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Review article, art therapy: a complementary treatment for mental disorders.

• 1 College of Creative Design, Shenzhen Technology University, Shenzhen, China
• 2 The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
• 3 Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China

Art therapy, as a non-pharmacological medical complementary and alternative therapy, has been used as one of medical interventions with good clinical effects on mental disorders. However, systematically reviewed in detail in clinical situations is lacking. Here, we searched on PubMed for art therapy in an attempt to explore its theoretical basis, clinical applications, and future perspectives to summary its global pictures. Since drawings and paintings have been historically recognized as a useful part of therapeutic processes in art therapy, we focused on studies of art therapy which mainly includes painting and drawing as media. As a result, a total of 413 literature were identified. After carefully reading full articles, we found that art therapy has been gradually and successfully used for patients with mental disorders with positive outcomes, mainly reducing suffering from mental symptoms. These disorders mainly include depression disorders and anxiety, cognitive impairment and dementias, Alzheimer’s disease, schizophrenia, and autism. These findings suggest that art therapy can not only be served as an useful therapeutic method to assist patients to open up and share their feelings, views, and experiences, but also as an auxiliary treatment for diagnosing diseases to help medical specialists obtain complementary information different from conventional tests. We humbly believe that art therapy has great potential in clinical applications on mental disorders to be further explored.

Introduction

Mental disorders constitute a huge social and economic burden for health care systems worldwide ( Zschucke et al., 2013 ; Kenbubpha et al., 2018 ). In China, the lifetime prevalence of mental disorders was 24.20%, and 1-month prevalence of mental disorders was 14.27% ( Xu et al., 2017 ). The situation is more severely in other countries, especially for developing ones. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, there is an urgent need to implement scalable mental health interventions to address this burden. While pharmacological treatment is the first choice for mental disorders to alleviate the major symptoms, many antipsychotics contribute to poor quality of life and debilitating adverse effects. Therefore, clinicians have turned toward to complementary treatments, such as art therapy in addressing the health needs of patients more than half a century ago.

Art therapy, is defined by the British Association of Art Therapists as: “a form of psychotherapy that uses art media as its primary mode of expression and communication. Clients referred to art therapists are not required to have experience or skills in the arts. The art therapist’s primary concern is not to make an esthetic or diagnostic assessment of the client’s image. The overall goal of its practitioners is to enable clients to change and grow on a personal level through the use of artistic materials in a safe and convenient environment” ( British Association of Art Therapists, 2015 ), whereas as: “an integrative mental health and human services profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psycho-therapeutic relationship” ( American Art Therapy Association, 2018 ) according to the American Art Association. It has gradually become a well-known form of spiritual support and complementary therapy ( Faller and Schmidt, 2004 ; Nainis et al., 2006 ). During the therapy, art therapists can utilize many different art materials as media (i.e., visual art, painting, drawing, music, dance, drama, and writing) ( Deshmukh et al., 2018 ; Chiang et al., 2019 ). Among them, drawings and paintings have been historically recognized as the most useful part of therapeutic processes within psychiatric and psychological specialties ( British Association of Art Therapists, 2015 ). Moreover, many other art forms gradually fall under the prevue of their own professions (e.g., music therapy, dance/movement therapy, and drama therapy) ( Deshmukh et al., 2018 ). Thus, we excluded these studies and only focused on studies of art therapy which mainly includes painting and drawing as media. Specifically, it focuses on capturing psychodynamic processes by means of “inner pictures,” which become visible by the creative process ( Steinbauer et al., 1999 ). These pictures reflect the psychopathology of different psychiatric disorders and even their corresponding therapeutic process based on specific rules and criterion ( Steinbauer and Taucher, 2001 ). It has been gradually recognized and used as an alternative treatment for therapeutic processes within psychiatric and psychological specialties, as well as medical and neurology-based scientific audiences ( Burton, 2009 ).

The development of art therapy comes partly from the artistic expression of the belief in unspoken things, and partly from the clinical work of art therapists in the medical setting with various groups of patients ( Malchiodi, 2013 ). It is defined as the application of artistic expressions and images to individuals who are physically ill, undergoing invasive medical procedures, such as surgery or chemotherapy for clinical usage ( Bar-Sela et al., 2007 ; Forzoni et al., 2010 ; Liebmann and Weston, 2015 ). The American Art Therapy Association describes its main functions as improving cognitive and sensorimotor functions, fostering self-esteem and self-awareness, cultivating emotional resilience, promoting insight, enhancing social skills, reducing and resolving conflicts and distress, and promoting societal and ecological changes ( American Art Therapy Association, 2018 ).

However, despite the above advantages, published systematically review on this topic is lacking. Therefore, this review aims to explore its clinical applications and future perspectives to summary its global pictures, so as to provide more clinical treatment options and research directions for therapists and researchers.

Publications of Art Therapy

The literatures about “art therapy” published from January 2006 to December 2020 were searched in the PubMed database. The following topics were used: Title/Abstract = “art therapy,” Indexes Timespan = 2006–2020.

A total of 652 records were found. Then, we manually screened out the literatures that contained the word “art” but was not relevant with the subject of this study, such as state of the art therapy, antiretroviral therapy (ART), and assisted reproductive technology (ART). Finally, 479 records about art therapy were identified. Since we aimed to focus on art therapy included painting and drawing as major media, we screened out literatures deeper, and identified 413 (84%) literatures involved in painting and drawing ( Figure 1 ).

Figure 1. Number of publications about art therapy.

As we can see, the number of literature about art therapy is increasing slowly in the last 15 years, reaching a peak in 2020. This indicates that more effort was made on this topic in recent years ( Figure 1 ).

Overview of Art Therapy

As defined by the British Association of Art Therapists, art therapy is a form of psychotherapy that uses art media as its primary mode of communication. Based on above literature, several highlights need to be summarized. (1) The main media of art therapy include painting, drawing, music, drama, dance, drama, and writing ( Chiang et al., 2019 ). (2) Main contents of painting and drawing include blind drawing, spiral drawing, drawing moods and self-portraits ( Legrand et al., 2017 ; Abbing et al., 2018 ; Papangelo et al., 2020 ). (3) Art therapy is mainly used for cancer, depression and anxiety, autism, dementia and cognitive impairment, as these patients are reluctant to express themselves in words ( Attard and Larkin, 2016 ; Deshmukh et al., 2018 ; Chiang et al., 2019 ). It plays an important role in facilitating engagement when direct verbal interaction becomes difficult, and provides a safe and indirect way to connect oneself with others ( Papangelo et al., 2020 ). Moreover, we found that art therapy has been gradually and successfully used for patients with mental disorders with positive outcomes, mainly reducing suffering from mental symptoms. These findings suggest that art therapy can not only be served as an useful therapeutic method to assist patients to open up and share their feelings, views, and experiences, but also as an auxiliary treatment for diagnosing diseases to help medical specialists obtain complementary information different from conventional tests.

Art Therapy for Mental Disorders

Based on the 413 searched literatures, we further limited them to mental disorders using the following key words, respectively: Depression OR anxiety OR Cognitive impairment OR dementia OR Alzheimer’s disease OR Autism OR Schizophrenia OR mental disorder. As a result, a total of 23 studies (5%) ( Table 1 ) were included and classified after reading the abstract and the full text carefully. These studies include 9 articles on depression and anxiety, 4 articles on cognitive impairment and dementia, 3 articles on Alzheimer’s disease, 3 articles on autism, and 4 articles on schizophrenia. In addition to the English literature, in fact, some Chinese literatures also described the application of art therapy in mental diseases, which were not listed but referred to in the following specific literatures.

Table 1. Studies of art therapy in mental diseases.

Depression Disorders and Anxiety

Depression and anxiety disorders are highly prevalent, affecting individuals, their families and the individual’s role in society ( Birgitta et al., 2018 ). Depression is a disabling and costly condition associated with a significant reduction in quality of life, medical comorbidities and mortality ( Demyttenaere et al., 2004 ; Whiteford et al., 2013 ; Cuijpers et al., 2014 ). Anxiety is associated with lower quality of life and negative effects on psychosocial functioning ( Cramer et al., 2005 ). Medication is the most commonly used effective way to relieve symptoms of depression and anxiety. However, nonadherence are crucial shortcomings in using antidepressant to treat depression and anxiety ( van Geffen et al., 2007 ; Nielsen et al., 2019 ).

In recent years, many studies have shown that art therapy plays a significant role in alleviating depression symptoms and anxiety. Gussak (2007) performed an observational survey about populations in prison of northern Florida and identified that art therapy significantly reduces depressive symptoms. Similarly, a randomized, controlled, and single-blind study about art therapy for depression with the elderly showed that painting as an adjuvant treatment for depression can reduce depressive and anxiety symptoms ( Ciasca et al., 2018 ). In addition, art therapy is also widely used among students, and several studies ( Runde, 2008 ; Zhenhai and Yunhua, 2011 ) have shown that art therapy also significantly reduces depressive symptoms in students. For example, Wang et al. (2011) conducted group painting therapy on 30 patients with depression for 3 months, and found that painting therapy could promote their social function recovery, improve their social adaptability and quality of life. Another randomized clinical trial also showed that it could decrease mean anxiety scores in the 3–12 year painting group ( Forouzandeh et al., 2020 ).

Studies have shown that distress, including anxiety and depression, is related to poorer health-related quality of life and satisfaction to medical services ( Hamer et al., 2009 ). Painting can be employed to express patients’ anxiety and fear, vent negative emotions by applying projection, thereby significantly improve the mood and reduce symptoms of depression and anxiety of cancer patients. A number of studies ( Bar-Sela et al., 2007 ; Thyme et al., 2009 ; Lin et al., 2012 ; Abdulah and Abdulla, 2018 ) showed that art therapy for cancer patients could enhance the vitality of patients and participation in social activities, significantly reduce depression, anxiety, and reduce stressful feelings. Importantly, even in the follow-up period, art therapy still has a lasting effect on cancer patients ( Thyme et al., 2009 ). Interestingly, art therapy based on famous painting appreciation could also significantly reduce anxiety and depression associated with cancer ( Lee et al., 2017 ). Among cancer patients treated in outpatient health care, art therapy also plays an important role in alleviating their physical symptoms and mental health ( Götze et al., 2009 ). Therefore, art therapy as an auxiliary treatment of cancer is of great value in improving quality of life.

Overall, art painting therapy permits patients to express themselves in a manner acceptable to the inside and outside culture, thereby diminishing depressed and anxiety symptoms.

Cognitive Impairment, and Dementia

Dementia, a progressive clinical syndrome, is characterized by widespread cognitive impairment in memory, thinking, behavior, emotion and performance, leading to worse daily living ( Deshmukh et al., 2018 ). According to the Alzheimer’s Disease International 2015, there is 46.8 million people suffered from dementia, and numbers almost doubling every 20 years, rising to 131.5 million by 2050. Although art therapy has been used as an alternative treatment for the dementia for long time, the positive effects of painting therapy on cognitive function remain largely unknown. One intervention assigned older adults patients with dementia to a group-based art therapy (including painting) observed significant improvements in the clock drawing test ( Pike, 2013 ), whereas two other randomized controlled trials ( Hattori et al., 2011 ; Rusted et al., 2016 ) on patients with dementia have failed to obtain significant cognitive improvement in the painting group. Moreover, a cochrane systematic review ( Deshmukh et al., 2018 ) included two clinical studies of art therapy for dementia revealed that there is no sufficient evidence about the efficacy of art therapy for dementia. This may be because patients with severely cognitive impairment, who was unable to accurately remember or assess their own behavior or mental state, might lose the ability to enjoy the benefits of art therapy.

In summary, we should intervene earlier in patients with mild cognitive impairment, an intermediate stage between normal aging and dementia, in order to prevent further transformation into dementia. To date, mild cognitive impairment is drawing much attention to the importance of painting intervening at this stage in order to alter the course of subsequent cognitive decline as soon as possible ( Petersen et al., 2014 ). Recently, a randomized controlled trial ( Yu et al., 2021 ) showed significant relationship between improvement immediate memory/working memory span and increased cortical thickness in right middle frontal gyrus in the painting art group. With the long-term cognitive stimulation and engagement from multiple sessions of painting therapy, it is likely that painting therapy could lead to enhanced cognitive functioning for these patients.

Alzheimer’s Disease

Alzheimer’s disease (AD) is a sub-type of dementia, which is usually associated with chronic pain. Previous studies suggested that art therapy could be used as a complementary treatment to relief pain for these patients since medication might induce severely side effects. In a multicenter randomized controlled trial, 28 mild AD patients showed significant pain reduction, reduced anxiety, improved quality of life, improved digit span, and inhibitory processes, as well as reduced depression symptoms after 12-week painting ( Pongan et al., 2017 ; Alvarenga et al., 2018 ). Further study also suggested that individual therapy rather than group therapy could be more optimal since neuroticism can decrease efficacy of painting intervention on pain in patients with mild AD. In addition to release chronic pain, art therapy has been reported to show positive effects on cognitive and psychological symptoms in patients with mild AD. For example, a controlled study revealed significant improvement in the apathy scale and quality of life after 12 weeks of painting treatment mainly including color abstract patterns with pastel crayons or water-based paint ( Hattori et al., 2011 ). Another study also revealed that AD patients showed improvement in facial expression, discourse content and mood after 3-weeks painting intervention ( Narme et al., 2012 ).

Schizophrenia

Schizophrenia is a complex functional psychotic mental illness that affects about 1% of the population at some point in their life ( Kolliakou et al., 2011 ). Not only do sufferers experience “positive” symptoms such as hallucinations, delusions, but also experience negative symptoms such as varying degrees of anhedonia and asociality, impaired working memory and attention, poverty of speech, and lack of motivation ( Andreasen and Olsen, 1982 ). Many patients with schizophrenia remain symptomatic despite pharmacotherapy, and even attempts to suicide with a rate of 10 to 50% ( De Sousa et al., 2020 ). For these patients, art therapy is highly recommended to process emotional, cognitive and psychotic experiences to release symptoms. Indeed, many forms of art therapy have been successfully used in schizophrenia, whether and how painting may interfere with psychopathology to release symptoms remains largely unknown.

A recent review including 20 studies overall was performed to summary findings, however, concluded that it is not clear whether art therapy leads to clinical improvement in schizophrenia with low ( Ruiz et al., 2017 ). Anyway, many randomized clinical trials reported positive outcomes. For example, Richardson et al. (2007) conducted painting therapy for six months in patients with chronic schizophrenia and found that art therapy had a positive effect on negative symptoms. Teglbjaerg (2011) examined experience of each patient using interviews and written evaluations before and after painting therapy and at a 1-year follow-up and found that group painting therapy in patients with schizophrenia could not only reduce psychotic symptoms, but also boost self-esteem and improve social function.

What’s more, the characteristics of the painting can also be used to judge the health condition in patients with schizophrenia. For example, Hongxia et al. (2013) explored the correlation between psychological health condition and characteristics of House-Tree-Person tests for patients with schizophrenia, and showed that the detail characteristic of the test results can be used to judge the patient’s anxiety, depression, and obsessive-compulsive symptoms.

Most importantly, several other studies showed that drug plus painting therapy significantly enhanced patient compliance and self-cognition than drug therapy alone in patients with schizophrenia ( Hongyan and JinJie, 2010 ; Min, 2010 ).

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental syndrome with no unified pathological or neurobiological etiology, which is characterized by difficulties in social interaction, communication problems, and a tendency to engage in repetitive behaviors ( Geschwind and Levitt, 2007 ).

Art therapy is a form of expression that opens the door to communication without verbal interaction. It provides therapists with the opportunity to interact one-on-one with individuals with autism, and make broad connections in a more comfortable and effective way ( Babaei et al., 2020 ). Emery (2004) did a case study about a 6-year-old boy diagnosed with autism and found that art therapy is of great value to the development, growth and communication skills of the boy. Recently, one study ( Jalambadani, 2020 ) using 40 children with ASD participating in painting therapy showed that painting therapy had a significant improvement in the social interactions, adaptive behaviors and emotions. Therefore, encouraging children with ASD to express their experience by using nonverbal expressions is crucial to their development. Evans and Dubowski (2001) believed that creating images on paper could help children express their internal images, thereby enhance their imagination and abstract thinking. Painting can also help autistic children express and vent negative emotions and thereby bring positive emotional experience and promote their self-consciousness ( Martin, 2009 ). According to two studies ( Wen and Zhaoming, 2009 ; Jianhua and Xiaolu, 2013 ) in China, Art therapy could also improve the language and communication skills, cognitive and behavioral performance of children with ASD.

Moreover, art therapy could be used to investigate the relationship between cognitive processes and imagination in children with ASD. One study ( Wen and Zhaoming, 2009 ; Jianhua and Xiaolu, 2013 ) suggested that children with ASD apply a unique cognitive strategy in imaginative drawing. Another study ( Low et al., 2009 ) examined the cognitive underpinnings of spontaneous imagination in children with ASD and showed that ASD group lacks imagination, generative ability, planning ability and good consistency in their drawings. In addition, several studies ( Leevers and Harris, 1998 ; Craig and Baron-Cohen, 1999 ; Craig et al., 2001 ) have been performed to investigate imagination and creativity of autism via drawing tasks, and showed impairments of autism in imagination and creativity via drawing tasks.

In a word, art therapy plays a significant role in children with ASD, not only as a method of treatment, but also in understanding and investigating patients’ problems.

Other Applications

In addition to the above mentioned diseases, art therapy has also been adopted in other applications. Dysarthia is a common sequela of cerebral palsy (CP), which directly affects children’s language intelligibility and psycho-social adjustment. Speech therapy does not always help CP children to speak more intelligibly. Interestingly, the art therapy can significantly improve the language intelligibility and their social skills for children with CP ( Wilk et al., 2010 ).

In brief, these studies suggest that art therapy is meaningful and accepted by both patients and therapists. Most often, art therapy could strengthen patient’s emotional expression, self-esteem, and self-awareness. However, our findings are based on relatively small samples and few good-quality qualitative studies, and require cautious interpretation.

The Application Prospects of Art Therapy

With the development of modern medical technology, life expectancy is also increasing. At the same time, it also brings some side effects and psychological problems during the treatment process, especially for patients with mental illness. Therefore, there is an increasing demand for finding appropriate complementary therapies to improve life quality of patients and psychological health. Art therapy is primarily offered as individual art therapy, in this review, we found that art therapy was most commonly used for depression and anxiety.

Based on the above findings, art therapy, as a non-verbal psychotherapy method, not only serves as an auxiliary tool for diagnosing diseases, which helps medical specialists obtain much information that is difficult to gain from conventional tests, judge the severity and progression of diseases, and understand patients’ psychological state from painting characteristics, but also is an useful therapeutic method, which helps patients open up and share their feelings, views, and experiences. Additionally, the implementation of art therapy is not limited by age, language, diseases or environment, and is easy to be accepted by patients.

Art therapy in hospitals and clinical settings could be very helpful to aid treatment and therapy, and to enhance communications between patients and on-site medical staffs in a non-verbal way. Moreover, art therapy could be more effective when combined with other forms of therapy such as music, dance and other sensory stimuli.

The medical mechanism underlying art therapy using painting as the medium for intervention remains largely unclear in the literature ( Salmon, 1993 ; Broadbent et al., 2004 ; Guillemin, 2004 ), and the evidence for effectiveness is insufficient ( Mirabella, 2015 ). Although a number of studies have shown that art therapy could improve the quality of life and mental health of patients, standard and rigorous clinical trials with large samples are still lacking. Moreover, the long-term effect is yet to be assessed due to the lack of follow-up assessment of art therapy.

In some cases, art therapy using painting as the medium may be difficult to be implemented in hospitals, due to medical and health regulations (may be partly due to potential of messes, lack of sink and cleaning space for proper disposal of paints, storage of paints, and toxins of allergens in the paint), insufficient space for the artwork to dry without getting in the way or getting damaged, and negative medical settings and family environments. Nevertheless, these difficulties can be overcome due to great benefits of the art therapy. We thus humbly believe that art therapy has great potential for mental disorders.

In the future, art therapy may be more thoroughly investigated in the following directions. First, more high-quality clinical trials should be carried out to gain more reliable and rigorous evidence. Second, the evaluation methods for the effectiveness of art therapy need to be as diverse as possible. It is necessary for the investigation to include not only subjective scale evaluations, but also objective means such as brain imaging and hematological examinations to be more convincing. Third, it will be helpful to specify the details of the art therapy and patients for objective comparisons, including types of diseases, painting methods, required qualifications of the therapist to perform the art therapy, and the theoretical basis and mechanism of the therapy. This practice should be continuously promoted in both hospitals and communities. Fourth, guidelines about art therapy should be gradually formed on the basis of accumulated evidence. Finally, mechanism of art therapy should be further investigated in a variety of ways, such as at the neurological, cellular, and molecular levels.

Author Contributions

JH designed the whole study, analyzed the data, and wrote the manuscript. JZ searched for selected the studies. LH participated in the interpretation of data. HY and JX offered good suggestions. All authors read and approved the final manuscript.

This study was financially supported by the National Key R&D Program of China (2019YFC1712200), International standards research on clinical research and service of Acupuncture-Moxibustion (2019YFC1712205), the National Natural Science Foundation of China (62006220), and Shenzhen Science and Technology Research Program (No. JCYJ20200109114816594).

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

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Keywords : painting, art therapy, mental disorders, clinical applications, medical interventions

Citation: Hu J, Zhang J, Hu L, Yu H and Xu J (2021) Art Therapy: A Complementary Treatment for Mental Disorders. Front. Psychol. 12:686005. doi: 10.3389/fpsyg.2021.686005

Received: 26 March 2021; Accepted: 28 July 2021; Published: 12 August 2021.

Reviewed by:

Copyright © 2021 Hu, Zhang, Hu, Yu and Xu. 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: Jinping Xu, [email protected]

This article is part of the Research Topic

A Critical Appraisal of Research in Arts, Health and Wellbeing

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Role of Art Therapy in the Promotion of Mental Health: A Critical Review

Apoorva shukla.

1 Preventive Medicine, School of Epidemiology and Public Health, Datta Meghe Institute of Medical Sciences, Wardha, IND

Sonali G Choudhari

2 Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND

Abhay M Gaidhane

Zahiruddin quazi syed.

Art therapy is used most commonly to treat mental illnesses and can aid in controlling manifestations correlated with psychosocially challenging behaviours, slowing cognitive decline, and enhancing the quality of life. Art therapy can help people express themselves more freely, improve their mental health, and improve interpersonal relationships. The basis of art therapy is established on the idea that people can recover and feel better via artistic expression. This review examines the current research on how active participation in the arts might improve mental health. A detailed literature search was carried out utilizing essential databases such as PubMed, the WHO's mental health database, and Google and Google Scholar. This review study looks into research done on art therapy and its potential advantages for adult mental health rehabilitation. It focuses on visual art therapy since it’s a key to reducing variation within the "creative arts" and defines the peculiar elements and effectiveness of art therapy used by mental health services. It was found that the use of art therapy as an adjunct treatment showed improved mental health in patients.

Introduction and background

Mental health has recently been identified as a serious public health concern. Mental diseases encompass symptoms, from minor anxiety to severe forms like behavioural abnormalities [ 1 ]. Art therapy refers to various treatments, such as theatre therapy, dance movement psychotherapy, body psychotherapy, music therapy, and drawing, painting and craft therapy [ 2 ]. Art therapy uses artistic means to treat mental illnesses and improve mental health. Art has become a significant element of the therapeutic sector and is used in several recovery and treatment procedures [ 3 ]. Art therapy uses integrative techniques to captivate the soul, body and mind in ways that verbal expression alone doesn't appear to [ 1 , 4 , 5 ]. Art therapy is gaining popularity in mental health settings because it provides a recovery-oriented, person-centred approach that includes emotional, spiritual, social needs and clinical demands [ 6 ].

This narrative review is undertaken with an objective to look at the existing research on art therapies and their possible benefits in mental health rehabilitation. The review accesses the effect on the patient's creative, nonverbal, emotional and structural qualities after using art therapy. It is essential to study the contribution of art therapy to mental disorders to obtain further insights into its functioning mechanism. This helps to gain self-expression, self-awareness, learning and personal development, as well as improve contact, communication, and interaction with other people. The review focuses on visual art therapy to reduce heterogeneity and define the specific qualities of art therapy used by mental health services [ 7 , 8 ].

This review will be helpful to psychiatrists, psychologists, mental health nurses, peer workers, social workers, therapists, occupational therapists, mental health recovery and rehabilitation workers, and other mental health professionals. This will be of use to public health professionals and epidemiologists as they research appropriate solutions to mental health concerns that affect people's physical and social well-being, making mental health an essential part of accomplishing public health goals.

Global silhouette

Mental and behavioural problems are responsible for 12% of the global disease burden [ 9 ]. According to the World Health Organization (WHO), India's mental health burden is 2443 disability-adjusted life years (DALYs) per one lakh population, with a 21.1 age-adjusted suicide rate per one lakh population [ 1 , 9 , 10 ]. Two out of three people with psychosis worldwide do not receive specialist mental health care [ 1 ]. The WHO stated in World Health Report 2001 that "just a small proportion" of the over 45 million people worldwide who suffer from mental and behavioural problems are appropriately cared for [ 9 ].

The causes of mental illness are numerous and complicated. They differ from one situation to another [ 11 ]. The economic loss caused by mental health disorders is estimated to be USD 1.03 trillion between 2012 and 2030 [ 1 ]. Despite technological advances, the puzzle of mental disease causation remains a complex interaction of the environment, brain and mind [ 11 ].

Mechanism of art therapy

A thorough literature analysis was conducted using essential databases such as PubMed, WHO's Mental Health database and an expanded search using sources such as Google and Google Scholar to find relevant articles. Articles specifically included art therapy intervention that deals with painting, drawing and craft. Articles included for review were from 2008 to 2021. Additional filters, such as free full text, were applied to all research. Furthermore, the reference lists and publications' citations were reviewed for other relevant sources. On examining the title and abstract, final inclusion was determined. This was done to eliminate mismatches with the review topic. The keywords used for advanced search were art-therapy, art, craft, drawing, painting and mood disorders, depression, common mental disorders, anxiety disorders, dissociative disorders, depression, schizophrenia, dementia, and Alzheimer's.

Looking back into history, thousands of years ago, people were practising and dependent on the arts for self-expression, healing and communication [ 3 , 12 ]. However, art therapy did not become a formalized curriculum until 1940. Doctors began to notice that people with a mental illness frequently enunciate themselves through drawings and other artworks. This inspired many to consider using art as a technique to heal [ 3 , 12 ]. It also had a high level of patient acceptance [ 7 ]. The scope of kinaesthetic, sensory, perceptual, and symbolic communication motivates the uncommon receptive and expressive communication modes that can function beyond language's limitations [ 1 ].

Some examples of art therapy used in mental health treatment include practising art with attention to skill development and mastery, studio art making, individual art making, program supervised and structured art groups, art psychotherapy, and personal art making with a healing goal [ 2 , 7 ]. Community-based art-making can enhance mental well-being. Individuals can increase their sense of value and self-esteem by using visual and symbolic expressions in art therapy. This makes it possible for people with mental illnesses to interact with one another and grow their social networks [ 7 ].

Art therapists plan sessions to achieve therapeutic goals and objectives by selecting suitable materials and interventions for their clients. They engage in creative processes to support their patients' growth to increase insight, decrease stress, heal trauma, increase cognitive, memory, and neurosensory capacities, improve interpersonal relationships and achieve a sense of self-fulfillment [ 13 ].

Common mental disorders

A category of diseases known as common metal disorders (CMDs) is a functional clinical classification for "deeper psychological discomfort experiences". The International Classification of Diseases, 10th Revision (ICD-10) classification of CMDs for primary healthcare includes depression, generalized anxiety, mixed anxiety and depression, adjustment disorder, dissociative disorder, unexplained somatic symptoms, neurasthenia, sleep disorders, phobic disorder and panic disorder [ 14 ].

Fear and anxiety are natural feelings for everyone. Still, anxiety builds up over time for those with anxiety disorders. Eventually, it does not commensurate with the actual threat or risk and becomes permanent [ 15 ]. Anxiety disorders are linked to problems with self-control [ 16 ].

Art therapy and mood disorders

Manic episodes, depressive episodes, bipolar disorder, recurrent depressive disorder and persistent mood disorder are all classified as mood disorders in the ICD-10 [ 14 ]. About 5% of adults worldwide suffer from depression. As stated by the WHO, women are more affected by depression than men. Depression significantly contributes to the global disease burden and can lead to suicide [ 17 ]. Major depressive disorder can have physical and mental side effects that affect one's overall physical well-being and quality of life. Only about half of individuals with depressive illnesses get their needed help [ 18 ]. The elderly, low-income and minority populations are more likely to be denied care. In the treatment of depression, pharmacotherapy is widely used, especially in moderate to severe instances [ 18 , 19 ].

Anxiety and mood disorder management has greatly succeeded in terms of understanding and treatment in the last two decades. Despite identifying unique processes, many believe creative expression can considerably improve mental health in clinical and community populations [ 7 , 16 ].

The evidence that shows how art therapy worked on people with mood disorders depicts different results. In a randomized control trial (RCT) by Ciasca et al., art therapists provided verbal advice as an introduction to the artistic procedure to help participants connect with the feelings and images associated with the theme being discussed. Patients utilized the resources available to deal with their problems. Techniques included weaving, collage, clay modelling, drawing and painting [ 18 ]. This randomized, single-blind trial found that introducing art-therapy intervention in patients with stable and pharmacologically treated major depressive disorder improved depression and anxiety symptoms. In another study, 118 participants 18-65 years of age were randomly assigned to intervention and standard therapy groups. No significant differences existed at baseline, and both groups demonstrated gains during the follow-up [ 20 ].

The effectiveness of art therapy on anxiety-related symptoms, anxiety severity, quality of life, and emotion regulation were examined. Studies have investigated the aspects that influence a treatment. Participants who had been diagnosed with generalized anxiety disorder, social anxiety disorder or panic disorder and had mild to moderate anxiety symptoms were introduced to art-therapy intervention. The study comprised a variety of creative exercises selected from a list of art-therapy activities. Because art therapy is a highly customized treatment, no set treatment procedure was used. Three types of exercises were offered: clay work, painting and drawing. The therapists documented the intricacies of the therapeutic approaches. Researchers then verified whether the deployed activities helped achieve the treatment objectives. According to the RCT, emotion regulation is a factor that causes anxiety reduction via art therapy [ 16 ]. The most significant gains in emotion regulation were better emotion acceptance and goal-oriented actions [ 8 ].

Art therapy and schizophrenia

Schizophrenia is a serious mental illness that has an adverse effect on 1 in 300 persons worldwide or about 24 million people. At least one in three people with schizophrenia will be able to recover, thanks to a variety of efficient treatment options [ 21 ]. Positive formal thought disorder, delusions, hallucinations and consistently unusual behaviour are characteristics of positive schizophrenia. Avolition, anhedonia, alogia, avolition, and affective flattening are the hallmarks of negative schizophrenia. In mixed schizophrenia, either both negative and positive symptoms are noticeable, or neither is noticeable [ 22 ].

Along with "positive" symptoms like delusions and hallucinations, many people have also encountered motivation loss, diversified energy levels and diminished concentration [ 22 ]. Some investigators have also attempted to investigate the productivity of schizophrenic patients using group art therapy as a complementary treatment. Patients were provided with various creative tools and encouraged to convey themselves freely. Art therapists often took a positive attitude toward empathizing with and encouraging their patients [ 23 ].

Various trials on the contribution of art therapy in schizophrenia have showed effective outcomes. The preliminary outcome showed identical results in the trial done by Crawford et al. to see if there were any benefits of group art therapy for schizophrenic patients [ 23 ]. Referring persons with schizophrenia to group art therapy, as done in this study, did not affect overall functioning, mental health or other health-associated outcomes [ 23 ]. However, in another pilot study, the art-therapy interventions aimed to assist the artist's process and understanding of the image. The patients who got art therapy showed a significant average decline in positive and negative manifestations of schizophrenia than patients who received standard care [ 24 ]. It implies that when art therapy was recommended to people with schizophrenia, they had greater emotional awareness scores at the end of the intervention period than patients treated with standard treatment. At post-treatment and follow-up, the art-therapy group had scarcely any positive manifestations of schizophrenia than the control group [ 24 ]. On the other hand, the most extensive, published three-arm RCT on art therapy (Multicenter Study of Art Therapy in Schizophrenia: Systematic Evaluation, or MATISSE trial) found no additional benefit in the global assessment of functioning in positive and negative manifestation scores. In this study, 417 schizophrenic patients were randomly allocated to art therapy and it did not enhance patient outcomes [ 2 , 23 ].

Art therapy and dementia

Dementia is described by a decline in the ability to remember, think or do other cognitive operations. Dementia comes in various forms, and multiple conditions can cause it [ 25 ]. More than 55 million people worldwide suffer from dementia, with around 10 million new cases diagnosed every year [ 26 ]. Mixed dementia is a condition in which different forms of dementia emerge in the brain. Alzheimer's disease is the leading cause of dementia and accounts for 60%-80% of cases. Dementia does not occur naturally as part of the ageing process. Damage to brain cells leads to a loss in the capacity to communicate, impacting thought, behaviour and feelings [ 25 - 27 ].

Art therapy, dance or movement therapy, music therapy and reminiscence therapy have all been studied as non-pharmacological treatments for Alzheimer's [ 27 ]. Studies have shown multidisciplinary cognitive rehabilitation in patients with mild Alzheimer's [ 28 ]. Art therapy was used as one of the activities for cognitive rehabilitation. Memory training, computer-assisted mental stimulation, expressive activities (drawing, verbal expression, writing), physiotherapy and physical training were all employed. As a consequence, patients' quality of life improved [ 29 ]. Participation in art interventions involving dance, expressive writing, music, theatre and visual arts was studied for their therapeutic and psychological impacts [ 30 ].

Richards et al. introduced art-therapy exercises to the intervention group for one and a half hours in their study. The activities included hat decoration, collage, embossing, painting, pottery, photography and printmaking. Each week, the participants developed an art product based on the instructions. Art therapy has been shown to boost self-esteem by reinforcing emotions of self-worth or competence. Finally, following the two-month course, participants continued to create artwork independently, resulting in a stronger sense of accomplishment and enhanced self-esteem [ 31 , 32 ].

Art-based practices and their benefits

According to a literature search, art therapy treats various mental problems. Research is currently looking into the contribution of art therapy in multiple areas, including depression, dementia, schizophrenia and psychosis. More extensive studies have examined topics like overall wellness or everyday anxiety [ 24 , 33 ]. It has been proposed that art can help people increase their self-esteem by providing abilities that can be acquired and mastered. Creating art, whether one becomes an artist or not, is inspiring. It develops inventive talents and an awareness of work planning and execution. It fosters the sense of self-sufficiency and the deep satisfaction of using one's artistic ability and mental capacity to generate outcomes one values and desires to share further.

Participating in creative activities can help people cope with stress and despair and alleviate the burden of chronic mental illnesses [ 7 ]. Many cultures have accepted the idea that artistic expression may considerably aid in the healing process. Throughout history, people have used paintings, storytelling, dances, yoga, and chants as healing rituals [ 7 , 34 , 35 ]. Over the last decade, health psychologists have carefully examined how art therapy help heal emotional traumas, enhance awareness of oneself and others, establish self-reflection capacity, reduce mental manifestations and transform behaviours and way of thinking.

Eisner best expresses this view of art education: "There are few things more problematic than a white sheet of paper or a lump of clay". Artists must create an art form out of these components. They must battle to understand how to feel about their efforts as they go and how to use their intelligence and experience to alter and improve them so that the ultimate obstacle is appropriately managed [ 36 ]. To put it another way, the process of creating an artwork is a continuous challenge to solve, and it involves numerous cognitive, emotional and physical factors.

Art therapy is also employed as a treatment modality in cancer patients, autism, HIV patients, Alzheimer's disease, COVID-19, dementia and Parkinson’s disease [ 34 , 37 , 38 ]. Art activities other than art and craft are music therapy, cognitive behavioural therapy, behavioural therapy, occupational therapy, clay modelling, and psychodynamic psychotherapy. These therapies also provide evidence about their effect on mental health. Unexplored art activities might provide additional proof of the impact on mental health, which includes fiction writing, sketching, interpretive dancing and photography [ 30 , 39 ].

Conclusions

The basic components of art-therapy interventions in the real world are hard to determine because there are currently no effective strategies for therapeutic, engaging, sensory art-therapy interventions. There is inadequate data to support the effectiveness of art therapy, and hence, more well-powered, high-quality trials with relevant outcome measures are required and more research is needed on the subject. Also, results of an intervention are not solely dependent on art therapy, as it is used along with pharmacotherapy. This made comparing all of the results difficult. The research comprising a small number of people makes it impossible to know how precise the results are, making it complicated to predict if the results will be the same in larger groups of people.

It is vital to raise awareness and mobilize support for mental health. Mental health concerns must be treated as soon as possible. Comprehensive measures for promotion, prevention, treatment and rehabilitation can be implemented through government approaches. Policymakers should be urged to enhance access to cost-effective treatment for prevailing mental illnesses in primary healthcare settings.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

• 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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Metrics details

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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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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Covid, Creativity, And Connecting Through Change: Reviewing The Literature On How Art Therapy Can Help Children And Adolescents Cope With Pandemic-Related Grief , Lydia Speicher 2023 Lesley University

Covid, Creativity, And Connecting Through Change: Reviewing The Literature On How Art Therapy Can Help Children And Adolescents Cope With Pandemic-Related Grief , Lydia Speicher

The COVID-19 pandemic has been one of the most significant global events in the past century, both resulting in massive casualties and significant mental health outcomes across the world. Some of the most impacted populations are children and adolescents whose lives have been interrupted during their formative years. The purpose of this literature review is to explore how art therapy has been used during the COVID-19 pandemic to address the grief experienced by children and adolescents through their losses of stability and peer support surrounded by uncertainty. This literature review seeks to understand exactly how the pandemic has affected the …

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How Art Can Heal

By girija kaimal.

Nonverbal therapy helps people work through trauma and build resilience.

Art Medicine Psychology

This Article From Issue

July-august 2020, volume 108, number 4.

DOI: 10.1511/2020.108.4.228

One-fourth of the global population is at risk of developing a mental health challenge in their lifetime, and one-fifth of children and adolescents could develop mental health problems, according to a 2014 World Health Organization report. Wars, adversity, discrimination, natural disasters, and illnesses such as COVID-19 further exacerbate these unmet needs for psychosocial support.

Oscar Wilde once said, “Man is least himself when he talks in his own person. Give him a mask, and he will tell you the truth.” Art provides a way to communicate experiences when individuals lack verbal skills or when words are insufficient. Humans evolved artistic expression as an imaginative tool for adapting to changing conditions and solving problems. Other scholars and I have asserted that art making is an integral part of human functioning, and that it helps humans survive. As an art therapist, I have spent decades trying to understand the role of art making as a therapeutic tool.

Art therapist Jacqueline Jones and Army Staff Sergeant Jonathan Meadows discuss his painting at Fort Belvoir Community Hospital’s Traumatic Brain Injury Clinic in Virginia. Although art therapy has been used for decades, researchers still have more to learn about how art making can help people grapple with complex emotions and work through life’s challenges to support mental health and well-being.

Photo by Marc Barnes/courtesy of U.S. Department of Defense

Professional art therapy began in the mid-20th century as a restorative practice that allowed people to express themselves in nonverbal ways, such as drawing and painting. Trauma affects the brain’s speech centers and can limit the effectiveness of traditional talk-based therapies. The impetus behind the creation of modern art therapy in the United States and Europe was to serve the needs of veterans from the two World Wars who were suffering from post-traumatic stress, and to address the development of children and adolescents with special needs.

Despite the prominent application of art therapy programs and the widespread belief that art supports mental health, many of the claims that art and art making can help people have remained anecdotal. My colleagues and I are among a growing group of art therapy researchers working to strengthen the scientific evidence that art can heal and to better understand how and why it does so.

Art as a Therapy Tool

Adults typically have complex, ambivalent feelings about art and art making; common responses range from dismissal and derision to awe and sometimes shame about their own lack of artistic skills. Young children, on the other hand, typically draw and sing and dance without worrying about their abilities. That freedom and joy is often lost as we grow and begin to self-consciously evaluate the quality of our art. Too often, we become viewers of others’ art rather than being active creators, and we lose the many benefits of creative self-expression. Art therapists guide people in connecting or reconnecting with the creative practices that support mental health, and that help people to grapple with life challenges and uncertainties. The United States has more than 6,000 credentialed art therapists, and the profession is growing in all parts of the world.

As a child, I used drawing and expressive writing to cope with boredom. (I was home sick a lot.) In India, I started a career as a textile designer, working in the vast and rich landscape of the artisanal traditions. But in the 1990s, as markets were disappearing, many artisans were despairing and committing suicide. I cherished working with them to adapt their exquisite craft to a modern market.

My interest in the connection between artistic practices and human well-being deepened, and I chose to pursue a master’s degree in art therapy and clinical work. As I worked with clients, I continued to wonder how humans can best work through traumatic experiences and grapple with adversity, and I eventually pursued my current work studying creative expression in a range of human populations.

Art therapy is founded on the assumption that everyone is creative and capable of self-expression. My job is to create a safe environment that allows clients to express themselves and communicate without worrying about whether they have great visual arts skills or whether their artwork is technically brilliant. Art therapy clinicians focus on the process of making rather than the artistic product, which allows our clients to gain insights about their situations and develop inner emotional resilience. Therapy sessions—in groups or with individuals—provide time for engaging all the senses and integrating these aesthetic experiences so that participants can reimagine and rework established neural pathways to establish new ways of seeing, thinking, and experiencing.

What is my superpower as an art therapist? I can change how you see yourself.

Art therapists can channel maladaptive or dangerous instincts into creative products that allow clients to communicate and work through difficult thoughts and complex emotions. I can guide a person toward taking risks in art making rather than engaging in risky behaviors in their outside life. These creative choices fulfill the brain’s desire for novelty without compromising personal safety. Rather than punch another human being, for instance, someone with aggressive tendencies could work with materials such as clay and wood that can absorb their energy and transform it into a creative product.

What is my superpower as an art therapist? I can change how you see yourself. Facebook Twitter

In the early 2000s, when I worked as an art therapist with teens in an alternative high school in Pennsylvania, the students often created socially inappropriate objects, such as clay penises and drug paraphernalia, during their art therapy sessions. By acting out with their art, the teens could visually express their family challenges and the developmental issues that brought them to the alternative school setting. Communicating these kinds of issues safely and nonverbally with a responsive adult can help such students make adaptive choices as they move into adulthood.

As we started looking at the science behind art therapy, my colleagues and I studied the effects of art making alone versus with an art therapist, starting with research at Drexel University with a test group of healthy adults, including students, faculty, and staff. We found that individuals who worked with an art therapist had lower levels of the stress hormone cortisol in their saliva; they also reported improved mood and self-efficacy and lower perceived stress than those who made art alone. These gains appeared across a variety of media, including collage, colored pencils, markers, modeling clay, and even new media, such as virtual reality.

Art therapy can influence a range of human functioning, we find, including self-perception and interpersonal interactions. Even a 45-minute creative activity can change a person’s mental state. Among healthy adults, some solitary activities, such as coloring, can help reduce stress and negative feelings. Working with an art therapist does even more: It can significantly enhance positive mood and boost measures of well-being, such as self-confidence and self-perception of creative abilities.

Healing the Body and Mind

After our initial studies with healthy adults, we wanted to examine whether cancer patients and caregivers experiencing chronic stress would benefit from art therapy. In 2017, with funding from the National Endowment for the Arts’ Research Labs program, we set up an art therapy study within the radiation oncology unit at a large urban hospital. We offered 22 patients and 34 caregivers individual, 45-minute sessions of coloring or free art making with an art therapist. Meanwhile, we monitored the patients with several surveys of psychological functioning before and after the sessions. Afterward, participants reported feeling more positive, less stressed, less anxious, and more self-confident. Several patients described these sessions as one of the few moments of respite from their hectic treatment schedule, and they appreciated the time and space to reflect on their experiences.

We also surveyed the caregivers, who reported feeling less burnout. Many responded that the experience distracted them from their daily concerns and allowed them to focus elsewhere. In addition, the art therapy session was the first time that some participants had a chance to process the psychological and existential challenges of dealing with cancer. I watched people open up and begin conversations with strangers after a facilitated drawing activity, in ways they might not have if they were only talking alone. Almost all participants took their creations home, and many have told me that they have kept their artwork in their home or office. They often can’t believe that they made it.

Trauma can affect the brain’s speech centers, making traditional talk therapies more difficult. Research conducted by the author and her colleagues is showing how art therapy can help individuals connect, find ways to express themselves, and heal. A service member created a mask ( left ) to represent two sides of himself. A cancer patient undergoing radiation treatment used mixed media to show her tumor breaking up ( right ).

© 2020 BMJ Publishing Group Ltd. ( left ); © 2020 SAGE Publications ( right )

Earlier this year, in the Journal of the American Medical Association , Maria Steenkamp of New York University Grossman School of Medicine and her colleagues reported that popular verbal psychotherapies, such as cognitive behavioral therapy and cognitive processing therapy, might not be adequate for military service members with post-traumatic stress disorder. For clients who struggle to understand and verbally share their psychosocial experiences, art therapy provides a nonverbal option. In a project to aid military service members, art therapists Melissa Walker at the Walter Reed National Military Medical Center, Jacqueline Jones, now at Eglin Air Force Base, and I have found that art making can help individuals who have experienced traumatic brain injury address their identity issues. (The project was supported by Creative Forces, a federally funded initiative of the National Endowment for the Arts, in partnership with the U.S. Departments of Defense and Veterans Affairs.) Service members’ experiences creating paintings, drawings, and sculptures allowed them to spend a long time working with their hands and to express and communicate thoughts and feelings that they had previously struggled to share.

In our studies, which combined quantitative and qualitative research methods, several hundred participants at Walter Reed and Fort Belvoir Community Hospital in Virginia reported that creative expression changed their perceptions of themselves, their relationships, and their life situations. A deep sense of grief and loss underlies trauma, and art therapy provides a metaphorical way to address the complex inner struggles of service members. Through art, they can slowly begin to communicate more openly about previously unsayable, shameful, or even taboo topics. They are better able to name their emotional experiences, and they use more words to express themselves.

Art therapy can also help service members to cope with the isolation and alienation that many feel after returning from a deployment, and to develop a sense of belonging and agency. In a retrospective study, we examined more than 400 pieces of visual artwork in the form of masks created by 370 service members between 2011 and 2015. These masks were created as part of an intensive military outpatient program at Walter Reed for service members who had a history of traumatic brain injury and other physical health conditions, and who had not responded to other treatments. We compared their artwork with clinical notes maintained by their therapists, looking for recurring themes and for links between image types and levels of post-traumatic stress, depression, and anxiety.

Service members who created fragmented imagery, we found, showed greater risk of mental health challenges, while those who created integrated images (depicting groups or cohesive visual metaphors) were more likely to show signs of improved psychological health. The correlation between the ability to express challenges visually and later well-being suggests that the act of naming and identifying ongoing challenges can help set the service member on a pathway to adaptive functioning.

Art Therapy in Virtual Reality

Today’s digital media technologies are expanding the options for art therapists to connect with clients, including the use of telehealth. Unlike traditional media, digital art media interfaces allow for a range of expression that includes sculpting and drawing in two and three dimensions. Participants can easily edit or change shapes and content, creating imagery that does not or cannot exist in real life. These technologies can present challenges because they only engage our visual and aural senses, and lack the tactile aspects of traditional art creation. But they provide a way of sustaining therapeutic connection by facilitating creative expression and communication through a digital interface, especially for clients who may be unwilling or unable to work with physical art materials.

To take the two-dimensional digital experience into three-dimensions and bring it closer to our lived experience of the world around us, my colleagues and I have been exploring the potential of virtual reality, both to expand our notions of what is possible and to encourage movement and immersion in digital artistic expression. In studies conducted in collaboration with Johns Hopkins University’s International Arts + Mind Lab and Drexel biomedical engineering professor Hasan Ayaz, we measured brain activity with functional near- infrared spectroscopy (fNIRS) in adults while they participated in virtual reality art therapy experiences. The data from brain scans and the participants’ self-reported responses indicate that novel media such as virtual reality can promote creative expression and physical activity, while also breaking down fears among many participants that they are not good at creating art. People don’t seem to associate the same stigmas and fears with creating in virtual reality as in traditional art media. This, in turn, helps participants engage in self-expression that they might not otherwise have had the confidence to explore.

Virtual reality provides an alternate universe where participants can move through objects, create structures that defy gravity, and step in and out of their creations. After creating in such a space, people often feel energized with a sense of creative possibility that they had not previously imagined. Though intangible, these digital experiences can help people appreciate the physical world in new ways, and technology such as 3D printing could soon help us make some digital creative experiences more tactile. As a result, virtual reality art therapy could be useful for patients with debilitating injuries and those who feel psychologically stuck in their life patterns.

Over the past half century, art therapy has expanded from a tool to address the unmet needs of individuals facing adversity and trauma to much wider use in hospitals, schools, and community organizations to promote health and well-being through artistic self-expression. In the future, the definition of therapy is poised to expand beyond talk therapy alone, and art therapy will be recognized as a cost-effective and sustainable psychosocial treatment option.

Telehealth will also help art therapists reach previously unreachable audiences in remote locations. As we connect with communities worldwide, where distinct traditional or indigenous practices remain intact, we will need to be mindful of and respect existing cultural practices. But we also hope to learn how traditional practices already integrate creativity to support mental health and well-being. Such insights could offer a deeper understanding about how art making can heal and lead to new tools to help others.

Bibliography

• Jones, J. P., M. S. Walker, J. M. Drass, and G. Kaimal. 2017. Art therapy interventions for active duty military service members with post-traumatic stress disorder and traumatic brain injury. The International Journal of Art Therapy 23:70–85.
• Kaimal, G., K. Ray, and J. M. Muniz. 2016. Reduction of cortisol levels and participants’ responses following art making. Art Therapy: Journal of the American Art Therapy Association 33:74–80.
• Kaimal, G., et al. 2017. fNIRS assessment of reward perception based on visual self- expression: Coloring, doodling, and free drawing. The Arts in Psychotherapy 55:85–92.
• Kaimal, G., M. S. Walker, J. Herres, L. M. French, and T. J. Degraba. 2018. Observational study of associations between visual imagery and measures of depression, anxiety and stress among active duty military service members with post-traumatic stress and traumatic brain injury. BMJ Open 8:e021448.
• Kaimal, G. 2019. Adaptive response theory (ART): A clinical research framework for art therapy. Art Therapy: Journal of the American Art Therapy Association 36:215–219.

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Open Access

Peer-reviewed

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 ).

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

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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