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Art Therapy; Efficacy for Patients with Major Depressive Disorder_butler_first draft

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Art Therapy; Efficacy for Patients with Major Depressive Disorder_butler

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Art Therapy; Efficacy for Patients with Major Depressive Disorder_butler

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Art Therapy; Efficacy for Patients with Major Depressive Disorder_butler

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Art Therapy; Efficacy for Patients with Major Depressive Disorder_butler

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I have five days to finish the essay => need to write more than 674 words per day

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Today we had a meeting so my supervisor could give me feedback for my essay's first five hundred words. The feedback was mainly positive except, I forgot to in-text cite of my sources which I have already fixed.

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Sedikides and Gress (2003)

stated that self-esteem refers to individual’s perception or subjective appraisal

of one’s own self-worth, one’s feelings of self-respect and self-confidence and

the extent to which the individual holds positive or negative views about self.

from:

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Does art therapy have a notable impact on reducing depressed mood and low self-esteem in patients diagnosed with major depressive disorder? 

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Does art therapy have a notable impact on reducing depressed mood and low self-esteem in patients diagnosed with major depressive disorder? 

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Core symptoms of major depressive disorder: relevance to diagnosis and treatment

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Core symptoms of major depressive disorder: relevance to diagnosis and treatment

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Kennedy, Sidney H. “Core Symptoms of Major Depressive Disorder: Relevance to Diagnosis and Treatment.” Dialogues in Clinical Neuroscience, vol. 10, no. 3, Sept. 2008, pp. 271–77, https://doi.org/10.31887/dcns.2008.10.3/shkennedy. Accessed 2 Mar. 2024.

NOTES

depressed mood

loss of interest in pleasurable activities

common symptoms - fatigue, sleep disturbance, anxiety, guilt,

potential symptoms not addressed by pharmacotherapy / made worse

very low requirement for diagnosis

different types of depressive episodes:

w melancholic features

atypical features

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started a myBib project (space for bibliography) do not know how to share it here, might transfer all the citations into a google doc

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started a google calendar to keep track of deadlines

https://calendar.google.com/calendar/u/0?cid=MzIwYmMwODQ5MDBiYjZmZDU2Y2M2ZThhOGRhOGI0MzRhMzc1ZmFiMzQ2YWYyMzVjMzE0YTFjNTBmNGI2NjhlY0Bncm91cC5jYWxlbmRhci5nb29nbGUuY29t

(haven't figured out how to share it properly yet, bear with me)

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Art therapy as an adjuvant treatment for depression in elderly women: a randomized controlled trial

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Art therapy as an adjuvant treatment for depression in elderly women: a randomized controlled trial

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Ciasca, Eliana C., et al. “Art Therapy as an Adjuvant Treatment for Depression in Elderly Women: A Randomized Controlled Trial.” Revista Brasileira de Psiquiatria, vol. 40, no. 3, Feb. 2018, pp. 256–63, https://doi.org/10.1590/1516-4446-2017-2250. Accessed 26 Mar. 2024.

NOTES

type - randomized, controlled, single-blind study

objective- evaluate is beneficial as an ad on to treatment for depression in old people

participants

elderly women w MDD on pharmacotherapy

56 participants

had to have had a lifetime MDD diagnosis

60<

method

experimental group (EG) had 20 weekly (90 mins) art therapy sessions

control group (CG) no changes

evaluated against geriatric depression scale (GDS), beck depression inventory (BDI), beck anxiety inventory (BAI), "cognitive measures" (what is that?)

results - EG = significant improvement in scores as opposed to CG, no diff in cognitive measures

conclusion - art therapy can improve symptoms of anxiety + depression

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reflection from first reflection session 20.3.2024

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reflection from first reflection session 20.3.2024

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In the past, I have taken part in art therapy. I found that it was a life-changing experience. So much so that I would like to explore it as a future career option. I have many friends who have gone through art therapy themselves and their feedback was mixed. A lot of the people I know take medicine to help with the symptoms of depression, however, drugs such as SSRIs and antipsychotics can have debilitating side effects. I would like to investigate how effective art therapy is in treating Major Depressive Disorder (MDD). After talking with my supervisor I realised that this is a too broad topic as MDD encompasses many different symptoms. Hence, I have chosen to analyse only the main symptoms which are depressive mood and low self-esteem. I have found that much research into the topic can be found analysed in literature reviews. The only problem with such sources is, that the research analysed does not have to be new and can be outdated. This is a problem with the validity of the research.

177 words

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preparation for first reflection session

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Art Therapy: A Complementary Treatment for Mental Disorders => WANT TO USE

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Art Therapy: A Complementary Treatment for Mental Disorders => WANT TO USE

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Notes

not enough systematic reviews

mainly drawing + painting

also useful for diagnostic purposes

historically most useful = painting + drawing (British Association of Art Therapists)

functions of art therapy (American Art Therapy Association) - fostering self-esteem, self-awareness

literature from 2006 -> Is it still relevant?

drawing / painting => blind drawing, spiral drawings, drawing moods, self-portraits

depression + anxiety

art therapy "significantly decreases" depression symptoms

Art painting therapy allows patients to express themselves in an acceptable manner

conflict of interest

authors declare research conducted in the absence of commercial/financial relationship

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Abstract

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.

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

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 ).

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

Type of diseases/author and year

Country

Number (painting)

Treatment

Subjects

Main results

Depression and anxiety

Cognitive impairment, and dementia

Alzheimer's disease

Autism

Schizophrenia

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

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.

Conflict of Interest

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

Publisher's Note

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

Footnotes

Funding. 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).

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Articles from Frontiers in Psychology are provided here courtesy of Frontiers Media SA

# data[].attributes.attachment_link.title
Art Therapy: A Complementary Treatment for Mental Disorders

# data[].attributes.attachment_link.description
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. ...

# data[].attributes.body
“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

“Art Therapy - the British Association of Art Therapists.” The British Association of Art Therapists, BAAT, 2015, baat.org/art-therapy/. Accessed 20 Mar. 2024.

“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

“About Art Therapy.” American Art Therapy Association, June 2017, arttherapy.org/about-art-therapy/. Accessed 20 Mar. 2024.

# data[].attributes.headline
Does art therapy have an impact on self-esteem in people with depressive symptoms?

# data[].attributes.subject
Does art therapy have an impact on self-esteem in people with depressive symptoms?

# data[].attributes.body
The previous research question was changed as it had two variables and too many limiting parameters => less data

EDIT:

after talking to my supervisor I am going back to my original quesstion

# data[].attributes.body
I need to further narrow down my research question, each variable needs to be specified.

MDD - symptoms

Art therapy - type

research group

I also have to decide if I want to actually perform research or want to analyze pre-existing research

if I perform research -> who will my sample be?

finding additional research in journals about psychology -> contain relevant, new studies

need to be careful about the credibility

Researched group:

if I perform the research a group of people who are not diagnosed but have depressive tendencies might be easier

until 31.1 reconsider RQ

artemiou@gympaba.sk

artemioumichaela@outlook.com

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depressed mood (subjective/ observed by others) in adolescents+children can manifest in irritableness

loss of interest & pleasure in things previously enjoyed

weight loss/gain

insomnia or hypersomnia

worthlessness & unprecedented feelings of guilt

decreased concentration

thoughts of death/suicide

https://www.mdcalc.com/calc/10195/dsm-5-criteria-major-depressive-disorder

hopelessness

low self-esteem

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DSM-5 Criteria for Major Depressive Disorder

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The DSM-5 Criteria for Major Depressive Disorder is a set of diagnostic criteria for major depressive disorder (MDD).

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I talked about my research question

currently, it has too many variables which are too broad - type of art therapy, disorder (major depressive disorder), the group studied

the suggested solution is that I should narrow down MDD to certain symptoms and only focus on those

my supervisor told me to also look for studies that are just related to my topic and the variables not just studies that directly relate to my RQ

we set a date for the next meeting this is also when I should have narrowed down my research question => 25 Jan

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The entangled butterfly and the blue cactus: two case studies on time-limited psychodynamic art psychotherapy (English) Manuscript (Other academic)

Abstract [en]

The aim of these two case studies is an in-depth analysis of the practice of scribbling in time- limited psychodynamic art psychotherapy. Our hypothesis is that the answers to "What do you see?" change as therapy proceeds, due to changes in emotions and cognitions expressed in scribbles and amplifications. The treatment is one hour per week for ten weeks, exempli- fied by two women with depression selected for differences in age, demographics and art expression. Analysis of the pictures and words is in two steps. The pictures were first tran- scribed into words using a phenomenological approach and then analysed according to con- tent analysis. Correspondingly, the words of the sessions were first transcribed verbatim and then analysed according to content analysis. The results show that the even if the two women have the same diagnosis at inclusion according to DSM IV, the symptoms of depression are expressed differently both in how they are manifested and in latent messages in the content analysis. The two women's therapies can be divided into three phases each marked by turning points in the pictures - hence the pictures rather than the words set the theme for the phase. On leaving therapy the patients are able to use their drawings, their amplifications are in a complete form, they symbolise in words what they have expressed in pictures.

The study's conclusion is that the practice of scribbling seems to give a better capacity to regulate affects and, hence, a better regulation of the self. The women used not only their intellects but also their bodies in making latent communications manifest; their self-esteem improved as therapy proceeded, and they regained a sensitivity of "me - not me", i.e. better boundaries. The clinical implications are that the time-limited model of art psychotherapy is well suited to process emotions connected with depression, and that the patient's problem should determine the length of the time limit.

Keywords [en]

Time-limited psychodynamic art psychotherapy, Scribble, Case study, Depression. National Category Psychology Research subject Psychology

Identifiers

URN: DiVA, id: urn:nbn:se:umu:diva-3286 OAI: oai:DiVA.org:umu-3286 diva2:141823

2008-05-292008-05-292018-06-09 Bibliographically approved

In thesis

1. What do you see?: studies on time-limited psychodynamic art psychotherapy

Open this publication in new window or tab >> 2008 (English) Doctoral thesis, comprehensive summary (Other academic)

Abstract [en]
Place, publisher, year, edition, pages Umeå: Psykiatri, 2008
The main purpose of this thesis is to explore experiences of two different psychological interventions based on art psychotherapy in women with a psychological or physical illness. The two interventions are art psychotherapy and art therapy. The difference between these two interventions is that the art therapist works with the transference in art psychotherapy but not in art therapy. The thesis consists of two studies of art psychotherapy: An art psychotherapy intervention is evaluated in Study 1 (papers III and V) which examines a group of patients diagnosed with depression and Study 2 (paper II) which examines experiences in a group of six patients diagnosed with vulva vestibulitis. An art therapy intervention is evaluated in the third study (papers I and IV); where experiences in patients diagnosed with breast cancer are examined.

In Study 1, forty-three (n=43) depressed women were randomly assigned to either an intervention group or a control group (verbal psychotherapy). The aim was to examine the outcome of time limited psychodynamic art therapy compared to time-limited psychodynamic verbal therapy for patients with depressive symptoms. Interviews were performed before, immediately after, and three months after the termination of psychotherapy, and self-rating scales which focus on stress reactions, depression and symptoms as well as an observer rating scale on depression were used. The interviews and the art sessions were video-recorded, and the verbal psychotherapy was tape-recorded. The results showed that the art and verbal psychotherapies were comparable. The conclusion was that short-term psychodynamic art psychotherapy could be a valuable treatment for depressed women. In an in-depth content analysis, the method of scribbling was further investigated and exemplified with the therapies of two participants. In this study, the patients' pictures and verbal expressions of progress, along with considerations of how to interpret the pictures were in focus. When leaving therapy the two patients took advantage of the paper, made complete forms, symbolised in words what they have expressed in pictures; in pace with psychotherapy the themes alter towards separation, individuation, and attempt to relate in a new way. The conclusion was that limelimited psychodynamic art therapy suggests giving a safer place for the self as the cohesion is firmer with better boundaries.

Study 2 is a pilot study, which involved six young patients newly diagnosed with vulva vestibulitis. The aim of the study was to investigate pain at vestibulum, mental health, and self-image after fifteen sessions of art psychotherapy. Five of the patients were judged to have less pain three months after termination of therapy. The conclusion was that art psychotherapy with its openness seemed to affect young women in their experiences of vulva vestibulitis in a positive direction.

Study 3 examined the potential benefit of art therapy for women with primary breast cancer. The sample comprised forty-one (n=41) patients who were randomly assigned either to an art therapy group or to a control group. The art therapy was going on during five weeks radiation treatment, one session per week. The aim was to investigate the outcome of art therapy, to quantify and compare the participant coping s, self-image, and the symptoms with the participant in the control group. Interviews were performed before, immediately after, and six month after inclusion. A set of self-rating scales was used: Coping Resources Inventory, the Structural Analysis of Social Behavior, and Symptom Check List - 90. The result showed that the patients in the art therapy group rated their coping s and especially their social s, higher than the control group, and that the average patients in the art therapy group improved in depressive symptoms and symptoms of anxiety, and that the general psychiatric symptoms improved as well. A linear regression analysis showed a tendency that the coping s increased in the art therapy group and decreased in the control group or even stagnated in the social domain. A second report on self-image, symptoms, treatment, and social variables showed that art therapy was related to lower ratings of depression, anxiety, and general symptoms after treatment; chemotherapeutic treatment predicted lower depressive symptoms and general symptoms in contrast to axilliary surgery and hormonal treatment. The results showed that art therapy could be valuable complementary therapy in routine oncology practise. The conclusion is that art therapy can have a positive long-term effect on the crisis following the primary breast cancer and its consequences.

Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1188
Conclusion: The results show that time-limited psychodynamic art psychotherapy is valuable for depressed women; that it is a valuable complement for women with vulva vestibulitis; and that art therapy is a valuable complement in the care and cure of women with primary breast cancer.

Keywords
Art psychotherapy, scribble, depression, anxiety, GSI, breast cancer, vulva vestibulitis, SASB, SCL-90, CRI, content analysis, phenomenology Research subject Psychiatry
Identifiers
urn:nbn:se:umu:diva-1684 (URN) 978-91-7264-570-7 (ISBN)
Public defence
2008-05-22, sal B, Tandläkarhuset, NUS, UMEÅ, 13:00 (English)
Opponent
2008-05-292008-05-292011-04-08 Bibliographically approved

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The entangled butterfly and the blue cactus: two case studies on time-limited psychodynamic art psychotherapy

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DiVA portal is a finding tool for research publications and student theses written at the following 50 universities and research institutions.

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Painting from Within - Developing and Evaluating a Manual-based Art therapy for Patients with Depression

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Painting from Within - Developing and Evaluating a Manual-based Art therapy for Patients with Depression

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Aim: The overall aim was to develop and evaluate a manual-based art-therapy programme for patients with depression, and hence, to clarify treatment effects and to describe participants' experiences of the treatment. The specific aims were: (I) To explore and describe how art therapy works in relation to therapeutic factors, clinical application, and circumstances in the experimental situation, for patients with depression; (II) To explore what experts in the field of art therapy consider to be the main aspects of treatment for patients with depression in clinical practice; (III) To investigate the effects of manual-based Phenomenological Art Therapy in addition to treatment as usual (PATd/TAU) compared with only treatment as usual (TAU) for patients diagnosed with moderate to severe depression; and (IV) To describe and explore the significance of manual-based Phenomenological Art Therapy as experienced by patients diagnosed with moderate to severe depression. Methods: (I) Systematic literature review according to Realist review; (II) Expert survey according to the Delphi technique (Studies I and II were used as a foundation for developing the manual-based Phenomenological Art Therapy for patients with depression (PATd)); to evaluate the effect and experience of PATd, (III) a randomized controlled trial (RCT) with intention-to-treat design was performed; and, thereafter, an interview study with (IV) a Phenomenological approach, according to Reflective Lifeworld Research. Results: (I) eight therapeutic factors were identified: self-exploration, self-expression, communication, understanding and explanation, integration, symbolic thinking, creativity, and sensory stimulation; (II) resulting in four main aspects of art therapy for patients with depression; expression through art-making and verbal communication concerning, depressive thoughts, feelings, life experiences, and physical symptoms. (III) PATd in addition to Treatment As Usual (TAU) showed a significant reduction of depression and an improved return to work compared to participants receiving only TAU. Self-esteem significantly improved, and suicide ideation did not change for either groups. (IV) PATd facilitates meeting oneself in an inner dialogue between the evident and the unaware. The art-making and describing that experience makes oneself and the situation visible, opening up and altering understanding through the inner dialogue. Conclusions: manual-based PATd seems to work as intended, being an effective treatment, and contributes to recovery for patients with moderate to severe depression.

I. Blomdahl C, Gunnarsson AB, Guregård S, Björklund A. A realist review of art therapy for clients with depression. The Arts in Psychotherapy 2013; 40(3):322-30. ::doi::10.1016/j.aip.2013.05.009

II. Blomdahl C, Gunnarsson BA, Guregård S, Rusner M, Wijk H, Björklund A. Art therapy for patients with depression: expert opinions on its main aspects for clinical practice. Journal of Mental Health 2016; 25(6); 527-35. ::doi::10.1080/09638237.2016.1207226

III. Blomdahl C, Guregård S, Rusner M, Wijk H. A Manual-based Phenomenological Art Therapy for patients diagnosed with moderate to severe depression (PATd) - a randomized controlled study (submitted).

IV. Blomdahl C, Wijk H, Guregård S, Rusner M. Meeting oneself in inner dialogue: a manual-based phenomenological art therapy as experienced by patients with moderate to severe depression. The Arts in Psychotherapy (In press).

Doctor of Philosophy (Health Care Sciences)

University of Gothenburg. Sahlgrenska Academy

Institute of Health and Care Sciences

Fredagen den 6 oktober 2017, kl. 9.00, Hörsal Arvid Carlsson, Academicum, Medicinaregatan 3, Göteborg

christina.blomdahl@vgregion.se

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Painting from Within - Developing and Evaluating a Manual-based Art therapy for Patients with Depression

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Aim: The overall aim was to develop and evaluate a manual-based art-therapy programme for patients with depression, and hence, to clarify treatment effects and to describe participants' experiences of the treatment.

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Art psychotherapy practice with adults who suffer from depression in the UK: Qualitative findings from a depression-specific questionnaire

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Art psychotherapy practice with adults who suffer from depression in the UK: Qualitative findings from a depression-specific questionnaire

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Abstract

The 'global burden' of depression demands more effective treatments. Evidence suggests that arts therapies are offered to individuals who suffer from depression. However, despite recent increases in research, the methods and tools used by arts therapists remain unclear. A nationwide survey of arts therapists was conducted in 2011; practitioners who work primarily with depression were identified and invited to complete an additional questionnaire that focused on specific aspects of their practices. Therapists responded by offering detailed descriptions of their work with the condition. Data analysis led to findings that greatly enrich the knowledge obtained from the main survey regarding the meaning of depression and techniques/tools used by the therapists. New insights into the work of arts therapists with individuals who suffer from depression encompass the therapeutic aims, as well as the challenges and rewards of the practice. The themes of motivation and time, as well as the paradox of isolation versus the need to relate, were identified by the respondents as crucial in the therapeutic process. The findings facilitate an understanding of the meaning and possibilities of arts therapies in the treatment of depression. This area would benefit from further in-depth research, particularly regarding the techniques used by therapists and the origins of therapeutic change. It is expected that this and future research will be of a special interest to arts therapists and other professionals who wish to gain insight into what arts therapies practice with depression entails.

Introduction

At a time when depression is steadily becoming the second most disabling illness in the world (WHO, 2010), the exploration of available treatment options appears vital. In the UK, the routinely offered treatments include antidepressant medication, psychosocial and psychological interventions; a combination of these approaches is also common (Sudak, 2011). However, the currently recommended therapies (NICE clinical guideline 90, 2009, SIGN guideline 114, 2010) do not offer effective solutions for all depression sufferers; thus, readmissions to mental health hospitals are common and the costs of the mental illness are rising (McCrone, Dhanasiri, Patel, Knapp, & Lawton-Smith, 2007).

Depression is a broad and heterogeneous disorder (NICE guideline 90, 2009) with "different etiological and clinical features" (Hammen & Watkins, 2007, p. 36) and a "multifactorial illness with biological, social and psychological factors" (SIGN guideline 114, 2010); thus, a variety of depression types are recognized. Moreover, multiple theories of depression have been developed over the years, each of which highlights one or several of depression's aspects but typically fails to provide a holistic perspective. For example, cognitive issues in depression have been addressed by the cognitive-behavioral model, its genesis has been explained by the psychodynamic theorists (Abraham, 2011), and its physical presentation is often addressed through prescribed exercise.

Referring to the biopsychosocial model of depression (O'Donohue & Graybar, 2009), the need for a holistic approach toward this condition is often stressed in current discourse (Llewllyn-Jones & Donnelly, 2000), and a comprehensive treatment plan within interdisciplinary clinical teams is typically considered the best way to achieve improvement in many aspects of life that are affected by depression.

Arts therapies (art therapy, music therapy, dance movement therapy and dramatherapy), which recognize the value of creativity and non-verbal communication, may offer a suitable treatment option for some patients/clients. Although there is evidence that arts therapies are offered to clients who experience depression, the scope and nature of these interventions remain unclear, which often impacts the credibility of evaluative studies.

Karkou and Sanderson (2006) offered a comprehensive general description of art therapy practices in the UK, but did not focus on the specifics of working with depression. Although the literature includes accounts of arts therapists who have addressed depression (Cattanach, 1999, Dokter, 1996, Payne, 1996, Reynolds et al., 2008), the available case studies often offer descriptions of individual practices, which do not form consistent patterns of the overall practice of arts therapies.

Questions regarding the essence of the therapeutic process and the specific aspects of practice that lead to a desired change have been posed since the very beginning of arts therapies and clearly hold clinical value for practitioners (Maratos, Crawford, & Procter, 2011). Many authors discuss therapeutic factors in arts therapies (e.g., Gersie, 1996 on dramatherapy, Schmais, 1985 on dance movement therapy). While the works often focus on the foundations of the psychotherapeutic interventions with the added value of art media and the role of artwork as significant objects in therapy, they rarely describe the tools or methods suited to particular client groups with varied needs, including depression.

A particularly relevant and valuable work in the area has recently been presented by Blomdahl, Gunnarsson, Guregård, & Björklund (2013), who offer a unique description of art therapy practice in individuals with depression in a review of 16 relevant articles. While this work identifies the therapeutic factors that contribute to positive change in art therapy, no similar reviews have been conducted in other arts therapies; thus, further description of the practice remains unavailable. Furthermore, recent publications of the results from a nationwide survey (Zubala et al., 2013, Zubala et al., 2014) have contributed to the general picture of arts therapies practice with depression. However, more in-depth insights into the essence of the therapeutic process are still required for a complete understanding of how arts therapies are applied in the treatment of depression and what exactly their practice involves.

The current paper presents additional qualitative findings obtained from a descriptive phase of a larger research project, which aimed to describe and evaluate arts therapies as interventions to address adult depression through the use of mixed methodologies. A description of how arts therapists work with individuals who suffer from depression was the focus of the first phase of this project; quantitative and qualitative data were collected through the Arts Therapies Survey, and the findings have been presented elsewhere (Zubala et al., 2013, Zubala et al., 2014). A depression-specific questionnaire followed the main Survey with aim to further increase the current understanding of the nature of arts therapists' work with depression. The current report is based on the detailed responses provided by arts therapists who specialize in the treatment of depression and it offers answers to the following research questions:

*
What is the meaning of depression for arts therapists who chose to target this condition in their practice?

*
What tools and interventions are commonly used by arts therapists in their work with depression?

*
What are the challenges and rewards of art therapy practice for individuals who suffer from depression?

This research received ethical approval from Queen Margaret University, Edinburgh, in May 2011.

Section snippets

Methodology

To further our understanding of the arts therapies' practice with individuals suffering from depression, following the main survey (Arts Therapies Survey 2011), an additional questionnaire with a series of open-ended questions was e-mailed to the participants who worked specifically with depression and agreed to be contacted. The short questionnaire was designed by the principal author of this report to enable the collection of more detailed accounts from the therapists who presumably had the

Findings

The report presents the findings within the five categories that classify the content of the arts therapists' responses. When direct quotations are used, they are labeled with the respondent's number only (e.g., T.3).

The first two categories are presented briefly because they enhance previous findings from the Arts Therapies Survey 2011, but do not offer new insights regarding the subject examined. The other three categories present findings unique to the depression-specific questionnaire and

Limitations

Although the study as a whole collected a large amount of data through the main Arts Therapies Survey and included accounts of particularly high quality through the depression-specific questionnaire, the latter received only seven responses, which were mostly obtained from art psychotherapists. Therefore, the themes of the aims and tools used in therapy, as well as the challenges and rewards of practice may not necessarily be relevant to other arts therapies disciplines and should be

Discussion

The current findings have enriched previous results obtained from the Arts Therapies Survey (Zubala et al., 2013, Zubala et al., 2014) by adding new depth to the points previously raised and introducing new concepts to the discussion regarding how arts therapists work with depression. The core findings will now be discussed in light of previous reports from the main survey and the knowledge available from the literature.

Firstly, the current findings support the previous finding that clients who

Conclusions

The findings from the current study, as expected, have provided additional depth to the previously reported results and have explored areas that could not be addressed through the use of quantitative data only. Seven arts therapists completed the qualitative survey and provided detailed and insightful comments on their practice with depression. Thus, additional information regarding the practitioners and their clients has become available, which facilitates the understanding of what an

Acknowledgements

Ania Zubala would like to thank all arts therapists who participated in the survey and especially those who shared insights into their practice regarding depression. She would also like to express gratitude to Queen Margaret University for awarding her with a PhD bursary to research arts therapies.

Selected papers on psychoanalysis

A. Cattanach
Process in the arts therapies

Doing qualitative research

Being together briefly: One-on-one brief dramatherapy with clients hospitalized for chronic or reactive depression

Outcome-based evaluation of a social skills program using art therapy and group therapy for children on the autism spectrum

The evolution of circular questions: Training family therapists

Dramatic approaches to brief therapy

Depression

The genogram

Arts therapies: A research-based map of the field

Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication

The use of genograms with solution based and narrative therapies

The many purposes of art therapy

View full text

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Art psychotherapy practice with adults who suffer from depression in the UK: Qualitative findings from a depression-specific questionnaire

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The 'global burden' of depression demands more effective treatments. Evidence suggests that arts therapies are offered to individuals who suffer from ...

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A realist review of art therapy for clients with depression

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A realist review of art therapy for clients with depression

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Creative arts groups in psychiatric care Development and evaluation of a therapeutic alternative

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Creative arts groups in psychiatric care Development and evaluation of a therapeutic alternative

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Dag Körlin

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Editorial: The State of the Art in Creative Arts Therapies

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Editorial: The State of the Art in Creative Arts Therapies

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The Emili Sagol Creative Arts Therapies Research Center, University of Haifa, Haifa, Israel

The School of Creative Arts Therapies, University of Haifa, Haifa, Israel

Faculty of Fine Art and Music, University of Melbourne, Melbourne, VIC, Australia

The Graduate Art Therapy Program, Florida State University, Tallahassee, FL, United States

Department of Creative Arts Therapies, Drexel University College of Nursing and Health Professions, Philadelphia, PA, United States

Creative Arts Therapies is an umbrella term for healthcare professions that use the creative and expressive process of art making to improve and enhance the psychological and social well-being of individuals of all ages and health conditions. Creative arts therapies use the relationship between the client and therapist and among clients in group or dyadic therapy in the context of the creative-expressive process as a dynamic and vital force for growth and change. The creative-expressive process engages physiological sensations, emotions, and cognition; facilitates verbal and non-verbal symbolization, narration, and expression of conscious or unconscious conflicts and meaning-making through internal and external dialogue and communication between oneself and others.

The major objective of this Research Topic was to introduce, collect, discuss, and disseminate new clinical practices, scientific evidence, methodologies, theoretical concepts, and notions about Creative Arts Therapies. By publishing this open-access articles under this Research Topic we hope not only to distribute updated knowledge among the many clinicians in this field, but also to inform and convey the importance and significant therapeutic impact of this field, to scientists and clinicians from other psychological disciplines.

Creative arts therapists work in a variety of settings such as hospitals, educational institutions, community mental health facilities, prisons, hospices, and private practices, and include a variety of Professional specializations. Contributors to this Research Topic included experts in dance-movement therapy (DMT), drama-therapy and psychodrama, film therapy, music therapy, and art therapy. The topics of their studies vary from theoretical concepts and underlying mechanisms through methodology and up to evidence-based clinical studies and their review or meta-analysis. In the following paragraphs we summarized the 36 different contributions to this Research Topic, based on their artistic modality.

Dance-Movement Therapy

Seven articles contributed to the modality of dance-movement therapy.

Payne and Brooks, wrote a theoretical article "Different Strokes for Different Folks: The BodyMind Approach as a Learning Tool for Patients with Medically Unexplained Symptoms to Self-Manage" in which, based on research and their DMT practice with patients with medically unexplained symptoms, they proposed a new approach to treat this population: The BodyMind Approach. A description of the theoretical underpinnings and philosophy of the proposed alternative to current interventions is presented as well as a description of the suggested intervention which incorporates creative arts therapies and adult learning techniques for self-management practices.

In their article "How Do We Recognize Emotion from Movement? Specific Motor Components Contribute to the Recognition of Each Emotion" Melzer et al., report a scientific study whose aim was to investigate the mechanism underlying DMT practices. In this study Melzer et al., demonstrated that the specific Laban motor components which were found in their earlier study ( Shafir et al., 2016) to enhance specific emotions when moved, enable recognition of the same emotions when being observed, even when the mover didn't try to express any emotion. This study supports the notion of the existence of associations in the brain between certain movement components and specific emotions, a notion which can explain how internal simulation by the mirror neurons of observed movements can create empathy in the observer and help therapists to understand their clients' emotional state, by eliciting a similar emotion to that which is elicited in the client who moves with those movement component.

In another article: "How Shall I Count the Ways? A Method for Quantifying the Qualitative Aspects of Unscripted Movement With Laban Movement Analysis" the same group ( Tsachor and Shafir) describe in details the methodology they had used in their 2016 study ( Shafir et al., 2016) to narrow down and select out of many movement components the ones they used as variables for the statistical analysis with which they determined which movement components enhance which emotion.

Another article which deals with methodology, although not methodology of the study but that of intervention assessment, is the article by Dunphy K. F. et al., "Outcome-Focused Dance Movement Therapy Assessment Enhanced by iPad App MARA." This article describes the applicability and benefits of using the iPad app MARA (Movement Assessment and Reporting App; Dunphy et al., 2016) to assess and report the progress of clients with intellectual disability as a result of a 16 weeks DMT program.

Three of the DMT articles reviewed the evidence for therapeutic effectiveness of this modality. While two articles reviewed the effectiveness of DMT on specific populations using mainly a qualitative synthesis: Karkou et al., examined the effectiveness of DMT in the treatment of adults with depression, and Goodill examined accumulating evidence for DMT effectiveness in Cancer care, the article which was published last in this Research Topic summarized nicely the overall effectiveness of this field. In their paper "Effects of Dance Movement Therapy and Dance on Health-Related Psychological Outcomes. A Meta-Analysis Update" Koch et al., conducted a very detailed meta-analysis (including a sensitivity analysis, assessment of heterogeneity, analysis of outliers and publication bias and analysis of follow-up data) on the effects of 21 DMT and 20 dance controlled intervention studies (2,374 participants) published between 01/2012 and 03/2018, on health-related psychological outcomes. They found in total a medium significant overall effect for dance and DMT intervention based on heterogeneous results. Since type of intervention was a significant source of heterogeneity, they explored the effects of DMT and dance separately and found that DMT consistently and with a high homogeneity significantly improved affect-related psychological conditions by decreasing anxiety and depression levels, and significantly increased quality of life and interpersonal and cognitive skills, whereas dance interventions increased (psycho-)motor Skills.

Drama Therapy, Psychodrama and Film Therapy

One drama therapy, one film therapy, and eight psychodrama studies are featured in this special topic.

Drama therapist Feniger-Schaal et al. report on the application of the mirror game to assess the embodiment of attachment in adulthood. Associating attachment scores with non-verbal movement interactions constitutes the first step toward validating the mirror game as a standardized assessment tool in drama therapy and dance movement therapy.

Azoulay and Orkibi report the results of a mixed method study on first year MA students' psychodrama field training experience in Israel. The results point out possible helpful and hindering factors in students' field training and trajectories in their perceived professional identity and suitability, all of which may inform the design of field training in psychodrama programs.

Cruz et al. conducted a systematic review of psychodrama techniques implemented in research and practice. The results provide an inventory of operationalized definitions of core psychodrama techniques that was confirmed through consensus by international psychodrama experts and will be of value to researchers and trainers.

Ron's case study of an open psychodrama group in a psychiatric inpatient ward in Israel highlights how the doubling technique and the group sharing phase reinforce empathy, relatedness, and support, which may offer psychiatric inpatients relief from distress and loneliness.

A study by Gonzalez et al. elegantly illustrate how to implement the mixed methods hermeneutic single case efficacy design to explore treatment effectiveness. The quantitative results generally suggest positive changes in clients' self-identified problem, symptoms, and spontaneity, while the qualitative results underpin the attribution of these changes to the treatment.

Bucută et al.'s mixed methods study probes how psychodrama methods and techniques can empower abused women and promote changes from their victim role. The findings and discussion may inform readers interested in psychodramatic gender violence interventions.

The quantitative results of Testoni et al. suggest that a death education course with psychodrama and movie making activities helped high school students in Italy to work through a case of suicide. Enhanced sense of life meaning and reduced death anxiety were among the findings related to the processing of death related trauma and grief.

Filmmaking was also used by Tuval-Mashiach et al. in their qualitative study on Israeli military veterans suffering from service-related trauma. The results indicate that the "I Was There" video therapy program contributed to alleviating participants' trauma processes and sense of agency and affiliation.

In his theoretical article, Yaniv draws on the neurocognitive concept of bottom-up/top-down processing to explicate the somewhat enigmatic state of spontaneity or "trusting the process" in psychodrama. He reviews the scientific evidence in support of J. L. Moreno's contention that all individuals can learn to let go of predetermined top-down conceptions and be open to bottom-up processing of experiences in the here-and-now.

Sang et al. provide a historical analysis of the spread and development of psychodrama in mainland China. This article identifies key actors and processes that led to the development of three major branches of psychodrama in that country.

Music Therapy

Two research studies were reported for music therapy. The first by Baker et al. was an interpretative phenomenological analysis of interviews with people with acquired neurodisabilities who had engaged in a songwriting program aimed at reconstructing a post-injured identity. Results of the analysis indicated that participants traveled through one of four recovery journeys. Some experienced their acquired injury as an opportunity for new beginnings, some were drawing on resilience from previous traumas to activate well-developed coping strategies, while others used the process of creating songs to identify new way of being in the world.

A study by Clark et al. of people living with dementia and their family caregivers focused on how therapeutic group singing enables these community dwelling older people to flourish. Interviews with participants revealed that the singing groups not only enhanced relationships between person with dementia and his or her family carer, but facilitated the development of new relationships with others attending the group. Participants also reported feeling more socially accepted and confident, experienced a lift in mood and an enhanced sense of purpose.

Art Therapy

Thirteen articles, a third of all of the peer-reviewed articles represented in this Research Topic of The State of the Art in Creative Arts Therapies, focused on art therapy. Many of the articles, recognizing the need to invest in and develop robust yet quite varied research agendas, were dedicated to how the arts, art meaning, and aesthetic interactions can bring about positive and sustained change. Gerber et al. relied on a robust qualitative research agenda to explore aesthetic and intersubjective phenomena in the creative arts therapies and how such therapeutic approaches can transform perception, behavior, relationship and well-being. Their study "Arts-based research approaches to studying mechanisms of change in the Creative Arts Therapies" relied on a "...deductive thematic analysis of written accounts of simulated arts therapies experiences..." to determine the potential for complex transformative phenomena "that occur in the nexus of art-based expression, reflection and relationships."

Focusing specifically on the need for empirical evidence on the therapeutic potential of art materials, Haiblum-Itskovitch et al.'s article, "Emotional response and changes in heart rate variability following art-making with three different art materials," addressed how three different art materials that varied greatly in levels of fluidity-pencil gouache, and oil pastels-elicit various emotive responses and changes. This important scientific study relied on a combination of data from self-reports and an electrocardiogram device to inform their findings. Another empirical study, Zeevi et al.'s "The efficiency of art-based interventions in parental training" differed in tone and focus. The authors, in providing 87 parents two questionnaires before and after 10 months of art therapy treatment for their young children, while the children and 14 art therapists completed two questionnaires, assessed the difference between those parents who received parental training with art-based interventions, verbal training or no training at all. Also focusing on the relationship between parents and their children, Gavron and Mayseless's "Creating art together as a transformative process in parent-child relations: The therapeutic aspects of the joint painting procedure," employed a qualitative method-as part of a much larger mixed-methods study-in which to ascertain the specific benefits of engaging in a specific art task to positively affect the relationship between 87 mother-child dyads.

Huss and Samson instituted a large-scale qualitative method to clarify the relationship between coping and art therapy, particularly the components of meaning, manageability, and comprehensibility, for those experiencing health-stress from cancer. In their study, "Drawing on the arts to enhance salutogenic coping with health-related stress and loss" they discovered that the arts naturally embodied the mechanisms that enhance and contain these components. As a natural extension of these positive results, they provide a protocol in how art can be used to enhance coping with such stressors. Nagamey et al. relied on an interpretive phenomenological analysis of semi-structured interviews and drawings to explore "Perspectives on social suffering..." specific to Palestinian adults who must cross a particular checkpoint into Israel for school and work. While regionally focused, their results could lead to a greater understanding of the social stressors by those experiencing political conflict around the world.

In addition, Binson and Lev-Weisel, relied on a phenomenological methodology to explore the benefits of applying experiential learning to facilitate personal and professional growth in doctoral students in Thailand attending academic lectures. As indicated in their article "Promoting personal growth through experiential learning..." they discovered that "...the experiential learning element within the course contributed to their personal well-being, improvements in their family and spousal relationships, enhanced social skills, as well as a changed self-perception in roles as lecturers and therapists."

There has been ever increasing debate over the years of the benefits of examining the formal elements within the art over content as assessable indicators. Pénzes et al. relied on a constructivist grounded theory approach to examine how art therapists may use the formal elements of a drawing to better understand the mental health of their client. In their article "How art therapists observe mental health using formal elements in art products: Structure and variation as indicators for balance and adaptability" the authors interviewed eight art therapists and determined that rather than contribute to an understanding of a client's symptoms or diagnosis, such characteristics inform the balance and adaptability of the artist. However, in their article "Associations between perception of parental behavior and 'Person Picking an Apple from a Tree' drawings among children with and without special education needs," Or et al. relied on the symbolic content of the Person Picking an Apple from a Tree drawing. Long associated with the Formal Elements Art Therapy Scale, rather than focus merely on how the drawings were completed, the authors relied on the content elements to quantitatively determine children's perceptions of parental behavior, which seemed much more revealing with those children with special needs.

It is imperative that research endeavors in art therapy be reexamined to ensure rigor, application of current theories as well as efficacy and viability of methodological approaches. In "Effectiveness of art therapy with adult clients of 201-What progress has been made," Regev and Cohen-Yatziv examined the last 27 published studies in the field that examined the efficacy of art therapy with adult clients among an array of seven specific categories. In doing so, the authors have continued the necessary dialogues instrumental in furthering our own examinations within the field. Feen-Calligan et al., in "Art therapy, community building, activism, and outcomes" provided a descriptive study that examined the interrelationships that developed amongst graduate art therapy students who were tasked to prepare undergraduate service-learning students as part of their research class with the directors of six community agencies preparing for such students. Noting the growing trend of such hands-on practice in the community, the authors recognized the value of such an examination to inform other art therapy programs who hope to rely on service-learning to teach research.

As we continue to advance research in the field of art therapy, there has expanded a greater acceptance of the need to think outside the box, to go beyond the limitations of just our field, to rely on new innovations and push the envelope to provide the best services. In her article "Summary of twenty-first century great conversations in art, neuroscience and related therapeutics," King emphasized the need for transdisciplinary collaboration to best understand the complexity of mental and physical disorders. Proposing that this article serves as a potential missing link to fill the gap amongst varied fields, King recounts a symposium at her home institution that brought together several divergent thinkers from a wide array of fields who were tasked to help develop a common language in which to advance the interplay of the creative arts therapies and neurosciences. And finally, in "The principles of art therapy in virtual reality," Hacmun et al. take us well-beyond the boundaries of our physical reality and offer various perspectives on the potentials and challenges of using virtual reality in the therapeutic milieu, outlining much needed principles of its use.

Multiple therapies

Two articles reviewed the effectiveness of interventions using different modalities of arts therapies. Lo et al. reported a qualitative systematic review of 11 (six music therapy, three visual art therapy, one DMT, and one applied literature therapy) creative arts-based intervention studies for stroke survivors. The authors identified five analytical themes: functional restoration, psychological support, social engagement, spiritual experience and short-comings and barriers, and concluded that overall art-based therapies have demonstrated strengths in addressing psychosocial needs for stroke survivals and that different art modalities are perceived to be useful in achieving different therapeutic goals.

Dunphy K. et al. examined the outcomes of four creative arts modalities (art, dance, drama, and music) interventions for older adults experiencing depression. In their review they also payed attention to the processes documented in those studies as contributing to the change, as well as the mechanisms considered to underlie these processes. Their analysis of 75 articles (17 art, 13 dance, 4 drama, and 41 music) indicated mostly significant qualitative or positive qualitative findings, where the mechanisms considered to contribute to the reduced depression included physical (e.g., increased muscle strength), intra-personal (e.g., enhanced self-concept; processing and communication of emotions), cultural (e.g., creative expression, aesthetic pleasure), cognitive (e.g., stimulation of memory), and social (e.g., increased social skills and connection) mechanisms.

Taken separately, each of the articles in this Research Topic provides a glimpse into the unique, complex, and far-reaching endeavors of members of our field. Together, the articles reflect not only the increasing evidence for the effectiveness of arts therapies interventions, but also the increasing diversity of perspectives as well as methodological sophistication in the field of arts therapies research, offering directions for how we might build on these foundations in the future.

Author Contributions

All authors contributed to writing up the editorial.

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.

References

Dunphy, K., Mullane, S., and Allen, L. (2016). Developing an iPad app for assessment in dance movement therapy. Arts Psychother. 51, 54-62. doi: 10.1016/j.aip.2016.09.001

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Shafir, T., Tsachor, R. P., and Welch, K. B. (2016). Emotion regulation through movement: unique sets of movement characteristics are associated with and enhance basic emotions. Front. Psychol. 6:2030. doi: 10.3389/fpsyg.2015.02030

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Editorial: The State of the Art in Creative Arts Therapies

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unexplained symptoms, they proposed a new approach to treat this population: The BodyMind Approach. A description of the theoretical underpinnings and philosophy of the proposed alternative to current interventions is presented as well as a description of the suggested intervention which incorporates creative arts therapies and adult learning techniques for selfmanagement practices.In their article "How Do We Recognize Emotion from Movement?

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Abstract

Creative art therapy (CAT) for severe mental illness (SMI) represents an extremely heterogenous body of literature that encompasses the use of a large variety of creative mediums (i.e. visual art, music, dance, drama, writing) in the treatment of mental disorders. The present review provides a narrative summary of the findings on the use of CAT for the selected SMI, being: schizophrenia, trauma-related disorders, major depression, and bipolar disorder. A database search of PubMed and the Cochrane Library was conducted related to the use of CAT in the treatment of mental disorders published between January 2008 and March 2019. A total of 9697 citations were identiﬁed to match the search criteria and 86 full-texts were reviewed. Although literature suggests CAT to be a potentially low-risk and high benefit intervention to minimize symptoms and maximize functioning in individuals living with SMI, the lack of methodological rigor, and inconsistency in study methods and outcome measures have prevented the advancement of CAT for use in SMI. Although creation of a single CAT regimen for all psychiatric disorders stands neither practical nor advisable, greater standardization of methods would improve evaluation of CAT interventions. Future research should elucidate biological mechanisms underlying CAT methods.

Introduction

Recent trends in psychiatry towards a more holistic approach in the treatment of mental disorders have placed increasing attention on psychotherapeutic methods like creative arts therapy (CAT). While advances in medicine, especially related to genetics, have kept pharmacological agents at the forefront of psychiatric disorder treatment, many psychotropic agents, and especially antipsychotics, contribute to poor quality of life and debilitating adverse effects even when the medications are able to alleviate the major symptoms of a disorder (Hanevik et al., 2013). Increasingly, clinicians have turned towards creative art therapy (CAT) and other psychotherapy in addressing the health needs of patients. The utilization of the creative arts for the treatment of mental disorders first appeared more than half a century ago, but the last three decades have witnessed the growth of a literature describing its potential utility (Attard and Larkin, 2016, Carr et al., 2013, Feirstein, 2016, Fenner et al., 2017, Stuckey and Nobel, 2010).

The concept of CAT encompasses a variety of methods including musical engagement, visual art, movement and dance, drama/theater, and expressive/creative writing (Stuckey and Nobel, 2010). Various types of CAT have been studied as adjunctive treatments for a range of psychiatric diagnoses including psychotic, mood, substance use, and trauma-related disorders (Aalbers et al., 2017, Crawford et al., 2012, Grocke et al., 2014, Levine and Land, 2016). Results regarding its effectiveness have been varied and sometimes contradictory (Attard and Larkin, 2016, Carr et al., 2013, Chung and Woods-Giscombe, 2016). Nonetheless, the use of CAT treatments extends beyond SMI or psychiatric disorders and has been shown to reduce disease-specific symptoms and improve mental health, satisfaction with care, and overall well-being for neurological and age-related disorders, such as Parkinson's and dementia, autoimmune disorders, cancers, cardiovascular disease, and more (Archer et al., 2015, Bradt and Dileo, 2009, Carr et al., 2013, Chancellor et al., 2014, de Natale et al., 2017).

Past reviews have analyzed the quality of and conclusions from data collected in previous CAT studies. This narrative review sought to contribute to the literature by suggesting mechanisms of action, identifying consistent conclusions regarding the effectiveness of CAT, discussing lingering issues with study design, and proposing necessary steps to advance the application of CAT in the treatment of mental disorders.

Section snippets

Review

To identify articles for review, we searched PubMed and the Cochrane Library using the MEDLINE tags ``art therapy," ``music therapy," ``dance," ``movement," ``clay," ``theater," ``drama," ``poetry," ``writing," combined with the terms ``mental disorder," ``severe mental illness," ``schizophrenia," ``depression," ``bipolar," ``post-traumatic stress disorder", or ``PTSD" (e.g. "art therapy AND schizophrenia", ``music therapy AND severe mental illness") published between January 2008 and March

Results

A total of 9697 citations were identified which matched the search criteria and 86 full-texts were reviewed (see Table 1 and Fig. 1).

Types of creative art therapy

CAT programs frequently make use of more than one type of method in their interventions (Im and Lee, 2014, Rawtaer et al., 2015). The most common types of art therapy have been categorized and their use in mental illness briefly summarized in the sections below.

2023, Journal of Interprofessional Education and Practice

The study aimed to identify the effectiveness of using art therapy (drawing) in alleviating feelings of anxiety and depression among a sample of Princess Noura University students, females (the study sample consisted of eighteen students in the third year (basic education) at the College of Designs and Arts. Their median age was 18 years old and suffering from high feelings of anxiety and depression. With art therapy, the results showed a statistically significant difference between the educational study achievement grades of the sample members before and after the therapy. Moreover, there is an improvement in the scale of "feeling anxious and depressed" with the using of art therapy (drawing). In conclusion, it is recommended in clinical and hospital settings, painting art therapy with psychiatric patients of anxiety and depression could produce a good benefit in improving non-verbal communication between patients and the on-side medical team, helping with their treatment and enhancing the moods therefore decrease the needs for medications.

2023, Journal of Bodywork and Movement Therapies

One of the reasons that may have led these interventions to be more effective in reducing negative symptoms is the fact that they encourage the exploration of unconscious material with the help of creative processes, improving the individual's ability to express themselves, through the symbolic (Anzacata 2021). Creative arts resort to non-verbal processes and have an embodiment approach, which transcends literal and logical meanings (Malchiodi 2019), enhancing the individual's healing (Chiang et al., 2019) and well-being (Anzacata 2021) through the therapeutic effects of creativity (Chiang et al., 2019; Anzacata 2021). Moderate and limited evidence is expected due to the small number of studies that assess the sub variables and due to the low quality of some studies.

In a stabilized phase of schizophrenia, negative symptoms are evident, on which body-oriented therapies can act. This systematic review examines the scientific evidence of the effects of all body-oriented therapies on the negative symptoms in people with schizophrenia and the effects of each type of body-oriented therapies on the negative symptoms in people with schizophrenia. To carry out this systematic review, the PRISMA guidelines were followed. The research was carried out through Pubmed, Cochrane, Web of Science, APAPsycNet, Science Direct, Scopus and the VHL Regional Portal. The methodological quality of the studies was assessed using the PEDro scale and data synthesis was performed. There were included 18 studies with the following interventions: creative arts, mind-body interventions, and body psychotherapy. Negative symptoms (total value), affective blunting, anhedonia, avolition, alogia, asociality, and psychomotor slowing were studied. In conclusion, there is strong scientific evidence that: body-oriented therapies do not promote positive effects on avolition, when it is assessed using the SANS scale; and creative arts reduce the total value of negative symptoms, when assessed by PANSS.

2022, Mental Health and Physical Activity

We decided to test them, presuming that they would be ineffective, but they nonetheless could have a positive outcome that could be interesting to clinical practice. According to Chiang et al. (2019) art and music therapy can reduce symptoms and signs of depression. A single bout of circuit EX and MB practices had positive effects on well-being and affect in patients with severe DEs.

To analyze acute effects of exercise (EX) and mind-body practices (MB) on anxiety, affect and well-being as well as on changes in markers of neurogenesis and inflammation in a sample of inpatients with depression.

A randomized, controlled crossover trial involving 33 inpatients (72.7% female, mean age 37.03 ± 14.32 years-old) with a depressive episode (DE). The participants performed a single bout of EX, MB, and a control activity (CA) and were randomized into groups that performed the activities in the order of EX-CA-MB or MB-CA-EX. EX involved mixed aerobic and anaerobic exercises, MB combined mindfulness, yoga and meditation practices while CA involved coloring figures or free hand drawing. Stait-Trait Anxiety Inventory (STAI), the Positive Affect and Negative Affect Schedule (PANAS), and an analogue visual scale (AVS) for well-being were used to assess effects on anxiety and well-being. Levels of brain-derived neurotrophic factor (BDNF), interleukins (IL) 1β, 6, 10 and tumor necrosis factor-alpha (TNF-a) were analyzed in samples collected immediately before and after each intervention.

All interventions showed a time-dependent effect on clinical and biological variables, except for IL-10. Among clinical variables, EX had a time-group interaction for well-being. EX and MB both had a time-group interaction for negative affect, and the effect was stronger than that for EX. Among biological variables, MB acutely decreased (IL) 1β, and EX acutely decreased TNF-α.

EX and MB have acute effects in reducing negative affect and anxiety, while promoting well-being and positive affect. These findings support that MB and EX (anaerobic and aerobic) alone can have acute effects on biological and clinical variables.

2023, Acta Academiae Medicinae Sinicae

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Creative art therapy (CAT) for severe mental illness (SMI) represents an extremely heterogenous body of literature that encompasses the use of a large...

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Effectiveness of mindfulness-based art therapy for symptoms of anxiety, depression, and fatigue: A systematic review and meta-analysis

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Effectiveness of mindfulness-based art therapy for symptoms of anxiety, depression, and fatigue: A systematic review and meta-analysis

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Effectiveness of Art Therapy With Adult Clients in 2018—What Progress Has Been Made?

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Effectiveness of Art Therapy With Adult Clients in 2018—What Progress Has Been Made?

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School of Creative Arts Therapies, University of Haifa, Haifa, Israel

In the year 2000, an important art therapy literature review addressed an essential question-does art therapy work? It discussed 17 articles dealing with the issue of the effectiveness of art therapy. Two decades later, this research field has extended its scope and is flourishing. Several current reviews of research work have described the broad range of methods implemented today, which includes qualitative and quantitative studies; other reviews have focused on art therapy with specific populations, or by age group. The aim of this systematic literature review is to contribute to the ongoing discussion in the field by exploring the latest studies dealing with the effectiveness of art therapy with a broad scope of adult clients. We conducted a comprehensive search in four databases and review of every quantitative article that has addressed outcome measures in the art therapy field from 2000 to 2017. This paper presents the latest 27 studies in the field that examine the effectiveness of art therapy with adult clients and divides them into seven clinical categories: cancer patients, clients coping with a variety of medical conditions, mental health clients, clients coping with trauma, prison inmates, the elderly, and clients who have not been diagnosed with specific issues but face ongoing daily challenges. It underscores the potential effects of art therapy on these seven clinical populations, and recommends the necessary expansions for future research in the field, to enable art therapy research to take further strides forward.

In 1999, nearly two decades ago, the American Art Therapy Association (AATA) (1999) issued a mission statement that outlined the organization's commitment to research, defined the preferential topics for this research, and suggested future research directions in the field. One year later, Reynolds et al. (2000) published a review of studies that addressed the therapeutic effectiveness of art therapy. They included studies that differed in terms of research quality and standards. In eight studies by different authors, there was a single group with no control group; in four studies, there was a control group, but no randomization of the participants between the experimental group and the control group; and in only five studies was there randomization of the experimental group and the control group (RCT - Randomized Control Trial). They concluded that there was a substantial need to expand research in the field of art therapy to better determine the most appropriate interventions for different populations.

Two decades later, the field of research in art therapy has developed considerably. There are several reviews in the field that describe the expanding body of research work. Some of these reviews present studies that have examined the effectiveness of art therapy, without distinguishing between different populations. For example, as an extension of the work and review by Reynolds et al. (2000), Slayton et al. (2010) reviewed articles published between 1999 and 2007 that measured the outcome of art therapy sessions with different populations. Their review included qualitative studies, studies based on a single client in therapy, studies with no control groups, studies with a control group but with no randomization, and a small number of studies with a control group and randomization. They concluded that there has been progress in the field, but further research is needed. Four years later, Maujean et al. (2014) summarized high-quality studies that implemented RCT that focused on art therapy with adults. They found eight such studies that were conducted between 2008 and 2013. Seven reported beneficial effects of art therapy for adult clients, but they also concluded that more reliable controlled studies were needed to draw conclusions.

Together with these comprehensive reviews, many literature reviews have appeared in recent years discussing specific populations and a range of research methods. For example, in the field of art therapy for adults, Holmqvist and Persson (2012) overviewed art therapy studies on clients with psychosomatic disorders, eating disorders, or facing crises, based on case studies and intervention techniques. They concluded that there were not enough studies to prove that art therapy is effective for these specific disorders. Similarly, Geue et al. (2010) and a year later, Wood et al. (2011) examined art therapy with cancer patients. They assessed quantitative and qualitative studies and found that most studies have dealt with women suffering from breast cancer. They also documented the intervention techniques that were specifically used with this population, and reported that overall, the quantitative studies reported an improvement in a number of emotional domains faced by these clients. Another article by Huet (2015) reviewed articles dealing with ways to reduce stress in the workplace through art therapy intervention techniques. In this article, a total of 11 articles were discussed that employed different research methods. The authors focused on describing different ways to use art therapy in this context and argued that there has been a gradual emergence of a vast body of knowledge that reinforces the benefits of art therapy for people working in stressful work environments.

In the past three years, a number of literature reviews of controlled quantitative studies have dealt more specifically with the issue of the effectiveness of art therapy in treating specific populations. Schouten et al. (2015) overviewed quantitative studies in art therapy with adult trauma victims. They found that only six studies included a control group (only one of which included randomization) in this field. Half reported a significant reduction in trauma symptoms and another study found a decrease in the levels of depression in clients treated with art therapy. They pointed out that it is difficult to produce quantitative meta-analyses in art therapy given the limited size of the groups and because the evaluation is often based on several therapeutic methods that are used simultaneously. Further Uttley et al. (2015a, b) reviewed all the studies dealing with art therapy for adult clients with non-psychotic psychiatric disorders (anxiety, depression, and phobias). They found 15 randomized controlled quantitative studies of which 10 indicated that the therapeutic process was effective (positive changes following therapy in comparison to the control group). They were unable to conduct a meta-analysis due to the clinical heterogeneity and lack of sufficient information in the studies. In addition, they reviewed 12 qualitative studies that provided data on 188 clients and 16 therapists.

This article deals with research that focuses on measuring the effectiveness of art therapy. It addresses two major challenges. The first is the definition of the term "effectiveness." We adopted the definition suggested in Hill et al. (1979); namely, "the attribute of an intervention or maneuver that results in more good than harm to those to whom it is offered" (p. 1203). The current review takes a positivist perspective ( Holton, 1993) and relates to the measurement of effectiveness reported in quantitative studies that have been conducted in the field. Since the field of art therapy is still young, the scope of research is limited and the quality of research is diverse, which makes it difficult to create a comparative review that presents the knowledge in the field and draws thorough conclusions. Therefore, our review is based on the systematic review framework proposed in Case-Smith (2013) who divided the studies she reviewed into three levels of evidence. Level 1 refers to randomized controlled trials (RCT's), level 2 refers to nonrandomized two-group studies, and level 3 refers to nonrandomized one-group studies.

The second challenge has to do with the definition art therapy. We applied the standard definition provided by the American Art Therapy Association:

Art therapy, facilitated by a professional art therapist, effectively supports personal and relational treatment goals, as well as community concerns. Art therapy is used to improve cognitive and sensorimotor functions, foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills, reduce and resolve conflicts and distress, and advance societal and ecological change ( American Art Therapy Association, 2018).

This definition makes it clear that art therapy is a process that takes place in the presence of a certified art therapist, and indicates different areas where an effect or outcome in therapy can be expected as a result of this form of treatment.

Thus, the research question was formulated according to "PICOS" components ( The PRISMA Group et al., 2009): Is art therapy effective for adult clients as measured in results published from 2000 to 2017, in various quantitative studies corresponding to Levels 1, 2, 3 ( Case-Smith, 2013)? These studies assessed the effectiveness of art therapy on variety of indices including symptoms and physical measures, health or mental health assessments, quality of life assessment, or coping resources. These indices were typically evaluated through questionnaires and occasionally by projective drawings or physiological indices.

By posing this question, this systematic review joins the ongoing discussion in the field on the level of effectiveness of art therapy with adult clients. This forms part of the academization process in the field of art therapy, which involves attempting to relate intervention techniques in the field with their significance for theoretical research.

Method

The search for relevant articles was carried out during the month of January 2017. Four major electronic databases were searched: Medline, PsycInfo, Scopus, and Web of Science. We searched for the term "art therapy" in the databases combined with the terms "Effectiveness," "Efficacy," "Outcome," "Measurement," "Treatment," and "Intervention." We restricted the search in the databases to articles published in English since the year 2000 for reasons of recency and the continued relevancy of the findings. In addition, all the literature reviews in the field (such as those reviewed above) were examined to locate additional articles that were pertinent to this study.

During the initial screening stage, the abstracts were read by both authors (who are certified art therapists) to exclude those that were irrelevant to the purposes of the study. At this point 151 articles remained (see Figure 1).

In the next stage, the remaining articles were read and selected if they met the following inclusion criteria (see Figure 1):

- Reported a quantitative assessment of the effectiveness of art therapy on a sample of clients. Hence case studies, method descriptions, qualitative analyses, and literature reviews that did not meet these criteria were omitted. A total of 80 articles were removed at this stage.

- Enabled the assessment of the unique impact of art therapy. We thus omitted articles that described the use of a combination of therapeutic intervention techniques with a variety of art mediums simultaneously, not only visual art. A total of 14 articles were omitted at this stage.

- The art therapy was conducted in an ongoing manner in the presence of a certified art therapist. We thus omitted articles that described art intervention techniques that were not used in the context of therapy or were used in one-off art therapy interventions or therapy sessions with a non-certified art therapist. A total of 17 articles were removed at this stage.

Articles that met these inclusion criteria were defined as articles that examined the "effectiveness" of Art Therapy, and that quantified the impact of art therapy in a measurable way. A total of 37 studies were located in 40 articles (three studies were published in two different articles each). Of the 40 articles, 27 dealt with adult populations and are covered in this systematic review. This article categorizes mentioned articles in terms of the levels of evidence proposed by Case-Smith (2013).

Findings

The findings derive from the 27 studies that we considered to have met the inclusion criteria. The choice to present the studies as a review rather than as a meta-analysis is due to the emergent nature of the field of art therapy. There is insufficient research in the field and the differences between studies and the indices measured are so great that it was impossible to produce a meta-analysis that would yield meaningful results (much like Uttley et al.'s conclusion, 2015a,b). In addition, the authors discussed the issue of the clinical categorization until full agreement was reached, to enable the reader to access the knowledge in the field in a way that will allow and encourage researchers to continue to conduct research. For samples where there has been more research (for example, art therapy with cancer patients), this area could have been separate and examined in and of itself, and relevant conclusions specific to this population could have been drawn. However, for other populations there was often a scarcity of studies which led us to group and categorize populations with similar characteristics (for example, medical conditions).

The next section presents the findings categorized into seven clinical categories. Different research methods were used: 17 of the articles (15 studies) used a comparison group with randomization (Level 1), five articles (four studies) used a comparison group without randomization (Level 2), and five articles used a single group without a comparison group (Level 3). In addition, there was a notable gender trend in that nine of the articles only examined women whereas only two of the articles exclusively referred to men. Sixteen did not define the research population by gender.

Category 1: Cancer Patients

The first category consisted of art therapy with cancer patients (see Table 1). Six studies that examined effectiveness have been conducted with this specific population since 2006 and have been described in seven different articles ( Monti et al., 2006, 2012; Oster et al., 2006; Öster et al., 2007; Bar-Sela et al., 2007; Svensk et al., 2009; Thyme et al., 2009). Five of the six studies were randomized (Level 1) and five dealt with women, most of whom had breast cancer. The total sample size ranged from 18 to 111 clients, most of whom were treated individually. Most of the therapeutic processes were short-term and ranged from five to eight sessions.

Some of the studies utilized different streams of art therapy. For example, the largest study of 111 participants, ( Monti et al., 2006) included a mindfulness-based art therapy intervention-a combination of art therapy with mindfulness exercises. The measurement indices were very different for these studies and included questionnaires that examined physical symptoms, coping resources, quality of life, depression, anxiety, and fatigue. One specific study ( Monti et al., 2012) also dealt with fMRI measurements. The findings of this category suggest that through relatively short-term interventions in art therapy (primarily individual therapy), it is possible to significantly improve the emotional state and perceived symptoms of these clients.

Category 2: Medical Conditions

The second category consisted of art therapy with clients coping with a variety of medical conditions that were not cancer-related (see Table 2). Three studies examining the effectiveness of art therapy have been conducted since 2011, each of which deals with a completely different medical condition and employs a different research method. The earliest study dealt with art therapy with clients with advanced heart failure ( Sela et al., 2011). This study had a sample size of 20 clients who were randomly divided into two groups (level 1). The clients participated in group art therapy for 6 weeks. A 2013 study addressed art therapy with clients coping with obesity ( Sudres et al., 2013). This study examined 170 clients who were randomly divided into two groups (level 1). One group consisted of 96 clients who received art therapy for 2 weeks. A 2014 study addressed art therapy with 25 clients with HIV/AIDS ( Feldman et al., 2014), who received art therapy in individual or group settings and did not include control groups (level 3). The duration of the therapeutic process was one or more sessions. Despite the considerable differences between the populations and the indices measured, these preliminary studies present an introductory description that points to the potential of art therapy to assist these populations.

Category 3: Mental Health

The third category covered art therapy with mental health clients (see Table 3). Four studies have been conducted since 2007 (two articles written on the same study- Crawford et al., 2012; Leurent et al., 2014, see Table 3). Research in this category falls into two main diagnostic areas. The first covers two studies on individuals with schizophrenia ( Richardson et al., 2007; Crawford et al., 2012; Leurent et al., 2014) that involved randomization (level 1) with large samples (90-159 clients). The therapeutic process ranged from 12 sessions to a full year of therapy and included group therapy. The variety of indices that were used in these studies include measures of function, relationships and symptoms. Despite the attempt to use different types of research indices, in both studies, little or no effect was found to be associated with art therapy. Two studies were classified into the second diagnostic area: one addressing clients with psychiatric symptoms ( Chandraiah et al., 2012) (level 3) and the other addressing women coping with depression ( Thyme et al., 2007) (level 1). The therapeutic process ranged from 8 to 15 weeks. The findings reported in both studies suggested a change occurred in the duration of the therapeutic process. However, since neither study compared clients who received art therapy with those who received no therapy, it is difficult to evaluate the effectiveness of art therapy. Hence, the accumulated results of the studies in this category suggest that further research is needed to assess the effectiveness of interventions in art therapy for clients dealing with mental health issues.

Category 4: Trauma Victims

The fourth category included art therapy with clients coping with trauma (see Table 4). In this category, two studies have been conducted since 2004, both with randomization (level 1). The first study ( Pizarro, 2004) was composed of a sample of 45 students who participated in two art therapy sessions. These students had dealt with a traumatic event, which could occur at different levels of intensity and at various stages in their lives. In addition, the comparison was made between an art-therapy group and two comparison groups where one underwent writing therapy and the other experimented with artwork, regardless of the traumatic event. Despite the attempt to use a wide range of indices, including symptom reporting and emotional and health assessments, and perhaps because of the short duration of therapy, this study failed to find significant results.

The second study ( Kopytin and Lebedev, 2013) examined a sample of 112 war veterans who participated in 12-14 art therapy sessions. In this study, in which the definition of the traumatic event was more specific and defined by involvement in war, an attempt was also made to measure the level of improvement through a wide range of research indices, including reports of symptoms, emotional state, and quality of life. For some of the indices, there was a significant improvement compared to the control group.

These two articles thus present an inconsistent picture of the beneficial effects of this intervention, which may depend on the indices measured, the duration of therapy, and possibly the type of traumatic event.

Category 5: Prison Inmates

The fifth category deals exclusively with David Gussak's extensive research on art therapy with prison inmates ( Gussak, 2004, 2006, 2009a, b) (see Table 5). In this area three effectiveness studies have been conducted since 2004 (two articles were written on the same study; see Table 5). The first examined an intervention group without a control group (level 3), in contrast to the other two studies which did include control groups (level 2); the sample sizes ranged from 48 to 247 participants in the 2009 study. The art therapy intervention was carried out in a group setting and lasted 4 weeks in the first study to 15 weeks in the most recent study. Initially, Gussak used measurements solely from drawings (FEATS), but in later and more comprehensive research, depression and locus of control were also assessed. In the three studies, there was a reported improvement attributed to the art therapy intervention, as seen in the emotional state of the prison inmates.

Category 6: The Elderly

The sixth category covered art therapy with the elderly (see Table 6). Three effectiveness studies have been conducted since 2006: one study was conducted with healthy Korean American older individuals ( Kim, 2013), the second study involved older individuals coping with depression ( McCaffrey et al., 2011), and the third dealt with older individuals with moderate to severe dementia ( Rusted et al., 2006). In all three studies, the participants were randomly divided into groups (level 1), in a group therapy setting, with a sample size of 39-50 clients. The number of sessions ranged from 6 to 40. The authors of these studies were interested in a variety of indices. In both the study of elderly Koreans and the elderly coping with depression, various aspects of the emotional state of the clients were measured. Art therapy was considered to have led to an improvement on these measures. In a study of older people with dementia, many observational measures were used to assess emotional states, behavior, and abilities, but change was found only in some of them.

The findings suggest that art therapy seems to have a beneficial effect on older individuals who are coping with a variety of challenges in their lives, as reflected in the changes in the indices in these studies.

Category 7: Clients Who Face Ongoing Daily Challenges

The seventh category consisted of art therapy with clients who face ongoing daily challenges that do not fall into one diagnostic category (see Table 7). Three studies have been conducted since 2008, two of which address issues such as stress, distress, and burnout of individuals working in various health professions ( Italia et al., 2008; Visnola et al., 2010). These studies were carried out without randomization; in one study ( Visnola et al., 2010) there was a control group (level 2), whereas in the other ( Italia et al., 2008) there was not (level 3). The sample size ranged from 20 to 60 participants. The therapeutic process lasted 9-13 sessions in a group art therapy setting. These studies suggest that art therapy can help healthcare professionals reduce levels of stress, anxiety, and burnout connected to their work.

The third article addresses art therapy for women undergoing fertility treatment ( Hughes and da Silva, 2011). The sample only included an intervention group (level 3) consisting of 21 women in a group art therapy setting. This study reported a reduction in anxiety and in feelings of hopelessness. The samples in the studies in this category were relatively small and usually did not include a control group. However, there is potential for further research in this area.

Discussion and Conclusion

The purpose of this review was to assess whether art therapy is effective for adult clients as measured in quantitative studies published from 2000 to 2017. Notably, since the Reynolds et al. (2000) review, the body of knowledge in this field has grown and established itself significantly, and a growing number of RCT studies (level 1) have been conducted with larger sample sizes. The advantage of such studies lies in the lesser likelihood of Type I errors as opposed to other studies with no control group or studies that have a control group but no randomization. Nevertheless, there are still only a small number of studies addressing each population, and these studies differ considerably in terms of the course of the therapeutic process, the proposed interventions and the indices that were examined, hence making a meaningful meta-analysis impossible. The findings however are largely encouraging and show a growing trend toward conducting more carefully designed studies that lend themselves to validation and replication; yet-there is a long road ahead. In the past, the effectiveness of art therapy was noticeable to those involved in the field, but less to other professionals. Today, by contrast, there are impressive published findings in a variety of areas. These studies can help expand the contribution of art therapists in other areas and with other populations.

During our search, we were struck by the large number of articles which appear to present interventions in the field of art therapy, but in fact were conducted by non-certified art therapists or were restricted to a therapeutic intervention of a single session in a manner that would not be considered therapy. The existence of such studies emphasizes the continued need to define, clarify and specify what art therapy is and what it is not, and specifically to clarify that this type of therapy must be composed of ongoing sessions and be conducted by a certified art therapist who meets the criteria defined for the profession ( American Art Therapy Association, 2018).

The first two clinical categories dealt with clients who are coping with a variety of medical conditions. In this section, we were surprised by the vast amount of research in the field of art therapy with cancer patients, most of which were categorized as level 1. Art therapy emerges strongly as a way to enhance their quality of life and their ability to cope with a variety of psychological symptoms. Our review supplements previous reviews in the field ( Geue et al., 2010; Wood et al., 2011) and shows that the findings on art therapy with cancer patients are primarily based on higher levels of evidence studies with randomization and relatively large samples.

The second category, which dealt with clients with a range of medical problems, was intended primarily to list the preliminary research in this field, due to the wide variability between the different populations. The differences in the populations treated suggests that, the measurement tools should be adapted to each type of medical issue. The only instrument that could possibly be applied to all these populations in future research is one that measures improvement in quality of life. It is surprising to note that unlike research on cancer patients, which has been considerable, there have been few studies on individuals with other medical conditions.

The third category dealt with clients with mental health issues. In this category we focused solely on adult clients (as opposed to children which will be reviewed in a separate article) and differentiated from the elderly (category 6). In addition, they were separated from clients coping with trauma (category 4). As a result, a relatively small number of studies met the strict criteria of this review regarding what could be defined as art therapy for clients with mental health issues, although some of the studies had large sample sizes and showed a higher level of evidence. For clients coping with schizophrenia, the reviewed findings are not optimistic. These data are congruent with the many articles on psychotherapy that have addressed this population and have emphasized the complexity of treating such individuals ( Pfammatter et al., 2006). Studies have shown that the most effective therapeutic approach for this population appears to be cognitive-behavioral ( Turner et al., 2014). Thus, future work should examine the effectiveness of the cognitive-behavioral approach in art therapy for this population. More research is also needed to better understand how art therapy can be effective with clients experiencing other mental health issues.

The fourth category addressed clients coping with trauma. While there have been few studies in this field, all of them are in a higher level of evidence. It is important to note that these studies did not assess post-traumatic stress disorder (PTSD), but rather individuals who have dealt with traumatic events. Even though the first study ( Pizarro, 2004) did not confirm the effectiveness of art therapy, the limited number of sessions with each client may have been a major factor. When dealing with trauma, there is a need for thorough processing of the experience, and it is quite possible that two sessions were insufficient. The second study ( Kopytin and Lebedev, 2013) reported that art therapy was beneficial when the intervention lasted longer. These data are consistent with the Schouten et al. (2015) review. Certain studies reviewed by Schouten et al. (2015) were not mentioned in our review because some were not published as articles, and others included single session interventions that were not led by a certified art therapist.

The fifth category addressed prison inmates. In this field, it is worth mentioning the work of Gussak, a researcher who has studied the field and conducted several studies with an increasing number of participants. His findings undoubtedly point to the potential of art therapy for inmates particularly in long term interventions.

The sixth category addressed the elderly. The field of geriatric art therapy has been gaining momentum in recent years ( Im and Lee, 2014; Wang and Li, 2016). It is clear from the articles that group therapy sessions are particularly suitable for these clients and that it is important to continue conducting research to target effective intervention methods for this population. The research findings certainly indicate the potential of this field.

The seventh and final category dealt with clients who are facing daily challenges in their lives. The findings suggest that art therapy can be a suitable form of treatment and a way to mitigate issues such as stress and burnout at work.

Overall, this review documents the extensive research conducted in recent years; although qualitative studies were not included in this article, there is no doubt that using a variety of research methods can help expand knowledge in the field. As concerns quantitative studies, the review examined the effectiveness of art therapy for adult clients from research in the field from recent years and with reference to seven clinical categories.

The current review has several limitations. First, due to the small number of studies in the field, it includes various levels of quantitative studies. Some lack comparison groups and others include comparison groups with other treatment methods (for example verbal therapy). This variability makes it difficult to generalize across findings, but not mentioning these studies would have led to the inclusion of an even smaller number of studies. Second, in many studies there are several indices of varying types (questionnaires, drawings, physiological indices). Occasionally, only some of these indices led to demonstrable indications of the effectiveness of art therapy. Due to the complexity of the findings, we were not always able to detail these subtleties and challenges in the current review, and future researchers interested in the field should examine these specific studies closely before conducting further research on the same population. In addition, due to the limited number of studies in this field, we needed to combine various subjects in certain cases, make decisions, and create artificial categories based on our professional knowledge and judgment. For example, the article on female infertility ( Hughes and da Silva, 2011) was placed in the seventh category of ongoing and daily challenges, and not in the second category of medical problems, due to the feasibility of this condition for various reasons, which are not necessarily medical.

Research in the field can be expanded in several ways. First, art therapy is a very broad domain that covers diverse populations, some of which have not yet been studied at all in the context of treatment effectiveness. Second, based on the conclusions derived from this review future studies should be planned so that they are performed by a certified art therapist, over a continuous period of time and on large enough samples. In so doing, within approximately a decade, it should be possible to produce a meaningful meta-analysis based on significant and comparable findings from the field, which could lead to more advanced and specific conclusions. Third, in order to raise the level of research in our field, it is important for researchers to devote time and thought to planning studies at the highest level (level 1). Large samples are not enough; one should also consider well-controlled studies (RCT), the blindness of the experiment, the blindness of the participants and the experimenters to the purpose of the research, the division of research groups and so on ( Liebherz et al., 2016; Munder and Barth, 2018). Finally, it is of great importance that researchers will select valid and reliable research tools that have been used extensively.

This documentation of the numerous studies on the effectiveness of art therapy was long and complex, but also filled us with hope. We are optimistic that this article will take the field one step further in this direction.

Author Contributions

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

Conflict of Interest Statement

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.

References

American Art Therapy Association (AATA) (1999). Art Therapy Research Initiative [Brochure]. Mundelein, IL: The American Art Therapy Association.

The PRISMA Group, Moher, D., Liberati, A., Tetzlaff, J., and Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 6:e1000097. doi: 10.1371/journal.pmed1000097
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Effectiveness of Art Therapy With Adult Clients in 2018-What Progress Has Been Made?

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In the year 2000, an important art therapy literature review addressed an essential question-does art therapy work? It discussed 17 articles dealing with the issue of the effectiveness of art therapy. Two decades later, this research field has extended its scope and is flourishing.

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Outcome Studies on the Efficacy of Art Therapy: A Review of Findings Sarah C. Slayton,

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Outcome Studies on the Efficacy of Art Therapy: A Review of Findings Sarah C. Slayton,

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To what extent can art therapy be used to treat major depressive disorder

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Outcome Studies on the Efficacy of Art Therapy: A Review of Findings 

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Outcome Studies on the Efficacy of Art Therapy: A Review of Findings 

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