomes for bereaved individuals across numerous studies. 95 It is also notable that meaning making is a difficult process for the bereaved and is rarely successful even in those who intentionally search for meaning following a loss, 96 which lends particular significance to the documented facilitation of meaning made in bereaved participants.

The minimal impact on negative grief symptoms may also be congruent with recent literature. The degree to which any intervention significantly alleviates negative symptoms within the range of normative grief reactions (as opposed to complicated grief) has been contended in the literature. 97 , 98 A meta-analysis of bereavement interventions suggested that treatment recipients with indications of complicated grief experience the greatest benefit and alleviation of functional impairment. 11 Further, negative grief symptoms may not be the most reliable marker of “progress” following the death of a loved one. A prospective study conducted by Bonanno et al 99 found strong evidence against the idea that those who do not exhibit grief following a loss are insecurely attached and emotionally distant. Thus, the absence of negative grief symptoms is not necessarily a marker of successful or unsuccessful adaptation to the death, especially considering that courses of grief responses are variegated, with some individuals endorsing delayed or inhibited grief. 10 There is also substantial evidence that negative grief symptoms alleviate over time for the majority of those bereaved, even without the assistance of therapeutic intervention. 99 Thus, much of bereavement therapy aims to facilitate the strength-based approaches to grief, focusing on positive outcomes and cognitive understanding of the impacts of the loss. 96 Thus, grief therapy is sometimes considered a preventative approach to bereavement, to buffer possible manifestations of impaired functioning, rather than the traditional aims of psychotherapy for direct alleviation of targeted symptoms. 11 As such, this review’s finding that visual art modalities demonstrate some evidence of developing positive outcomes but not impacting negative outcomes may indicate congruent trends with existing treatment aims for the bereaved.

Perhaps the most convincing piece of evidence in support of continued research can be found in the self-report measures collected by investigators. Participants overwhelmingly endorsed a positive subjective impact of the treatments incorporating visual art modalities. Across several studies, participants rated their well-being as significantly improved. 100 , 101 Although this finding is ineffectually captured with measurement of objective changes, it warrants further attention and perhaps speaks to the efficacy of visual art techniques witnessed by clinicians across disciplines. The use of positive or growth-oriented measures (e.g., personal growth, posttraumatic growth, benefit-finding, and self-efficacy) could be an avenue of future research that provides insight into participants’ experiences and whether they translate to objective outcomes.

Limitations and considerations for future research

The findings of this review highlight significant problems in number, content, and rigor of the relevant existing literature. Our review uncovered substantial weaknesses in the following domains: 1) operationalized definitions, 2) study design, 3) outcome measurement, 4) underreporting of individual difference variables, and 5) underreporting of intervention characteristics and development. Each domain is examined in more detail in the following sections followed by considerations for addressing each domain.

Operationalized definitions

A reappearing difficulty in compiling the current literature review was the paucity of operational definitions, particularly within the niche of visual art interventions. Where does one differentiate between visual art therapy techniques, art as therapy, expressive art modalities, and creative expressionism within psychotherapy? As previously noted, this review could not rely on an existing operational definition of therapeutic visual art modalities. Rather, the inclusion criteria for types of interventions reviewed were created with reference to multidisciplinary sources. 69 , 70 Expressive art therapy has historical difficulty in forming an accurate, comprehensive, and concise definition of its services (a thorough historical review is given in the study by Kalmanowitz and Potash 102 ). The American Art Therapy Association’s current definition of its treatment parameters has been contradictorily criticized for both its detail and incompleteness: (art therapy is)

art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior and addictions, develop social skills, improve reality orientation, reduce anxiety, and increase self-esteem. 69

This definition is difficult to truncate, and researchers have recommended for American Art Therapy Association to seek a simpler definition that more clearly conveys the scope of the profession. 104 , 105 Spooner 105 describes the expressive arts’ lack of operational definitions as a marketing problem: because practitioners using these methods are unable to clearly articulate their scope of practice to other disciplines, art therapy is suffering from a lack of brand awareness. The confusion over treatment characteristics and categorization is negatively affecting researcher’s ability to conduct research with reliable terminology. This is especially true when disciplines outside of art therapy attempt to evaluate efficacy of modalities within the scope of their practice, as is the case in the current review. Used consistently, clear and memorable definitions would enhance the empirical study of expressive arts in therapy. Specifically, clarifying treatment terminology and defining brackets of intervention would facilitate cross-disciplinary research methods investigating the expressive arts as therapeutic modalities.

The review of included studies’ methodologies points to the importance of rigorous study design. Only 7% of included studies used a control group. Researchers have highlighted the importance of using control groups in research with bereaved. 106 For intervention efficacy studies, particularly with the bereaved, it is evident that an active control group is essential to help establish causation and strengthen internal validity. Without control groups, it is difficult to examine whether the suggested facilitation of meaning making and continuing bonds could be attributable to the visual art intervention or whether these effects occurred due to other factors. When using control groups, other important aspects of study design with bereaved populations are the use of random or matched assignment, inclusion of enough participants for sufficient power due to high rates of attrition, and preventing poor adherence to the intervention. 99 Bereavement researchers have advocated for evaluation of grief therapies to be conducted in a laboratory setting or in an online format for increased validity and reliability and decreased attrition to reach necessary statistical power. 107 This would improve intervention efficacy, which can later be generalized as appropriate, but is difficult in application for clinicians conducting research alongside their existing clinical practice.

Practicing clinicians who use expressive art modalities with grieving individuals are often confident of the therapeutic benefits, but can rarely explain with precision how the artwork was produced in therapy or what specific factors contributed to client improvement. 108 Furthermore, many clinicians often express doubt in the feasibility of communicating therapeutic benefits of the expressive arts through research. Consequently, quantitative analysis of visual art effectiveness is scant, and qualitative analysis is varied in form and rigor. The findings of this review reveal a heavy reliance of the case study approach in research conducted by both psychologists and art therapists. The case study avenue of research provides helpful qualitative detail on individual treatment levels, but leaves a paucity of generalizable quantitative data or other evidence for larger-scale effectiveness. The frequent implementation of single case design may reflect the regularity of visual arts’ use within the clinical field. Indeed, one significant finding from this review was the prevalence of practicing clinicians’ as the primary research investigators. However, if the majority of the literature on the use of visual arts with grief therapy is conducted by practicing clinicians as this review suggests, the field’s aim of more robust research methodology faces some barriers. For example, the majority of clinicians do not work in settings conditional for experimental research. Community mental health clinics, private practice, and small nonprofit organizations rarely have formal structures or financial support for complex study design, requiring clinicians in these settings to navigate research endeavors on their own. Art therapists may face particular challenges in conducting independently driven, robust methodologies as research is often only peripherally incorporated into art therapy education programs. Art therapists report feeling far more confident about their clinical skills than research skills, and offer skepticism in their ability to provide evidence for their practices’ efficacy. 105 This mindset is demonstrable by art therapists’ reported distaste for the spreading “clinification syndrome” of art therapy, 105 a term used to describe the perception of increased favoritism of empirically driven treatment approaches at the detriment of art therapists’ uniquely layered artistic expertise.

Accordingly, one future avenue of research that is sensitive to the needs of practicing clinicians aiming to evaluate their practice is the implementation of baseline symptom measurement. Pre–post outcomes provide empirical support and can elevate the rigor of clinical evaluation to a single-case experimental study. Using brief quantitative measures in this regard could also benefit the clinician’s therapeutic practice as results offer feedback and potential courses of discussion within the treatment setting. Specific examples of possible quantitative measures are offered in the following section.

The majority of quantitative outcome measures used in the included studies were well validated and reliable measurement tools. Collectively, these measures allowed assessment of a wide scope of negative grief symptoms, but were limited in their ability to quantitatively capture treatment effects on continuing bonds and meaning making. Most studies additionally included an essay evaluation form, which typically used single items to assess the participants’ subjective experiences during and after the intervention. Other measures developed by the researchers were based on several single-item Likert-scale questions and were sometimes used as supplemental measurement tools, but investigators puzzlingly did not report the mean or SD of these outcomes. Nonetheless, the inclusion of a variety of assessments helped provide triangulation of data and is a methodological strength.

A noted trend in the outcome measurement of the included studies of this review is the propensity to rely on participants’ artwork created during grief treatment as an indicator of outcome change. For example, Carew 75 used the KFD style to measure family environment and relational functioning. Many studies that included this form of clinician-rated judgment outcome measurement were not mixed methods, and this pattern compromises their internal validity. Luckily, increased recognition of theory-driven data has yielded a number of empirically validated measures of bereavement adaptation. The CBS is a brief measure that rates 10 dimensions of continuing bonds (e.g., reminiscing, linking objects, and ongoing expressions of love). 52 Meaning-making processes can be reliably assessed with prompts for participants to consider whether they have been able to make sense of their loss and in what ways. 58 For a singular but comprehensive measure of grief symptomatology, the HGRC provides a multidimensional report on both negative and positive aspects of bereavement experiences, such as personal growth, anger, and cognitive disorganization. 66 Since the HGRC’s development, it has been identified as one of the most widely employed instruments for measuring grief reactions and personal growth after a loss. 109 In addition, the HGRC has been found to be compatible with the meaning reconstruction model of grief, allowing for consistency in grief conceptualization, symptom tracking, and treatment aims. 17 This section only listed a limited number of measures and focused on the outcomes investigated for the purpose of this review (i.e., continuing bonds, meaning making, and negative grief symptomatology), where a more comprehensive review of available bereavement measurements is given in the studies by Minton and Barron 110 and Neimeyer. 111

Outcome measurement used in the included studies of this review provides modest preliminary support for visual art treatment modalities’ effectiveness in facilitating continuing bonds and meaning making, largely based on subjective outcome measures of participant self-report and investigators’ clinical judgment. In addition to objective outcome measures of continuing bonds and meaning making, future research may benefit from assessment of other positive changes that can occur during bereavement such as posttraumatic growth and positive identity changes. These outcomes can be reliably assessed through well-established measures such as the Personal Growth subscale of the HGRC and the Grief and Meaning Reconstruction Inventory. 66 , 112 Use of these measures in future research endeavors will address the paucity of objective outcome measurement in the literature while also capturing possible intervention effects that would have otherwise been missed. When used in conjunction with clinician-rated judgment of symptom improvement and projective tests of visual artwork created during the course of the intervention, these tools can facilitate validation and clarification of the mechanisms of change within existing clinical practice.

Underreporting of individual difference variables

Given the complexity of individual difference variables’ influence on adjustment to bereavement, it is especially important to report participant demographics and characteristics of the loss experience when evaluating the effectiveness of grief therapies. However, few of the reviewed studies reported participants’ type of loss (i.e., homicide, suicide, illness, or accident), expectedness of the loss, relationship to the deceased, or other important variables that influence the trajectories of grief expressionism. Future intervention research should not only gather this information for inclusion of publications but also allow it to inform clinician decision-making of intervention characteristics. Current bereavement theory emphasizes the variety within reactions to bereavement, despite its ubiquitous nature, and is beginning to inform the development of applicable interventions based on participant characteristics. This is evidenced by Thompson and Neimeyer’s 33 recently published manual of more than 50 expressive art techniques to incorporate into grief therapy, many of which are introduced by guiding the reader in situational characteristics of the client or the death experience that would yield most efficacious results.

If research further substantiates the benefit of therapeutic visual art modalities with the bereaved, empirical focus should shift to investigation of possible mechanisms of change. This next step would be advanced by identifying treatment components most salient to influencing measurable outcomes. For example, in the included studies of this review, visual art modalities were often an adjunct to other formulation of grief therapy. Parceling psychoeducation about grief, exposure to grief cues, encouragement of emotional expression, cognitive or meaning-oriented interventions, and group format vs. individual disclosure would allow for an elevated understanding of the underlying influencers of objective outcomes in this modality of grief therapy. Investigating these characteristics may enhance bereavement interventions by providing guidance on the ways individual difference variables influence the efficacy of particular treatment methods.

Underreporting of intervention characteristics and development

A rarer but equally problematic limitation of included studies was the exclusion of specific treatment descriptions. Every included study identified the visual art modality used within the treatment setting (e.g., drawing about the loss and making a memorial scrapbook) but few specified treatment detail over time. This is especially problematic to the literature’s treatment reliability as only 9% of included studies reported following a treatment manual. Similarly, few studies explained the theoretical underpinnings and the operational implementation of their interventions. It was rare for studies to describe how the interventions were developed, which empirically informed theories were drawn from, or proposed hypotheses for agents of change. This reference deficit to theoretical frameworks has been similarly implicated in literature reviews of bereavement therapies unrelated to expressive arts. 11 Future research endeavors aiming to investigate treatment efficacy would enhance their methodology and appropriateness if informed by specific treatment aims rooted in existing grief theory. Furthermore, as in most intervention research, investigators in the reviewed studies failed to qualify their findings with clarification over which clients were treated by the same therapist. This absence can pose validity issues, as researchers have noted that such nesting can lead to the overestimation of treatment benefit because of therapist effects or group effects. 113 , 114

This review examined the clinical effectiveness of using visual art modalities in a therapeutic context with bereaved individuals. The applicability of the Stroebe and Schut’s dual-process model of bereavement and Neimeyer’s meaning reconstruction model for understanding treatment outcomes and conceptualizing future avenues of research was also investigated. The heterogeneity of the studies investigated by this review indicates that visual art modalities are a psychotherapeutic approach adaptive to an assortment of clinical situations. Although this review revealed modest but promising preliminary evidence of visual art modalities’ effectiveness with a bereaved population, the existing literature is scant, heterogeneous, and thereby difficult to generalize. Important work in the area of using visual art modalities with grief therapy has been completed, but the designs of the majority of the available studies do not provide sufficient evaluation of this treatment modality and a great deal of work remains. Findings from our review suggest that grief interventions using visual art techniques facilitate continuing bonds and meaning making, but there is little evidence to support a significant impact on negative grief symptomatology. Furthermore, we know very little of the processes by which visual arts facilitate continuing bonds and meaning making. Given the multitude of individual differences and responses to loss, future research into the increasingly varied methods of grief therapies used to address the diversity of the bereavement experience is warranted. In the next stage of research examining expressive art as treatment modalities with the bereaved, an increase in theory-driven interventions, experimental research designs, assessment of individual difference variables, and quantitative analysis should be prioritized. As described earlier, operational definitions, experimental research designs, inclusion of individual difference variables, and empirically validated assessments are promising avenues that can guide future considerations within this area.

The authors report no conflicts of interest in this work.