art therapy research paper example

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Research Article

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

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

* E-mail: [email protected]

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

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

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

Roles Conceptualization, Writing – review & editing

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

Roles Writing – review & editing

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

Roles Conceptualization, Supervision, Writing – review & editing

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

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

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

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

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

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

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

Conclusions

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

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

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

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

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

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

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

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

Introduction

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

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

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

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

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

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

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

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

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

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

Protocol and registration

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

Eligibility criteria

Types of study designs..

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

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

Types of participants.

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

Types of interventions.

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

Types of comparisons.

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

Types of outcome measures.

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

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

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

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

Study selection

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

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

Data collection process

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

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

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

Risk of bias in individual studies

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

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

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

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

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

Quality of evicence

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

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

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

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

Screening of references from systematic reviews.

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

Study characteristics

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

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

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

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

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

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

Risk of bias within studies

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

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

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

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

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

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

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

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

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

Outcomes of individual studies

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

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

Anxiety–in study with inactive control.

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

Anxiety–in studies with active control.

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

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

Summary of outcomes and quality.

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

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

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

Meta-analysis.

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

Narrative synthesis

Benefiting populations..

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

Characteristics of AT for anxiety.

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

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

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

Working mechanisms of AT.

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

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

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

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

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

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

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

Summary of evidence and limitations at study level

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

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

Strengths and limitations of this review

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

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

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

Comparison to the AT literature

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

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

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

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

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

Future perspectives

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

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

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

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

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

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

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

Supporting information

S1 checklist. prisma checklist..

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

S1 File. Full list of search terms and databases.

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

S1 Table. Data extraction form.

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

S2 Table. Excluded studies with reasons for exclusion.

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

S3 Table. Background characteristics of the included studies.

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

Acknowledgments

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

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

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

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

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

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Introduction

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

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

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

Data extraction

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

Study inclusion and assessment

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

PRISMA 2009 flow diagram

Participant characteristics

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

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

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

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

Forms of art therapy intervention and assessment (Table 1 )

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

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

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

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

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

Outcome measures and statistical analysis (Table 1 )

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

Study design: children with psychiatric symptoms (Table 2 )

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

Forms of intervention and assessment (Table 2 )

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

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

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

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

Outcome measures and statistical analysis (Table 2 )

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

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

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

Assessment of bias

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

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

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

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

Strengths and limitations

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

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

Conclusions and future perspectives

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

Availability of data and material

Data can be made available to reviewers if required.

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Acknowledgements

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

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

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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 ,
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• Anne Berghöfer   ORCID: orcid.org/0000-0002-7897-6500 1  

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

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

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

Systematic review registration

PROSPERO ID CRD42021233272

Peer Review reports

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

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

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

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

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

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

Methods/Design

Registration and reporting.

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

Eligibility criteria

Type of study.

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

Types of participants

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

Types of interventions

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

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

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

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

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

Comparison interventions

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

Stakeholder involvement

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

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

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

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

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

Grouping for primary analysis comparisons

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

Search strategy

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

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

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

Data collection and data management

Study selection process.

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

Data extraction

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

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

Risk of bias assessment for included studies

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

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

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

Measures of treatment effect

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

Unit of analysis issues

Cluster trials.

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

Cross-over trials

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

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

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

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

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

Missing data

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

Assessment of clinical, methodological, and statistical heterogeneity

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

Reporting bias

Funnel plot.

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

Data analysis and synthesis

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

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

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

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

Subgroup analysis

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

Sensitivity analysis

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

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

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

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

Availability of data and materials

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

Abbreviations

• Active visual art therapy

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols

Randomised controlled trial

Risk of Bias tool

Intention to treat

Per protocol

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

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

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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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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]

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

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What Is Art Therapy?

Blend Images - KidStock / Brand X Pictures / Getty Images

Effectiveness

Things to consider, how to get started.

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

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

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

Types of Creative Therapies

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

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

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

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

Techniques used in art therapy can include:

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

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

What Art Therapy Can Help With

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

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

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

Benefits of Art Therapy

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

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

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

Some situations in which art therapy might be utilized include:

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

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

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

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

You Don't Have to Be Artistic

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

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

It's Not the Same as an Art Class

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

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

Art Therapy Can Take Place in a Variety of Settings

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

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

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

Art Therapy Is Not for Everyone

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

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

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

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

Becoming an Art Therapist

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Art Therapy for Psychosocial Problems in Children and Adolescents: A Systematic Narrative Review on Art Therapeutic Means and Forms of Expression, Therapist Behavior, and Supposed Mechanisms of Change

Liesbeth bosgraaf.

1 Faculty of Healthcare and Social Work, NHL Stenden University of Applied Sciences, Leeuwarden, Netherlands

2 Alliade, Care Group, Heerenveen, Netherlands

3 KenVaK, Research Center for Arts Therapies, Heerlen, Netherlands

4 Faculty of Psychology, Open University, Heerlen, Netherlands

Marinus Spreen

Kim pattiselanno, susan van hooren.

5 Faculty of Healthcare, Zuyd University of Applied Sciences, Heerlen, Netherlands

Associated Data

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Background: Art therapy (AT) is frequently offered to children and adolescents with psychosocial problems. AT is an experiential form of treatment in which the use of art materials, the process of creation in the presence and guidance of an art therapist, and the resulting artwork are assumed to contribute to the reduction of psychosocial problems. Although previous research reports positive effects, there is a lack of knowledge on which (combination of) art therapeutic components contribute to the reduction of psychosocial problems in children and adolescents.

Method: A systematic narrative review was conducted to give an overview of AT interventions for children and adolescents with psychosocial problems. Fourteen databases and four electronic journals up to January 2020 were systematically searched. The applied means and forms of expression, therapist behavior, supposed mechanisms of change, and effects were extracted and coded.

Results: Thirty-seven studies out of 1,299 studies met the inclusion criteria. This concerned 16 randomized controlled trials, eight controlled trials, and 13 single-group pre–post design studies. AT interventions for children and adolescents are characterized by a variety of materials/techniques, forms of structure such as giving topics or assignments, and the use of language. Three forms of therapist behavior were seen: non-directive, directive, and eclectic. All three forms of therapist behavior, in combination with a variety of means and forms of expression, showed significant effects on psychosocial problems.

Conclusions: The results showed that the use of means and forms of expression and therapist behavior is applied flexibly. This suggests the responsiveness of AT, in which means and forms of expression and therapist behavior are applied to respond to the client's needs and circumstances, thereby giving positive results for psychosocial outcomes. For future studies, presenting detailed information on the potential beneficial effects of used therapeutic perspectives, means, art techniques, and therapist behavior is recommended to get a better insight into (un)successful art therapeutic elements.

Introduction

Psychosocial problems are highly prevalent among children and adolescents with an estimated prevalence of 10%−20% worldwide (Kieling et al., 2011 ; World Health Organization, 2018 ). These problems can severely interfere with everyday functioning (Bhosale et al., 2015 ; Veldman et al., 2015 ) and increase the risk of poorer performance at school (Veldman et al., 2015 ). The term psychosocial problems is used to emphasize the close connection between psychological aspects of the human experience and the wider social experience (Soliman et al., 2020 ) and cover a wide range of problems, namely, emotional, behavioral, and social. Emotional problems are often referred to as internalizing problems, such as anxiety, depressive feelings, withdrawn behavior, and psychosomatic complaints. Behavioral problems are often considered as externalizing problems, such as hyperactivity, aggressive behavior, and conduct problems. Social problems are problems related to the ability of the child to initiate and maintain social contacts and interactions with others. Often, emotional, behavioral, and social problems occur jointly (Vogels, 2008 ; Jaspers et al., 2012 ; Ogundele, 2018 ). The etiology of psychosocial problems is complex and varies with regard to the problem(s) and/or the specific individual. A number of theories seek to explain the etiology of psychosocial problems. The most common theory in Western psychology and psychiatry is the biopsychosocial theory, which assumes that a combination of genetic predisposition and environmental stressors triggers the onset of psychosocial problems (Lehman et al., 2017 ). But also, attachment theories get renewed attention (Duschinsky et al., 2015 ). These theories focus on the role of the early caregiver–child relationships and assume that (a lack of) security of attachment affects the child's self-(emotion)regulatory capacity and therefore his or her emotional, behavioral, and social competence (Veríssimo et al., 2014 ; Brumariu, 2015 ; Groh et al., 2016 ). Research has identified a number of biological, psychological, and environmental factors that contribute to the development or progression of psychosocial problems (Arango et al., 2018 ), namely, trauma, adverse childhood experiences, genetic predisposition, and temperament (Boursnell, 2011 ; Sellers et al., 2013 ; Wright and Simms, 2015 ; Patrick et al., 2019 ).

Psychosocial problems in children and adolescents are a considerable expense to society and an important reason for using health care. But, most of all, psychosocial problems can have a major impact on the future of the child's life (Smith and Smith, 2010 ). Effective interventions for children and adolescents, aiming at psychosocial problems, could prevent or reduce the likelihood of long-term impairment and, therefore, the burden of mental health disorders on individuals and their families and the costs to health systems and communities (Cho and Shin, 2013 ).

The most common treatments of psychosocial problems in children and adolescents include combinations of child- and family-focused psychological strategies, including cognitive behavioral therapy (CBT) and social communication enhancement techniques and parenting skills training (Ogundele, 2018 ). These interventions are designed with the idea that cognitions affect the way that children and adolescents feel and behave (Fenn and Byrne, 2013 ). However, this starting point is considered not suitable for all youngsters, in particular, for children and adolescents who may find it difficult to formulate or express their experiences and feelings (Scheeringa et al., 2007 ; Teel, 2007 ). For such situations in clinical practice, additional therapies are often offered. Art therapy (AT) is such a form of therapy.

AT is an experiential form of treatment and has a special position in the treatment of children and adolescents because it is an easily accessible and non-threatening form of treatment. Traditionally, AT is (among others) used to improve self-esteem and self-awareness, cultivate emotional resilience, enhance social skills, and reduce distress (American Art Therapy Association, 2017 ), and research has increasingly identified factors, such as emotion regulation (Gratz et al., 2012 ) and self-esteem (Baumeister et al., 2003 ) as mechanisms underlying multiple forms of psychosocial problems.

Art therapists work from different orientations and theories, such as psychodynamic; humanistic (phenomenological, gestalt, person-centered); psychoeducational (behavioral, cognitive–behavioral, developmental); systemic (family and group therapy); as well as integrative and eclectic approaches. But also, there are various variations in individual preference and orientation by art therapists (Van Lith, 2016 ). In AT, the art therapist may facilitate positive change in psychosocial problems through both engagement with the therapist and art materials in a playful and safe environment. Fundamental principles in AT for children and adolescents are that visual image-making is an important aspect of the natural learning process and that the children and adolescents, in the presence of the art therapist, can get in touch with feelings that otherwise cannot easily be expressed in words (Waller, 2006 ). The ability to express themselves and practice skills can give a sense of control and self-efficacy and promotes self-discovery. It, therefore, may provide a way for children and clinicians to address psychosocial problems in another way than other types of therapy (Dye, 2018 ).

Substantial clinical research concerning the mechanisms of change in AT is lacking (Gerge et al., 2019 ), although it is an emerging field (Carolan and Backos, 2017 ). AT supposed mechanisms of change can be divided into working mechanisms specific for AT and overall psychotherapeutic mechanisms of change, such as the therapeutic relationship between client and therapist or the expectations or hope (Cuijpers et al., 2019 ). Specific mechanisms of change for AT include, for instance, the assumption that art can be an effective system for the communication of implicit information (Gerge, and Pedersen, 2017 ) or that art-making consists of creation, observation, reflecting, and meaning-making, which leads to change and insight (Malchiodi, 2007 ).

Recently, it has been shown that AT results in beneficial outcomes for children and adolescents. Cohen-Yatziv and Regev ( 2019 ) published a review on AT for children and adolescents and found positive effects in children with trauma or medical conditions, in juvenile offenders, and in children in special education and with disabilities. While increasing insight into the effects of AT for different problem areas among children is collected, it remains unclear whether specific elements of AT interventions and mechanisms of change may be responsible for these effects. In clinical practice, art therapists base their therapy on rich experiential and intuitive knowledge. This knowledge is often implicit and difficult to verbalize, also known as tacit knowledge (Petri et al., 2020 ). Often, it is based on beliefs or common sense approaches, without a sound basis in empirical results (Haeyen et al., 2017 ). This intuitive knowledge and beliefs consist of (theoretical) principles, art therapeutic means and forms of expression, and therapist behavior [including interactions with the client(s) and handling of materials] that art therapists judge necessary to produce desired outcomes (Schweizer et al., 2014 ). Identifying the elements that support positive outcomes improves the interpretation and understanding of outcomes, provides clues which elements to use in clinical practice, and will give a sound base for initiating more empirical research on AT (Fixsen et al., 2005 ). The aim of this review is to provide an overview of the specific elements of art therapeutic interventions that were shown to be effective in reducing psychosocial problems in children and adolescents. In this review, we will focus on applied means and forms, therapist behavior, supposed mechanisms of change of art therapeutic interventions. As the research question was stated, i.e., which art therapeutic elements support positive outcomes in psychosocial problems of children and adolescents (4–20)?

Study Design

A systematic narrative review is performed according to the guidelines of the Cochrane Collaboration for study identification, selection, data extraction, and quality appraisal. Data analysis was performed, conforming narrative syntheses.

Eligibility Criteria

In this review, we included peer-reviewed published randomized controlled trials (RCTs), non-randomized clinical controlled trials (CCTs), and studies with group pre–posttest designs for AT of psychosocial problems in children and adolescents (4–20 years). Studies were included regardless of whether AT was present within the experimental or control condition. Qualitative data were included when data analysis methods specific for this kind of data were used. Only publications in English, Dutch, or German were included. Furthermore, only studies in which AT was provided by a certified art therapist to individuals or groups, without limitations on duration and number of sessions, were inserted. Excluded were studies in which AT was structurally combined with another non-verbal therapy, for instance, music therapy. Studies on (sand)play therapy were also excluded. Concerning the outcome, studies needed to evaluate AT interventions on psychosocial problems. Psychosocial problems were broadly defined as emotional, behavioral, and social problems. Considered emotional (internalizing) problems were, for instance, anxiety, withdrawal, depressive feelings, psychosomatic complaints, and posttraumatic stress problems/disorder. Externalizing problems were, for instance, aggressiveness, restlessness, delinquency, and attention/hyperactivity problems. Social problems were problems that the child has in making and maintaining contact with others. Also included were studies that evaluated AT interventions targeted at children/adolescents with psychosocial problems and showed results on supposed underlying mechanisms such as, for instance, self-esteem and emotion regulation.

Fourteen databases and four electronic journals were searched: PUBMED, Embase (Ovid), PsycINFO (EBSCO), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Web of Science, Cinahl, Embase, Eric, Academic Search Premier, Google Scholar, Merkurstab, ArtheData, Relief, and Tijdschrift Voor Vaktherapie (Journal of Arts Therapies in the Netherlands). A search strategy was developed using keywords (art therapy in combination with a variety of terms regarding psychosocial problems) 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 ( Appendix 1 ). The search period had no limitation until the actual first search date: October 5, 2018. The search was repeated on January 30, 2020. If online versions of articles could not be traced, the authors were contacted with a request to send the article to the first author. 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 RefWorks file of all identified references was produced. Duplicates were removed. The following selection procedure was independent of each other carried out by four researchers (LB, SvH, MS, and KP). Titles and abstracts were screened for eligibility by three researchers (LB, SvH, and KP). The full texts were subsequently assessed by three researchers (LB, MS, and KP) according to the eligibility criteria. Any disagreement in study selection between a pair of reviewers was resolved through discussion or by consultation of the fourth reviewer (SvH).

Quality of the Studies

The quality of the studies was assessed by two researchers (LB and KP) applying the EPHPP “Quality Assessment Tool for Quantitative Studies” (Thomas et al., 2004 ). Independent of each other, they came to an opinion, after which consultation took place to reach an agreement. To assess the quality, the Quality Assessment Tool was used, which has eight categories: selection bias, study design, confounders, blinding, data collection methods, withdrawal and dropouts, intervention integrity, and analysis. Once the assessment was completed, each examined study received a mark ranging between “strong,” “moderate,” and “weak.” The EPHPP tool has a solid methodological rating (Thomas et al., 2004 ).

Data Collection and Analysis

The following data were collected from the included studies: continent/country, type of publication of study, year of publication, language, impact factor of the journal published, study design, the primary outcome, measures, setting, type of clients, comorbidity, physical problems, total N, experimental N, control N, proportion male, mean age, age range, the content of the intervention, content control, co-intervention, theoretical framework AT, other theoretical frameworks, number of sessions, frequency sessions, length sessions, outcome domains and outcome measures, time points, outcomes, and statistics. An inductive content analysis (Erlingsson and Brysiewicz, 2017 ) was conducted on the characteristics of the employed ATs concerning the means and forms of expression, the associated therapist behavior, the described mechanisms of change, and whether there were significant effects of the AT interventions. A narrative analysis was performed.

The first search (October 2018) yielded 1,285 unique studies. In January 2020, the search was repeated, resulting in 14 additional unique studies, making a total of 1,299. Four additional studies identified from manually searching the reference lists from 30 reviews were added, making a total of 1,303 studies screened on title and abstract. In the first search, 1,085 studies, and in the second search, nine studies were excluded, making a total of 1,094 studies being excluded on title and abstract. This resulted in 209 full-text articles to assess eligibility. In the full-text selection phase, from the first search, another 167 studies were excluded; in the second search, five studies were excluded. This makes a total of 172 studies being excluded in the full-text phase. Twenty-three studies were excluded because a full text was unavailable; five studies because the language was not English, Dutch, or German; 99 studies did not meet the AT definition; 16 studies had a wrong design; 10 studies did not treat psychosocial problems; and 19 studies concerned a wrong population. In total, 37 studies were included (see Figure 1 for an overview of the complete selection process).

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart.

The final review included 16 RCTs, eight CCTs, and 13 single-group pre–post designs (total n = 37). Of the RCTs, a mixed-method design, involving both quantitative and qualitative data, was used in two studies. In one RCT, the control group received AT meeting our criteria, while the experimental group did not receive such a therapy (11). In another RCT, the experimental and the control group both received AT meeting our criteria (13). Also, two CCT studies used a mixed-method design, but these qualitative results were not included due to inappropriate analysis. Of the single-group pre–posttest designs, two studies had a mixed-method (quantitative and qualitative) design ( Table 1 ).

Study characteristics/outcome.

ASD, Autism Spectrum Disorder; CATIS, Childhood Attitude Toward Illness Scale; CBCL, Child Behavior Checklist; CCT, Clinical Controlled Trial; DAS, Draw a Story; DSM, Diagnostic Statistic Manuel of Mental Disorders; ID, Intellectual Disability; RCT, Randomized Controlled Trial; LOC, Locus of Control; PTSD, Post Traumatic Stress Disorder; SCIT, Synallactic Collective Image Therapy; SF-AT, Solution Focused Art Therapy; SSRS, Social Skills Rating System; TF-ART, Trauma Focused Expressive Art Therapy; TRS, Teacher Rating Scales; UCLA, University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index .

Of the 16 RCTs, two studies were evaluated as weak, 11 studies received a moderate score, and three studies were labeled as strong. Concerning the CCTs, five studies were evaluated as weak, one study as moderate, and two studies as strong. Of the 13 pre–posttest designs, five studies were assessed as weak and eight studies as moderate ( Table 1 ).

Study Population

The studies in this review included children and adolescents (ages 2–20) with a wide range of psychosocial problems and diagnoses. Most of the studies included children from the age of 6 years onward, with children's groups ranging from 6 to 15, adolescent groups ranging from 11 to 20, and mixed groups with an age range of 6–20 years. In 13 studies, both boys and girls were included, three studies only included boys, three studies only included girls, and 18 studies did not report the gender of the participants. Psychiatric diagnoses were reported, such as depression, autism spectrum disorder (ASD), conduct disorder (CD), post-traumatic stress disorder (PTSD), and mild intellectual disability (MID). However, also more specific problems were reported, such as children with suicidal thoughts and behavior, children having a brother/sister with a life-threatening disease, boys and girls in an educational welfare program needing emotional and psychological help, and orphans with a low self-esteem. Another group of children that were reported had medical concerns, such as persistent asthma, traumatic injuries, or serious medical diagnoses such as cancer, often combined with anxiety problems and/or trauma-related problems ( Table 1 ).

Number of Participants

The sample sizes of the RCTs ranged from 16 to 109. The total number of children of all RCTs was 707, of which 317 were allocated to an experimental condition and 390 to a control condition ( Table 1 ). The sample sizes of the CCTs ranged from 15 to 780, and the total number of participants was 1,115. The total number of participants who received an AT treatment was 186; the total number of the control groups was 929. Notice that the sample size for the CCTs was influenced by one study in which a control sample database of 780 was used. The sample size of the included pre–posttest designs ranged from 8 to 94 participants, with a total number of 411 participants ( Table 1 ).

Type of Intervention, Frequency, and Treatment Duration

In the 37 studies, a total of 39 AT interventions were studied. In two studies, two AT interventions were studied. Of the 39 interventions, 30 studies evaluated group interventions, seven studies evaluated an individually offered intervention, one study evaluated an individual approach within a group setting, and in one study, the intervention was alternately offered as a group intervention or as an individual intervention. The number of sessions of the AT interventions varied from once to 25 times. The frequency of the AT interventions varied from once a week ( n = 14) or twice a week ( n = 5) and variations such as four times a week in 2 weeks ( n = 1); six sessions were varying from one to three times a week ( n = 1), 10 sessions during 12 weeks ( n = 1), and eight sessions in 2 weeks ( n = 1). The frequency of sessions has not been reported in nine studies. In five studies, the intervention was offered once ( Table 1 ).

Control Interventions

In six RCTs, care, as usual, was given to the control groups. In study four, this also concerned AT, but it was offered in a program that consisted of different forms of treatment as child life services, social work, and psychiatric consults and therefore did not meet our criteria for inclusion. The control groups receiving “care as usual” received routine education and activities of their programs in school (6); counseling/medications and group activities as art, music, sports, computer games, and dance (8); standard arts- and craft-making activities in a group (9); and standard hospital services (14). One study did not specify what happened as care as usual (2). In five RCTs, a specific intervention of activity was offered in the control condition. These control interventions involved 3 h of teaching (5), a discussion group (7), offering play material (magneatos) (12), and a range of games (11), and one study offered weekly socialization sessions, these sessions were offered by the same professionals as the experimental group, and activities were playing board games, talking about weekend activities, and taking walks on the school grounds (16). Two RCT studies did not mention the condition in the control group (1, 10). Two studies mentioned that the control group did not receive any intervention program (3, 11). One study mentioned that the control group had the same assessments as the treatment group but did not receive therapy until all of the assessments were collected (15).

Regarding the eight CCTs, two studies described the control condition in more detail, consisting of academic work (21) or 3 h of informal recreational activities (24). No intervention was offered to the control group in four studies (19, 20, 22, 23). The control intervention was not described within two studies (17, 18) ( Table 1 ).

Applied Means and Forms of Expression

The applied means and forms of expression in the AT interventions could be classified into three categories: art materials/techniques, topics/assignments given, and language as a form of verbal expression accompanying the use of art materials. Results will be shown for 39 AT interventions in total, coming from 37 studies ( Table 2 ). Two studies applied two different types of AT interventions. These two types of AT will be referred to as 13 a/b and 29 a/b.

Characteristics AT interventions.

ATI, Art Therapy Institute; CBT, Cognitive Behavioral Therapy; DBT, Dialectic Behavioral Therapy; ETC, Expressive Therapies Continuum; LOC, Locus of Control; PTSD, Post Traumatic Stress Disorder; SF-AT, Solution Focused Art Therapy .

Materials/Techniques

Regarding the category art materials/techniques, three subcategories were found. In the first subcategory, only two-dimensional art media/techniques were used, such as drawing, painting, or printing (the art product possessed length and width, but not depth). Used as materials were for instance, (acrylic) paint, markers, color pencil, crayons, gouache and water, white pieces of paper, cardboard, construction paper with pencils and colored markers, a “sketch” coloring, pencils, markers, and oil pastels (1, 3, 6, 7, 10, 14, 18, 21, 23). No specific art techniques concerning the way the materials were applied were mentioned in this subcategory. In the second subcategory, both two-dimensional and three-dimensional art media and techniques (art that can be defined in three dimensions: height, width, and depth) were offered: clay, papier-mâché masks, paint, paper decoration forms and markers, pictures and journals, paper, cardboard, construction materials, hospital socks, buttons and threads, sewing materials, magic beans, sand, fiberfill, photos, wood, stone, plaster, felt and other textiles, and yarn. In this subcategory, specific art techniques were mentioned, such as paper cutting and paper folding, collage technique, bookmaking, building a face, basket-making, clay techniques, guided fantasy, group painting, story-making through a doll, placing feelings in boxes, drawing/sculpting feelings, making clay shapes, creating self-portraits, and molding clay (2, 5, 8, 11, 13a, 19, 20, 22, 26, 27, 28, 29a, 29b, 30, 31, 32, 33, 36, 37). In the third category, both two-dimensional and three-dimensional art materials/techniques were applied, which matched the specific assignment or topic given (4, 9, 12, 13b, 14, 15, 17, 24, 25). For instance, drawings were made, and the collage technique was used to make a book (9). Four sets of facial features (eyes, noses, mouths, and brows), as well as a mannequin head, were offered for representing facial emotions (12), and in one study, patients used buttons, threads, and sewing materials with which they constructed their Healing Sock Creature, which the children filled with magic beans, sand, or fiberfill (15).

Topics/Assignments

Three subcategories were found concerning the category topics/assignments. The first subcategory, free working with the materials without topics/assignments given , was applied in five AT interventions (3, 5, 11, 13a, 16). In the second subcategory, 26 AT interventions used assignment(s) or gave topics (1, 2, 4, 7, 8, 9, 10, 12, 13b, 14, 15, 17, 19, 20, 21, 22, 23, 24, 25, 27, 29 a/b, 32, 33, 36, 37). The third subcategory concerned combinations of these two. Two studies mixed free working and giving topics/assignments (28, 30), and seven studies did not describe the intervention explicit enough to classify them (6, 18, 26, 31, 34, 35, 36). A wide range of activities based on topics and/or assignments were reported. Eleven categories could be detected; (1) getting familiar with the art material (1, 17) like “learning about art media” (1) and “warm-up clay activities and introduction to theme-related clay techniques” (17); (2) focusing on family perspective , like for instance, “draw first childhood memory/family relations”(1, 23), drawing family as animal (19); (3) working with visualization, fantasy, and meditation (1, 10, 20, 21), such as guided fantasy with clay, and story-making through a doll (20); (4) expressing emotions (1, 14, 19, 20, 23, 32) like “the participant was asked to create four different faces, representing happiness, sadness, anger, and fear” (14) or “make an anger collage” (19); (5) focusing on specific problems such as chronic disease or stress-related events (2, 4, 8, 9, 14, 15, 19, 37) such as “the experience associated with stress is drawn on small white paper and the future solution contents will be drawn on colorful, larger paper” (8) and “drawing feelings, drawing perpetrators, placing of these in boxes” (19); (6) applying group activities (10, 19, 20, 32), for instance, “make a group painting”(20) and “all the children were asked to work on a group project to bring closure by drawing a ceremony on a large paper together with comments” (10); (7) working on an exhibition of artwork (10, 32), for instance, “at the end, a small exhibition of artwork was made” (10); (8) focusing on the material/technique (17, 21, 27, 37) such as “making shapes using clay” (17) and “mold clay into a pleasing form, which could be an animal, a person, an object, or an abstract form” (21); (9) focusing on specific art techniques (19, 21, 29) such as “arrange a variety of objects in a pleasing orientation and draft the still life with a pencil” (21) or “make a photo collage”(19); (10) working with a product/object as a result (24, 25, 27, 32) such as, for instance, “making a bracelet” (32), “making paper bags” (27), or creating therapeutic art books (25); (11) applying general activities (1, 7, 19, 22, 27, 32) like drawing of a picture (7) and “the given theme was heroes”(22). Two studies (13b, 33) gave assignments/topics but did not specify these.

The Role of Language

Three subcategories were found concerning the role of language as a form of verbal expression accompanying the use of art materials and techniques: the produced artwork was mainly discussed afterward in a group meeting or on an individual basis (1, 2, 3, 4, 9, 10, 11, 13b, 14, 17, 29, 36) or feelings and concerns were mainly discussed and reflected on while working (5, 12, 13a, 15, 18, 22, 25, 26, 28) and other varieties such as: the work was (verbally) presented (4) and/or patients also retold the narrative created (5). In one study (7), the originator gave a title, offered associations to it, and said how he/she felt before and after drawing other members gave their associations. In one study (8), all artworks were gathered as a collection and reviewed at the end of the intervention (last session) together with the parents.

Therapist Behavior

Regarding therapist behavior, the information is structured in two categories: the therapist behavior, including social interactions with the client(s) , and the handling of materials by the therapist, including material interactions with the client(s) .

Therapist Behavior, Including Social Interactions With Their Client(s)

The information revealed three broad behaviors: non-directive behavior, directive behavior, and behavior that can be considered eclectic . Non-directive behavior refers to AT interventions in which the therapists showed mainly a following and facilitating attitude toward the children/adolescents. Thirteen AT interventions applied this kind of therapist behavior (13a, 15, 16, 17, 18, 20, 21, 22, 23, 25, 29a, 30, 36). Interactions with clients were for example, “the therapist was non-interpretive, with the participants creating their direct statements and finding their meanings in the individual artwork they created” (21) and “the therapist facilitates the creation of the artistic product and is supportive” (13a). Directive behavior refers to AT interventions in which the therapist showed an active and leading role toward the children/adolescents. Ten AT interventions (4, 8, 10, 11, 12, 13b, 24, 26, 28, 29b) used this kind of therapist behavior. Interactions with the clients were, for example, “the therapist asks exception/difference questions” (8) or “the participant was directed to choose a mouth, nose, eyes, and brows that represented the correct emotion” (12). A mix of these two types of therapist behaviors (eclectic) was applied in nine AT interventions (2, 5, 7, 9, 14, 32, 33, 34, 35), for instance: “each adolescent was asked at the beginning of the session to do a ‘feelings check-in’ describing how he or she was feeling in the moment and a ‘feelings check-out’ at the end of the session. In the art-making period, a minimal discussion took place” (9) or “art therapists worked with their clients to form therapeutic goals during initial sessions, followed by both structured and unstructured weekly AT sessions” (34). In seven AT interventions (1, 3, 6, 19, 27, 31, 37), insufficient information was given to classify the therapist's behavior.

The Handling of Materials by the Therapist, Including Material Interactions With the Client(s)

Information was provided by seven studies: “the therapist assists and supports the youngster in carrying out the activity” (5), “the therapist embeds solution-focused questions and skills in the art-making process” (8), “during working with materials, there was minimal discussion” (9), “the child was directed to choose features/materials that represented the correct emotion” (12), “the therapist gave delineated verbal instructions and directions for art media” (13a), “the therapist-assisted the child having difficulty with a specific medium” (13b), “the therapist became the co-creator” (15), and “the therapist avoided giving art instructions” (25).

Supposed Mechanisms of Change

In the introduction and discussion sections of the articles, a range of supposed mechanisms of change as substantiation of the intervention and outcomes were described ( Table 2 ). The supposed mechanisms of change could be categorized into two categories: art therapy specific and general psychotherapeutic mechanisms of change .

Specific Mechanisms of Change

Eight subcategories of a specific mechanism of change were detected. The first category was Art therapy as a form of expression to reveal what is inside . This large subcategory, could be divided into three forms: art as a form of visualizing and communication in general (1, 13, 15, 19, 20, 26, 28, 33, 35, 36), such as, “it enables the child to visualize” (15); art as a manageable expression and/or regulation of emotions (1, 2, 3, 7, 8, 10, 19, 20, 23, 27, 28, 31, 33, 35, 37), e.g., “through art emotions can be processed” (2); and art as a way of expression through specific processes (1, 4, 5, 9, 10, 11, 14, 15, 17, 19, 22, 25, 28, 29, 31, 32), for instance, “reduces threat inherent in sharing experiences of trauma by permitting a constructive use of displacement via the production of imagistic representations” (9). The second category was Art therapy as a way of becoming aware of oneself , mentioned by 10 studies (1, 2, 11, 13, 16, 23, 24, 25, 35, 36), for instance, “to regain a sense of personal agency” (1). The third category was defined as art therapy as a way to form a narrative of life , like “facilitation of the integration of the experience into one's larger, autobiographical life narrative” (4), while the fourth category dealt with art therapy as integrative activation of the brain through experience , which was mentioned in six studies (4, 12, 14, 16, 34, 26), for instance, “utilizing the integrative capacity of the brain by accessing the traumatic sensations and memories in a manner that is consistent with the current understanding of the transmission of experience to language”(4). The fifth category art therapy as a form of exploration and/or reflection was mentioned in seven studies (1, 9, 15, 18, 30, 5, 8), for instance, “to explore existential concerns” (1), and the sixth category the specifics of the art materials/techniques offered in art therapy was mentioned in three studies (13, 17, 30), for instance, “because they could change the shape as they wished, which contributed to a positive evaluation of their own performance”(17). The seventh category art therapy as a form to practice and/or learn skills was mentioned in four studies (10, 19, 28, 33), for example, “in art therapy interventions, children can learn coping responses, new skills, or problem-solving techniques” (10). Finally, the eighth category art therapy, as an easily accessible, positive and safe intervention by the use of art materials was mentioned by 15 studies (1, 2, 6, 8, 10, 16, 19, 23, 24, 25, 28, 29, 30, 32, 37), for instance, “non-verbal expression that is possible in art therapy is a safe way”(10).

General Mechanisms of Change

Two subcategories of general mechanisms of change could be defined. The first subcategory was defined as art therapy as a form of group process , mentioned by eight studies (7, 9, 13, 18, 20, 29, 30, 36), for instance, “present thoughts and feelings in a non-verbal way within the structure of the group”(7). The second, the therapeutic alliance in art therapy , was mentioned by six studies (5, 8, 16, 18, 26, 29), for instance, “the primary role of the therapist as listening, accepting, and validating” (16).

Synthesized Findings

Means and forms of expression and therapist behavior.

Concerning the search for similarities and differences, the three found forms of therapist behavior were used to distribute the means and forms, which gave the following results.

The Therapist Behavior Was Non-directive

The therapist showed mainly a following and facilitating attitude toward the children/adolescents; in this category ( n = 13), the use of means and forms of expression was variable, but most often, children and adolescents worked on base of topics and assignments with both two- and three-dimensional materials and techniques, while during working, process and product were discussed. Specifically, four AT interventions used only two-dimensional materials/techniques (15, 18, 21, 23), six AT interventions offered both two- and three-dimensional materials/techniques (13a, 20, 22, 29a, 30, 36), and three AT interventions offered materials/techniques fitting the topic/assignment (15, 17, 25), which included a combination of two- and three-dimensional materials/techniques. Three AT interventions let the clients work freely without topics and assignments given (13a, 18, 30), eight AT interventions were based on topics/assignments (15, 20, 21, 22, 23, 25, 29a, 36), and two AT interventions combined both ways (17, 30). Concerning the use of language, in three AT interventions, there was a discussion on process/product afterward (17, 29a, 36), in five AT interventions, there was a verbal exchange while working (13a, 15, 18, 22, 25), and five studies (16, 20, 21, 23, 30) in this category did not make their use of language explicit as an additional form of expression. The most mentioned subcategories of supposed mechanisms of change for this category were “art therapy as a form of expression to reveal what is inside,” “art therapy as a form of exploration,” and “art therapy as a way of experiencing the self.”

The Therapist Behavior Was Directive

The therapist showed mainly an active and leading role toward the children/adolescents; the use of means and forms of expression was again variable in this category ( n = 10), but most often, children and adolescents worked on base of topics and assignments with both two- and three-dimensional materials/techniques, whereby the process and work were reflected upon afterward in different forms. Specifically, one intervention used only two-dimensional materials/techniques (10), five AT interventions offered both two- and three-dimensional materials/techniques (8, 11, 26, 28, 29b), and four AT interventions offered materials/techniques fitting the topic/assignment (4, 12, 13b, 24), which included two- and three-dimensional materials/techniques. Two AT interventions let the clients work without topics and assignments given (11, 28), and seven AT interventions were based on topics/assignments (4, 8, 10, 12, 13b, 24, 29b), one AT intervention combined both ways (28), and one study did not provide information on this topic (26). Concerning the use of language, in five AT interventions, there was a discussion on process/product afterward (4, 10, 11, 13b, 29b), in three AT interventions, there was a verbal exchange while working (12, 26, 28), and one study used language in a specific form (reviewing the collection with children and parents) (8). One AT intervention discussed the work afterward in a different form (a narrative retold) (4). One intervention did not make the use of language explicit as an additional form of expression (24). The most-reported subcategories of supposed mechanisms of change were the same as for the non-directive therapist behavior.

The Therapist Both Performed Directive and Non-directive Behavior (Eclectic) Toward Clients

Also, the use of means and forms of expression was variable in this category ( n = 9). All kinds of materials/techniques were used but most often were worked on base of topics/assignments. The use of language was not often mentioned, but if it was used, it was used as a discussion afterward. Specifically: two AT interventions used only two-dimensional materials/techniques (7, 14), four AT interventions offered both two- and three-dimensional materials/techniques (2, 5, 32, 33), and two AT interventions offered materials/techniques fitting the topic/assignment (9, 14), which included both two- and three-dimensional materials/techniques. One study did not provide information on this topic (34). In one AT intervention, the clients worked freely without topics and assignments given (14), and six AT interventions were based on topics/assignments (2, 5, 7, 9, 32, 33). Concerning the use of language, in three AT interventions, there was a discussion on process/product afterward (2, 9, 14), no AT interventions mentioned a verbal exchange while working, and four studies (32, 33, 34, 35) in this category did not make their use of language explicit as an additional form of expression. The most-reported subcategories of supposed mechanisms of change for this category were “art therapy as a form of expression to reveal what is inside”; “art therapy as a form of exploration,” and “art therapy as an easily/safe accessible intervention.”

In seven studies (1, 3, 6, 19, 27, 31, 37), the AT interventions were not enough explicated to make combinations.

Therapist Behaviors in Relation to Psychosocial Outcomes

The division into three categories of non-directive, directive, and eclectic therapist behavior gave the opportunity to show outcomes in accordance with these. To structure the outcome, these are reported by categorizing psychosocial problems into internalizing problems, externalizing problems, and social problems and in outcomes that can be considered underlying mechanisms of psychosocial problems. These underlying mechanism outcomes were divided into the domains self-concept/self-esteem and emotion regulation.

Non-directive Therapist Behavior

Eight studies (15, 16, 18, 20, 21, 23, 25, 36), which applied the non-directive therapist behavior, focused on Internalizing Problems as an outcome. These results showed significant improvement in post-traumatic stress symptoms (23); emotional functioning (36, 16), depression, rejection, and anxiety (16), reduction of symptoms of Separation Anxiety Disorder (18), and symptoms of anxiety and depression (20). The quality of two studies (16, 23) was strong, and the other three studies were assessed as being of weak quality. Also, four times no significant improvement was reported for negative mood states (15), negative mood and distress (25), feelings of anxiety (23), and anxiety, depression, internalizing problems, and emotional symptoms (21). The quality of these studies was strong (23) or weak (15, 21, 25).

Five studies (13a, 16, 21, 29, 36) showed results for Externalizing Problems . The results showed significant improvement in inattention/hyperactivity problems for the Honors track group (21) (weak), behavioral conduct (29) (moderate), attention span (16) (strong), and problem behavior (13a) (moderate). However, also, no significant improvement was reported on behavioral problems (36, 16) and inattention/hyperactivity for the Average track group (21).

Four studies (16, 21, 29a, 36) reported results for Social Problems . A significant effect was found on social functioning and resilience (36) (weak), social acceptance (29a) (moderate), personal adjustment (21), and degree of perceived support available from others and reliance upon others (16) (strong). No significant improvement was found for personal adjustment (21). The qualitative data revealed improvement in behavioral and peer interaction (36, 21).

Some studies evaluating interventions with non-directive therapist behavior showed results on outcomes that can be considered underlying mechanisms of psychosocial problems. For the domain Self-concept/Self-esteem , nine studies (13a, 16, 20, 21, 23, 25, 29a, 30, 36) showed results on this domain. They reported significant improvement in self-esteem (21, 30); feelings around body image (30) (weak); self-approval (29a); sense of identity, overall personality, positive feelings about themselves (16); and resilience (36). Also, no significant improvement was shown on this domain, e.g., self-esteem (10, 21, 25, 29a), self-concept (23) (strong), and Locus of Control (13a) (refers to how strongly people believe they have control over the situations and experiences), which was a study of moderate quality. Qualitative results showed improvement in this domain on resilience (13, 36). Two studies reported results on Emotion Regulation . In one study, a significant improvement was seen in emotion regulation and maladaptive strategies (22) (moderate), while in another study, no improvement was found. This study was assessed as being a weak study (17). Qualitative results showed that participants reported that “ventilation of uncomfortable feelings occurred, and an outlet for alleviating stress was provided” (21), and there were improvements in emotional expression and cognition (36).

Directive Therapist Behavior

Four studies that applied the directive therapist behavior (4, 8, 24, 28) showed results for Internalizing Problems . In these studies, there was a significant improvement in internalizing behaviors (28), PTSD, and sleep-related problems (8). The quality of these studies was moderate (28) and strong (8). No significant improvement was reported for mood, depression (24), PTSD, and acute stress (4). The quality of these two studies was strong and moderate.

Four studies (10, 13b, 26, 28) reported results for Externalizing Problems , and significant improvement was found on anger (10), problem behavior (13b), hyperactivity/inattention (26), hyperactivity scores, and problem behavior (28). Also, no significant improvement was reported, specifically on problem behaviors (26). The qualitative results of these AT interventions described improved classroom behavior (13). The quality of these studies was moderate (10, 13, 28) and weak (26).

Four studies (11, 26, 28, 29) reported results for Social Problems . These studies reported significant improvement for close friendship (29) and assertion (28). But in other studies, no significant improvement was reported for social skills (26), socially lonely (11), and responsibility (28). The quality of the studies was assessed as being moderate (11, 29) and weak (26, 28). Qualitative results revealed that “the clients appeared to initiate social exchanges more independently and were improved on sharing feelings, thoughts, and ideas” (26).

Some studies applying directive therapist behavior showed results on (supposed) underlying mechanisms. Five studies (10, 11, 13, 24, 29) showed results on Self-esteem/Self-concept . Significant improvement was found on self-esteem (10) and self-approval (29). Also, no significant improvement was found on self-esteem (29, 24, 11), a sense of empowerment (11), responsibility for success/failure at school (11), Locus of Control (13), and educational self-esteem (10). The quality of the studies was strong (24) and moderate (10, 11, 13, 29). Also, positive qualitative results were reported in this domain, i.e., “a shift in self-image, were more confident and assured of their skills, and were more capable of expressing their ideas, thoughts, and feelings and in sharing these. They also showed an increased capacity to reflect on their behaviors and display self-awareness” (26) and improved Locus of Control (13). One study reported no significant improvement in Emotion Regulation (12). This study was of moderate quality.

Eclectic Therapist Behavior

Seven studies (2, 5, 9, 14, 32, 33, 34) in which interventions with eclectic therapist behavior was applied showed results on Internalizing Problems . Significant improvement was reported on internalizing problems (5), anxiety (2, 32, 33), and parent & child worry (2), depression, dissociation, sexual concerns, sexual preoccupation, and sexual distress (33), dissociative symptomatology (32), and post-traumatic stress (9, 32, 33). However, no significant results were reported on anxiety (34), depression (2, 32), dissociation (fantasy) (33), sexual concerns (32), and PTSD symptoms (14). The quality was assessed as being weak (2, 9) and moderate (14, 32, 33, 34).

Five studies (2, 5, 32, 33, 35) reported on Externalizing Problems , and they reported significant improvement on externalizing problems (5), problematic behaviors (35), and anger (33). No significant improvement was reported for disruptive behavior (2), hyper-response (33), and anger (2, 32). The study quality was weak (2, 35) and moderate (5, 32, 33).

Two studies (2, 7) reported on Social Problems , and significant improvement was found for parent and child communication (2) (weak). No significant improvement was reported on sociability, responsibility, and assertiveness (7).

Within the category eclectic therapist behavior, one study showed results on underlying mechanisms, specifically no significant improvement on Self-concept (34). This study was being assessed with moderate quality.

Overall Results

As is shown in Table 3 , more than 50% of the studies on the effects of AT interventions using non-directive therapist behavior showed significant effects on the outcome domains, with high impact on externalizing (80%), social problems (75%), and internalizing problems (62,5%). Self-esteem/self-concept and emotion regulation showed lower figures, with 55.6 and 50%, respectively. AT interventions in which directive therapist behavior was used showed a different picture. The number for treating externalizing problems stood out, with 100% of the studied AT interventions being significantly effective in this domain. However, percentages of significant interventions for internalizing problems, social problems, self-esteem/self-concept were equal to or <50%. AT interventions using eclectic therapist behavior showed best results on internalizing and externalizing problems with, respectively 71.4 and 60% of the AT interventions that were evaluated on these outcome domains.

Number and percentage of interventions per type of therapist behavior showing significant effects on outcomes.

The purpose of this systematic narrative review was to provide an overview of AT interventions that were effective in reducing psychosocial problems in children and adolescents. The emphasis was on the applied means and forms of expression during AT, the therapeutic behavior applied, and the supposed mechanisms of change to substantiate the use of the intervention. The main results showed that a broad spectrum of art materials and techniques are used in AT treatments for psychosocial problems in children and adolescents. No specific art materials or techniques stood out. Also, forms of structure such as working on the basis of topics or assignments and the way language is applied during or after the sessions vary widely and do not seem to relate to a specific category of therapist behavior. From this point of view, it seems less important which (combination of) materials/techniques and forms of structure art therapists use in treatments of psychosocial problems. The wide variety of materials, techniques, and assignments that are used in AT shows that AT is very responsive to individual cases in their treatments. This is in line with the concept that art therapists can attune to the client's possibilities and needs with art materials/techniques (Franklin, 2010 ).

Therapist behavior appeared to be the only distinctive component in the interventions. Three broad forms were found: non-directive, directive, and eclectic. In practice, art therapists often define their practice with orientations such as psychodynamic, gestalt, person-centered, etc. or choose an approach according to their individual preferences (Van Lith, 2016 ). For instance, a stance in which the therapist sees its role as being a witness to the experience of the inherent process of knowing the self (Allen, 2008 ) is often related to a non-directive therapist behavior or a stance in which they elicit meaning-making by engendering a new perspective (Karkou and Sanderson, 2006 ) is often related to a form of directive therapist behavior. Also, many art therapists work from the point of view that the art therapist should adapt to the client needs, which can be considered an eclectic approach (Van Lith, 2016 ) and which incorporates both forms of therapist behavior. Next to individual preferences, many psychotherapeutic approaches are being used in art therapeutic treatments of children and adolescents (Graves-Alcorn and Green, 2014 ; Frey, 2015 ; Gardner, 2015 ; Van Lith, 2016 ). However, in the end, they all range on a continuum from non-directive to directive therapist behavior (Yasenik and Gardner, 2012 ).

The results of this review show that AT for children and adolescents with psychosocial problems can lead to improvement in all domains for all three forms of therapist behavior in combination with a variety of means and forms. And, although the focus of this review was less on therapy outcomes, the results confirm the conclusion of Cohen-Yatziv and Regev ( 2019 ) that AT for children and adolescents with psychosocial problems can be effective. Non-directive therapist behavior, whereby the therapist is following and facilitating, shows the most significant effects in this study for psychosocial problems, next to eclectic therapist behavior for internalizing and externalizing problems. Also, it was striking that directive therapist behavior was effective for externalizing problems in all studies evaluating interventions with this type of therapist behavior, while this was not the case for the other outcome domains. Children and adolescents with externalizing problems may thus profit from directive, non-directive, and eclectic art therapist behavior. In addition, the findings suggest that we need to carefully consider using directive behavior in children with internalizing or social problems.

To substantiate the use of the AT interventions and the results, a variety of supposed mechanisms of change were described. Both specific and more general mechanisms of change were reported to substantiate AT interventions. The majority concerned specific AT mechanisms of change. Often, AT is considered a form of expression to reveal what is inside or its effects are explained by an exploration of feelings, emotions, and thoughts. These mechanisms of change were seen in AT interventions with non-directive, directive, and eclectic therapist behavior. The simultaneous occurrence of supposed mechanisms of change in all these categories of therapist behavior that differ substantially from one another can be explained by the central use of art materials, which distinguishes AT from the other ATs and from other psychotherapeutic approaches (Malchiodi, 2012 ). It can be considered as an additional and specific value of AT and, therefore, frequently used as substantiation for the used AT interventions and their effects.

Corresponding between the studies that showed positive results was the adaptation of the materials/techniques, forms of structure, and therapist behavior to the problems and needs of the children and adolescents involved. This process is called responsiveness. Responsiveness consists of interacting in a way such that the other is understood, valued, and supported in fulfilling important personal needs and goals. It can be seen as a moment-by-moment process of the therapeutic alliance between therapist and client (Sousa et al., 2011 ). Responsiveness supports and strengthens both the relationship and its members (Reis and Clark, 2013 ). In AT, therapist behavior and the use of materials and techniques can both be adapted to these needs and may be considered an important element in explaining the positive effects of AT. Processes such as responsiveness and therapeutic alliance relate partially to attachment theories. In AT, a therapeutic alliance includes, next to the client and art therapist, a third “object,” the art medium, comprised of art materials, art-making, and artworks (Bat Or, and Zilcha-Mano, 2018 ). From the perspective of attachment theory, the encounter between client and art material in AT may reflect attachment-related dynamics (Snir et al., 2017 ). Therefore, art therapists recapitulate positive relational aspects through purposeful creative experiences that offer sensory opportunities to reinforce a secure attachment (Malchiodi and Crenshaw, 2015 ). In this way, materials and techniques can offer the child and adolescent a “safe bridge” to bond with the therapist and explore and grow in developmental areas that are treated.

Given the results, relational, experiential (combined with art) knowledge to connect to the children's and adolescent's problems and needs seems indispensable for art therapists. This study included AT interventions performed by certified art therapists. Art therapists get a thorough education in relational and experiential (art) skills and obtain tacit knowledge through practice. By having more insight into the importance of the role of therapist behavior and the use of materials/techniques in AT interventions for children and adolescents, art therapists can improve results. Choices for therapist behavior and the use of materials/techniques should not depend that much on context or individual preference but on the client's problems and needs and which therapist behavior fits the client best. The results of this study provide clues on which and how to use AT elements in clinical practice, but above all, it gives a sound base for initiating more empirical research on AT. For practice and research purposes, a thorough elaboration and description of the therapist behavior in manuals are then of importance.

Strengths and Limitations of This Review

In this study, a narrative synthesis was performed because of the focus on substantive aspects and the heterogeneity of the studies. A common criticism of narrative synthesis is that it is difficult to maintain transparency in the interpretation of the data and the development of conclusions. It threatens the value of the synthesis and the extent to which the conclusions are reliable. For instance, in this study, we searched for similarities and differences in two core elements of AT (Schweizer et al., 2014 ). Sometimes, forced choices had to be made in the division of the defined components into group categories and, eventually, to divide them into categories of therapist behavior. Separating and distinguishing components of an intervention are not straightforward.

From the literature, it is known that studies with positive results are overrepresented in the literature (Mlinarić et al., 2017 ). Probably also in this study, therefore, publication bias must be taken into account when interpreting the results.

Also, regarding showing significant results, some studies showed significant and no significant results in the same domain. This can cause bias, for example, considering a study to be significantly effective in internalizing problems, but in reality, the study shows significant results in anxiety, but for instance, not in depression. It should be taken into account that, in this study, only a broad overarching view is given.

In this study, we included RCTs, CCTs, and group pre–posttest designs because these three designs (in this order) can be considered to provide the most reliable evidence (Bondemark and Ruf, 2015 ). Questionable is whether these types of designs are the most appropriate designs for (a part of) the research question posed in this study. For detailed, more qualitative information on interventions, case studies seem very suitable. Potential advantages of a single case study are seen in the detailed description and analysis to gain a better understanding of “how” and “why” things happen (Ridder, 2017 ).

Recommendations

Remarkably, seven studies did not describe their AT interventions sufficiently explicitly concerning the use of means and forms of expression and therapist behavior. This, while art materials/techniques and therapist behavior constitute the basis for AT interventions (Moon, 2012 ). Insight into the core elements of interventions helps us better understand why and how certain interventions work. By understanding these components of an intervention, we can compare interventions and improve the effectiveness of interventions (Blase and Fixsen, 2013 ). Therefore, for future AT studies, it is recommended to present more information on used therapeutic perspectives, means, art materials and techniques, and therapist behavior.

The results of this study show that AT interventions for children and adolescents are characterized by a variety of materials/techniques, forms of structure such as giving topics or assignments, the use of language, and therapist behavior. These results point out to more specific aspects of the dual relationship of material–therapist, which contributes to the effects, such as, for instance, responsiveness. More (qualitative) research into these specific aspects of the therapeutic relationship and the role of the relational aspects of the material could provide more insight and be of great value regarding AT for children and adolescents.

The results of the AT interventions show that AT leads to positive results for psychosocial problems, although, in some studies, both significant and not significant results were seen within a domain. A more personalized research approach, which is linked to individual treatment goals, can possibly give more clarity on the effects. Goal Attainment Scales (GAS) can be considered useful for this purpose.

Conclusions

This study shows that the use of means and forms of expression and therapist behavior is applied flexibly. This suggests a responsiveness of AT, in which means and forms of expression and therapist behavior are applied to respond to the client's needs and circumstances, thereby giving positive (significant) results for psychosocial problems. Searching for specific elements in the use of materials and the three defined forms of therapist behavior that influence the result is therefore recommended.

Data Availability Statement

Author contributions.

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

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.

Acknowledgments

We would like to thank Mrs. T. van Ittersum of the Research Institute SHARE/Research office UMCG in Groningen for her help with search strategy and data collection.

Funding. This research was funded by NHL/Stenden, University of Applied Science in Leeuwarden and Care-group Alliade in Heerenveen, Netherlands.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2020.584685/full#supplementary-material

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