art therapy literature review

• Open access
• Published: 16 May 2022

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

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

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

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

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

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

Systematic review registration

PROSPERO ID CRD42021233272

Peer Review reports

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

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

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

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

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

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

Methods/Design

Registration and reporting.

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

Eligibility criteria

Type of study.

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

Types of participants

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

Types of interventions

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

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

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

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

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

Comparison interventions

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

Stakeholder involvement

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

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

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

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

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

Grouping for primary analysis comparisons

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

Search strategy

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

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

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

Data collection and data management

Study selection process.

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

Data extraction

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

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

Risk of bias assessment for included studies

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

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

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

Measures of treatment effect

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

Unit of analysis issues

Cluster trials.

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

Cross-over trials

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

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

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

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

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

Missing data

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

Assessment of clinical, methodological, and statistical heterogeneity

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

Reporting bias

Funnel plot.

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

Data analysis and synthesis

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

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

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

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

Subgroup analysis

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

Sensitivity analysis

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

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

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

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

Availability of data and materials

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

Abbreviations

• Active visual art therapy

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols

Randomised controlled trial

Risk of Bias tool

Intention to treat

Per protocol

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

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Art therapy: a complementary treatment for mental disorders.

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

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

Introduction

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

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

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

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

Publications of Art Therapy

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

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

Figure 1. Number of publications about art therapy.

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

Overview of Art Therapy

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

Art Therapy for Mental Disorders

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

Table 1. Studies of art therapy in mental diseases.

Depression Disorders and Anxiety

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

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

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

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

Cognitive Impairment, and Dementia

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

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

Alzheimer’s Disease

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

Schizophrenia

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

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

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

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

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

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

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

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

Other Applications

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

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

The Application Prospects of Art Therapy

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

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

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

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

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

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

Author Contributions

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

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

Conflict of Interest

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

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

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

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

Reviewed by:

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

*Correspondence: Jinping Xu, [email protected]

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

Art Therapy: A Literature Review of Efficacy in Improving Psychosomatic Symptoms in Patients With Cancer

Affiliation.

• 1 DePaul University.
• PMID: 32196015
• DOI: 10.1188/20.CJON.123-126

A high percentage of patients with cancer receive a comorbid diagnosis of anxiety, depression, or another psychological disorder. However, research evaluating the efficacy of art therapy as an intervention to alleviate these symptoms is limited. Art therapy can offer psychosomatic symptom relief among patients with cancer, but more rigorous and randomized controlled clinical trials are warranted to strengthen evidence-based research supporting its clinical utility.

Keywords: anxiety; art therapy; depression; holistic medicine; quality of life.

Publication types

• Anxiety / therapy
• Art Therapy*
• Depression / therapy
• Holistic Health
• Neoplasms / psychology*
• Quality of Life

The effectiveness of therapeutic artmaking on depression, anxiety, quality of life, and psychological distress in cancer patients on chemotherapy: a systematic review of the literature

• Published: 22 March 2024
• Volume 32 , article number  245 , ( 2024 )

Cite this article

• Juan Peng 1 &
• Dan Cheng 2  

The purpose of this study was to evaluate the evidence of art therapy on depression, anxiety, quality of life, and mental distress in cancer patients undergoing chemotherapy.

A systematic literature search was conducted. A systematic search of online electronic databases including, PubMed/MEDLINE, Scopus Web of Science, PsycINFO, and EMBASE was performed using keywords extracted from Medical Subject Headings such as “Art Therapy,” and “Neoplasms,” “Cancer,” and “Chemotherapy” from the earliest to January 11, 2023. A total of 3890 publications were assessed for relevance by title and abstract. The remaining 1298 articles were examined using three inclusion criteria: interventions were guided by an artist or art therapist, participants were actively involved in the creative process, and anxiety, depression, and/or quality of life were included as outcome measures. The methodological quality of the included studies was appraised using specific checklists.

A total of 495 patients with cancer undergoing chemotherapy participated in ten studies. Among the participants, 87.21% were female and 63.43% of them were in the intervention group. The mean age of the participants was 53.93 in five studies that reduced depression in cancer patients undergoing chemotherapy. Six studies investigated the effect of different art therapy methods on the anxiety of patients, which in four studies reduced their anxiety. Also, three studies investigated the effect of different art therapy methods on patients’ distress, which in two studies reduced their distress.

Art therapy had positive effects on depression, anxiety, quality of life, and psychological distress of cancer patients undergoing chemotherapy. Meanwhile, research on art therapy in cancer patients on chemotherapy is insufficient. We cannot conclude that art therapy benefits cancer patients on chemotherapy. More rigorous research is needed.

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Peng, J., Cheng, D. The effectiveness of therapeutic artmaking on depression, anxiety, quality of life, and psychological distress in cancer patients on chemotherapy: a systematic review of the literature. Support Care Cancer 32 , 245 (2024). https://doi.org/10.1007/s00520-024-08427-0

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Art Therapy: A Literature Review of Efficacy in Improving Psychosomatic Symptoms in Patients With Cancer

Denise LaPenna

A high percentage of patients with cancer receive a comorbid diagnosis of anxiety, depression, or another psychological disorder. However, research evaluating the efficacy of art therapy as an intervention to alleviate these symptoms is limited. Art therapy can offer psychosomatic symptom relief among patients with cancer, but more rigorous and randomized controlled clinical trials are warranted to strengthen evidence-based research supporting its clinical utility.

AT A GLANCE

• Art therapy uses creative processes to enrich and enhance the lives of patients experiencing psychosomatic symptoms.
• Based on a literature review of eight studies, art therapy improved patients’ anxiety in seven studies, depression in five studies, and overall quality of life in four studies.
• Additional research on the benefits of art therapy are needed to fully understand its efficacy in improving symptoms of anxiety and depression and overall quality of life in patients with cancer.

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Uttley L, Scope A, Stevenson M, et al. Systematic review and economic modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic mental health disorders. Southampton (UK): NIHR Journals Library; 2015 Mar. (Health Technology Assessment, No. 19.18.)

Systematic review and economic modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic mental health disorders.

Chapter 3 the acceptability and relative benefits and potential harms of art therapy: qualitative systematic review.

This chapter aims to provide an overview of the evidence for service user and service provider perspectives on the acceptability, relative benefits and potential harms of art therapy for people with non-psychotic mental health disorders.

• Review methods

Bibliographic database searching

As the searches for the clinical effectiveness were comprehensive for art therapy literature, the same database was used for both the quantitative and qualitative reviews (see Chapter 2 , Literature search methods ).

Screening and eligibility

All abstracts, and then full papers, were read by two reviewers (AS and LU) who made independent decisions regarding inclusion or exclusion, and consensus, where possible, was obtained by meeting to compare decisions. In the event of disagreement, a third reviewer (EK) read the paper and made the decision. Study types included were:

• qualitative research reporting the perspectives and attitudes of people with non-psychotic mental health disorders who have received art therapy in order to examine issues of acceptability
• qualitative data embedded in trial reports or in accompanying process evaluations, to inform an understanding of how issues of acceptability are likely to affect the clinical effectiveness of art therapy
• qualitative data either from separately conceived research or embedded within quantitative study reports, reporting the acceptability of art therapy to health care practitioners.

The inclusion and exclusion criteria for the qualitative review are reported in Figure 6 . Studies in all settings were included, although the community was the main setting of interest.

Eligibility criteria for the qualitative review.

Quality assessment strategy

Studies meeting the inclusion criteria were evaluated by two reviewers using the CerQual approach. CerQual (certainty of the qualitative evidence 67 ) aims to assess how much certainty can be placed in the qualitative evidence for the review finding, or, in other words, how reliable the review finding is. This approach relies on assessing both the methodological quality of the individual included studies and the coherence of the review finding as defined by the extent to which a clear pattern across the individual study data is identifiable.

To assess methodological quality individual studies were appraised using an abbreviated version of the CASP quality assessment tool for qualitative studies. 68

Two reviewers (AS and LU) independently applied the set of quality criteria to each included study. In the event of a disagreement, a third reviewer (EK) was consulted. Studies were included in the review regardless of study quality.

Whereas study quality applies to each individual included study, ‘coherence’ relates to the review finding which is subsequently developed through the synthesis of the individual studies. Therefore, the coherence of each review finding was then assessed by looking at the extent to which a clear pattern across the data was identified and was contributed by each individual study. This was assessed by looking to see if the review finding was consistent across multiple contexts and if the review finding incorporated explanations for any variation across individual studies. Coherence was further strengthened when the individual studies contributing to the finding were drawn from a wide range of settings. Using the assessment of methodological quality and assessment of coherence together, the certainty of each review finding was rated as high, moderate or low.

Data extraction strategy

Data extraction from included qualitative studies was undertaken independently by AS using a data extraction tool adapted and tailored for the precise purpose of the qualitative review. All data extractions were checked by LU, with any discrepancies being discussed by both data extractors. Where data for included studies were missing, reviewers attempted to contact the authors at their last known e-mail addresses.

For the purpose of data extraction, two principal approaches to decide what counts as qualitative evidence have been proposed. 69 In the first, only data from primary studies which are illustrated by a direct quotation from the respondent are extracted, whereas in the second all qualitative data identified in the primary studies and relevant to the review question are extracted. Given the anticipated paucity of evidence, the latter, more inclusive, approach to data type was adopted, together with a selective approach to extract data relevant to the specific research question. A framework for extraction was developed which focused specifically on data relating to the review question, including how art therapy helped (relative benefits); how art therapy was unhelpful (potential harms); neutral effects (neither benefits or harms); barriers to participation [acceptability (a)]; and recommendations for service delivery [acceptability (b)] from patients and health practitioners. Table 18 illustrates the data extraction elements.

Data extraction elements from the qualitative review

Data synthesis strategy

Qualitative meta-synthesis was undertaken to provide added value to the quantitative analysis by indicating patient issues around the acceptability of art therapy as a treatment for non-psychotic mental health disorders. Specifically, thematic synthesis was used to aggregate the findings. 70 The framework developed for data extraction was used to shape the synthesis of the findings.

Combining the quantitative and qualitative data

Methodological work to date has been unable to establish the superiority of conducting the qualitative and quantitative synthesis in parallel or of conducting quantitative followed by qualitative, qualitative followed by quantitative or some more iterative approach. Our choice of method of combining data was determined by the needs of this particular review, in which the quantitative data were the main focus and the qualitative data were used for their explanatory potential. We, therefore, employ methods similar to those described by Noyes et al. 71 to explore the effectiveness review in the light of supporting qualitative research data.

• Results of the qualitative review

Included studies: qualitative review

From the 10,270 citations identified from the initial searches (see Chapter 2 ), 290 were considered following abstract sift and 42 papers were considered at full paper sift for the qualitative review. Figure 7 shows the flow chart of studies included in the qualitative review. The sifting process resulted in the inclusion of 12 studies (13 sources) at full paper sift. All included full papers were published between 2002 and 2013 (although one study was an unpublished manuscript linked to a published abstract within this time scale 72 ). Two were theses, 73 , 74 and one of these had an associated peer-reviewed paper 75 which reported the same study.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart of studies included in the qualitative review.

Study respondents

Eleven studies assessed patients’ attitudes and two studies assessed health practitioner attitudes to the intervention [general practitioners (GPs) = 1; art therapists = 1]. The studies contained qualitative data from 188 patients and 16 health practitioners. The primary diagnoses of the patient populations studied included cancer ( n  = 6), depression/anxiety/stress ( n  = 3), PTSD ( n  = 1) and obesity ( n  = 1). The symptoms being treated by art therapy included depression, stress, anxiety, psychological distress, low self-esteem, fatigue and fear.

Six studies did not report the age of the participants. Where age range was reported, 73 , 76 – 78 ages ranged from 26 to 82 years. Five studies 77 , 81 – 84 did not report the gender of the participants. In four studies, 72 , 73 , 76 , 78 all participants were female, while one study 79 included 69 men and 88 women and a final study 80 included four women and one man.

Study setting

Three studies 80 – 82 were conducted in the UK. One of these studies 82 provided data from patients and the other from GPs who referred patients to art therapy. 81 Four studies 73 , 74 , 78 , 83 were conducted in the USA, with one of these studies 73 also including participants from Canada. Three of these studies 73 , 78 , 83 provided data from patients and the final study 74 provided data from art therapists. The remaining five studies were conducted in European countries, Sweden, 76 Germany, 77 France, 72 Italy 79 and Switzerland, 84 and provided data from patients.

In seven studies, 72 , 74 , 76 , 77 , 79 , 82 , 84 the art therapy took place in secondary care; one study 81 took place in primary care and one study 78 took place in a state correctional facility (USA). In another study 73 participants had taken part in art therapy in varied settings including secondary care and private sessions. The setting was not reported in two studies. 80 , 83

Intervention description

The reporting of the art therapy intervention was limited in a number of cases. One study 81 did not report any details of the intervention, and two studies 73 , 80 reported on perceptions of patients who had taken part in a variety of different interventions, although details of each were not reported. Of the remaining eight studies assessing patient views of art therapy, in four studies 77 , 82 , 83 , 84 the art therapy had been conducted in a group, with group sizes ranging from four to nine participants, while three studies 76 , 78 , 79 reported on individual sessions; in one study, 72 the format was not reported. In six studies 72 , 76 , 79 , 82 – 4 it was reported that the intervention had been delivered by an art therapist. This was reported to be a professional or qualified art therapist in three of these studies 72 , 79 , 82 and an art therapy psychotherapist in a further study. 84 The service provider was not reported in the remaining two studies. 77 , 78 Sessions were 1 hour in length in three studies 72 , 78 , 79 and 2 hours in length in two studies; 82 , 84 duration was not reported in three studies. 76 , 77 , 83 The number of sessions delivered ranged from 1 to 22. Sessions were reported as occurring weekly in four studies; the frequency was not reported in three studies. One study 82 reported perceptions of patients who had taken part in art therapy as part of a rolling programme. Table 19 shows the study characteristics of qualitative studies with data from patients.

Study characteristics of qualitative studies with data from patients

Table 20 shows the study characteristics of qualitative studies with data from service providers.

Study characteristics of qualitative studies with data from service providers

• Quality of the included studies

Table 21 shows the methodological quality assessment of the included studies (adaptation of the critical appraisal skills programme checklist for qualitative studies.

Methodological quality assessment of the included studies (adaptation of the critical appraisal skills programme checklist for qualitative studies)

Our inclusion criteria specified that qualitative research or qualitative data within mixed methods studies were acceptable for inclusion; however, only three studies could be described as qualitative research. 74 – 76 Researcher reflexivity can be described as awareness of the researcher’s contribution to the construction of meanings throughout the research process and an acknowledgement of the impossibility of remaining ‘outside of’ one’s subject matter while conducting research. Few studies made reference to researcher reflexivity, and in those that did these descriptions were often brief. Most studies provided descriptions of the context and aims of the study, recruitment methods and data collection methods, although these tended to be brief. The study methods used were interview methods in most studies ( n  = 10) [semistructured interviews ( n  = 7), in-depth interview ( n  = 1), interview ( n  = 2)]. One study used the focus group method, one used patient diaries, one used field notes, and one used the transcription of a video-recorded group discussion which had been used for a television programme. Only around half of the included studies provided an adequate description of data analysis methods, and in only a few studies were in-depth, detailed and rich data presented. It should be noted that this may have been, in part, a result of limitations imposed by journals. Furthermore, the level of evidence that was included was extended to include data identified in both the results section and the discussion and will include author comments and interpretation. If data were limited only to participants, it was feared that important data would be missed.

Certainty of the review findings

As described in the Quality assessment strategy section, the CerQual approach to assess the certainty of the review findings was applied. The CASP quality assessment finding, together with the number of studies contributing to the finding, and an assessment of the consistency of study setting and population, was assessed. Each finding could potentially be graded as being of high, moderate or low certainty. For the evidence from patients, there were a total of 38 findings: 20 were assessed to be of moderate certainty and 18 were assessed to be of low certainty. For the evidence from service providers, as only two studies contributed to the evidence, there were a total of 25 findings: 19 were assessed to be of moderate certainty and six were assessed to be of low certainty. Owing to the limited number of studies contributing to each finding, together with the fact that the majority of the individual studies included in the review were of low to moderate quality, no findings were assessed as being of high certainty.

• Qualitative synthesis: evidence from patients

Table 22 shows the patient views regarding how art therapy helped (relative benefits).

Patient views regarding how art therapy helped (relative benefits)

Table 23 shows the patient views regarding how art therapy was unhelpful (relative harms).

Patient views regarding how art therapy was unhelpful (relative harms)

Table 24 shows the patient views regarding the neutral effects of art therapy (neither nor benefits)/acceptability.

Patient views regarding the neutral effects of art therapy (neither harms nor benefits)/acceptability

Table 25 shows the service delivery recommendations from patients.

Service delivery recommendations

Benefits of art therapy

Relationships.

A number of respondents across several studies 72 , 73 , 77 , 79 – 83 talked about relationships as important in art therapy. They suggested that art therapy was effective when a relationship with the art therapist was established. 79 , 80 , 83 One patient commented ‘I felt she [the art therapist] really understood what I am going through’. 79 A good relationship with the art therapist was seen as a requirement for an optimal art therapy programme, 73 , 81 and that the art therapist should act as a guide. 73 However, it was also noted that art therapy could be unhelpful if the art therapist was not skilled. 73 One patient recounted, ‘I was getting very, sort of out there in terms of the anxiety and that kind of thing, and it seemed to become evident she couldn’t go there with me . . . She couldn’t deal with it, which was quite upsetting’. 73

Respondents also discussed relationships with other group members and felt that art therapy was beneficial when these relationships could be established. 73 , 77 , 80 , 82 , 83 These findings were observed in studies across a range of settings and in a range of populations.

Respondents also felt that art therapy had the effect of facilitating improved relationships with family members, friends and caregivers. 72 This finding was observed in only one study, in which respondents had cancer, and therefore this finding may not be generalisable to other populations. In one study, 81 respondents with anxiety, depression and stress suggested that art therapy could serve to reduce isolation.

Understanding

Several studies included data concerning the importance of increased understanding as a beneficial result of art therapy. 72 , 73 , 76 , 77 , 79 , 81 – 84 More specifically, respondents talked about an increased understanding of self 73 , 77 , 79 , 81 – 84 and that art therapy promoted thinking about the future. 72 , 73 , 76 , 77 , 81 , 83 These findings appeared to be consistent across different populations. In two studies, one in patients with obesity 84 and the other in people with breast cancer, 73 art therapy was felt to facilitate understanding of these illnesses; thus, this finding may be specific to people with a diagnosis of a physical illness.

Perspective

A further beneficial effect of art therapy was the provision of strength and perspective. 76 , 83 This was illustrated by a participant in the McCaffrey et al. study:

These classes have put some perspective on my feelings and even though I am still sad and would give the whole world to have my husband back, I realize I can go on and I can have a good life. McCaffrey et al. 83 (p. 83)

However, it should be noted that this finding was judged to be of low certainty because it occurred in only two studies of overall low quality.

Distraction

Respondents highlighted distraction as a beneficial aspect of art therapy. 72 , 73 , 84 More specifically, respondents pointed to distraction from pain 72 and distraction from the illness, or escapism. 72 , 73 , 84 As might be expected, these findings were restricted to cancer and obesity populations, and were, therefore, rated as low to moderate certainty.

Personal achievement

Several studies included data reflecting that the provision of art therapy gave participants a sense of personal achievement. In a number of studies, 72 , 73 , 78 , 79 , 84 respondents commented that art therapy provided pleasure, satisfaction, accomplishment and a sense of pride. A patient reported, ‘I underestimate myself and didn’t think I was capable of doing what I did and of having any ideas. I am proud and I’ve rarely been that in my life’. 84 In one study of women with cancer, 72 it was reported that art therapy provided an opportunity to leave a legacy for loved ones.

Freedom of expression emerged as important across a range of studies. 73 , 76 , 77 , 78 , 80 – 82 A patient commented, ‘It can touch the feelings that are buried . . . the art frees you up to touch deeper down that [sic] you would verbally’. 81 Specifically, art therapy was thought of as a safe place to express emotions, such as fear 73 , 76 – 78 , 81 , 82 and anger. 73

A number of studies reported data suggesting art therapy provided a healing experience, comfort, encouragement, support and relaxation. 73 , 77 , 78 , 80 , 81 One participant reported, ‘it was really relaxing and afterwards I felt good and encouraged’. 77

Empowerment

Recipients of art therapy expressed that it gave them a sense of empowerment. This came in the form of control over emotions. 73 , 76 , 80 , 81 In the Collie study, 73 the author reports:

[The art therapist stated] ‘What art can do is it gives you . . . access to a larger part of who you are.’ She said art can take people away from their pain and show them that they are more than pain, and therefore can give a sense of control. Collie 73 (p. 77)

Art therapy also promoted control over real-life situations 76 and it was also cited as raising self-esteem. 78

Acceptability and potential harms of art therapy

Although recipients in most of the studies indicated a high level of acceptability of art therapy, some studies also described less positive attitudes. 72 , 73 , 78 , 79 , 81 Some respondents made comments that indicated that, although they did not feel art therapy would be harmful, they did not feel it would be beneficial. In one study, 79 a participant commented that art therapy was superficial; ‘I did not find anything particularly useful in it: afterwards I felt as before [she makes a gesture of opening her hands]. It is a little chat with a person who maybe can understand you, but in the end . . .’. Another patient felt it was childish. In another study, 81 a participant felt it was self-indulgent, and, in a final study, 78 a participant simply had a preference for other therapies. These findings were seen across only three studies of low to moderate quality.

More serious concerns included art therapy causing anxiety, 72 increasing pain, 72 and resulting in the activation of emotions that were not resolved. 73 In one study, 73 a participant was also concerned that art therapy may be harmful if the art therapist was not skilled. A final concern was that it may be harmful if art therapy is suddenly terminated. 73 These findings were seen across only two studies, both in patients with cancer.

The provision of art therapy

Across several studies 73 , 76 , 78 , 81 recommendations for art therapy were made. A participant in one study 76 said that it was important that privacy be respected during art therapy. In addition, emotional support, 73 a good relationship with the art therapist 73 , 81 and that the art therapist should act as a guide 73 were suggested to be important aspects of art therapy. Suggested improvements for art therapy were made in one study, 78 including the need for further sessions of art therapy and for additional input from other therapies, such as individual counselling.

Barriers to participation

Barriers to participation in art therapy were reported in three studies. 72 , 79 , 80 Respondents commented that they thought they were too ill to take part in the therapy, 72 and in a further study respondents reported that art therapy was restricted to people with certain medical conditions. 80 Other barriers included a fear of not being ‘good at art’ 80 and in two studies 79 , 80 participants commented that a lack of understanding of art therapy could be a barrier to participation. Figure 8 shows the overall synthesis of patients’ views regarding the relative benefits, harm and acceptability of art therapy.

Overall synthesis of patients’ views regarding the relative benefits, harms and acceptability of art therapy.

• Qualitative synthesis: evidence from service providers

Table 26 shows the service providers’ views regarding how art therapy was helpful (relative benefits).

Service providers’ views regarding how art therapy was helpful (relative benefits)

Table 27 shows the service providers’ views regarding how art therapy was unhelpful (relative harms).

Service providers’ views regarding how art therapy was unhelpful (relative harms)

Table 28 shows the service providers’ views regarding the neutral effects of art therapy (neither harms nor benefits)/acceptability.

Service providers’ views regarding the neutral effects of art therapy (neither harms nor benefits)/acceptability

Table 29 shows the service delivery recommendations from service providers.

In many ways the data from the two studies examining service provider views of art therapy mirrored those of the patients. Service providers felt that art therapy was beneficial when patients have time invested in them. 81 One GP stated that ‘simply having the time to have somebody interested in them is therapeutic in itself’. 81 Service providers also felt that a good indicator of the benefit of art therapy was when the patients say they like it or they felt they benefited. 74 , 81 Art therapists felt that art therapy was most helpful when the therapist examines the effect of art-making process with clients. 74 Furthermore, it was seen as beneficial when clients can communicate through artwork, 74 when art therapists help clients improve their ability to manage anger, 74 when it increases pride and self-esteem, 74 and when thoughts and feelings are expressed more effectively. 74 Finally, on a more practical level, art therapists felt that art therapy could be beneficial when it provides an opportunity for clients to do something better with their time. 74

Service providers made a number of observations about the acceptability and potential harms of art therapy. According to the study that examined the perspectives of GPs referring patients to art therapy 81 GPs, while not believing that art therapy could be harmful, do not regard it as beneficial either. In that study, GPs referring patients to art therapy commented on a lack of understanding of art therapy, reporting, ‘I don’t think I understood what the art bit was about’. 81 They also suggested that the art part of the therapy was irrelevant, stating ‘[I] thought it was about offering people an opportunity to discuss things in therapy. If you or I went to a group we’d get something out of it’. 81 They felt it was unlikely to help everyone, 81 and on a more practical note they felt that art therapy gave them with an opportunity to take time back: ‘leaves me free for more medical care’. 81 It should be noted that all of these neutral findings were generated from only one study of low quality, which looked at the opinions of GPs referring patients to art therapy and, therefore, cannot be generalised across other groups.

In terms of more serious detrimental effects of art therapy, Sharf 74 reported findings from art therapists. These potential harms included when administrative decisions lead to poor treatment outcomes, for example when a client is not allowed to continue with art therapy; when the client lacks commitment or is non-compliant; and when the client is resistant to art therapy.

The provision of art therapy (service delivery)

Both types of service providers (GPs and art therapists), like patients, felt that a good relationship with the art therapist was important. 74 , 81 GPs also reported that they felt the one-to-one contact was an important aspect of the therapy. 81 Art therapists also felt that client commitment to recover, the client’s enjoyment of art therapy, providing a safe environment to express thoughts, feelings and experiences, matching techniques and materials to clients, displaying artwork, and creating art along with clients were important aspects of effective art therapy. 74

Barriers to the provision of art therapy

Art therapists felt that their profession was not respected by members of other professional groups, 74 and that this created a barrier to patients being referred to art therapy. Art therapists went on to suggest that, in situations where art therapists and other professionals were able to work together, improvements to the service, patient outcomes and accessibility of art therapy were made. Figure 9 shows the overall synthesis of service providers’ views regarding the relative benefits, harms and acceptability of art theraphy.

Overall synthesis of service providers’ views regarding the relative benefits, harms and acceptability of art therapy.

• Combining the quantitative and qualitative findings

Qualitative meta-synthesis was undertaken to provide added value to the quantitative analysis by indicating patient issues around the acceptability of art therapy as a treatment for non-psychotic mental health disorders. This section aims to synthesise the findings from the two reviews.

The findings from the quantitative review demonstrated that depression, anxiety, low mood, distress and self-esteem were significantly reduced, and QoL and coping were significantly increased, relative to the control group in one to six studies. 48 , 52 , 58 , 59 , 61 , 62 Trauma was not significantly improved relative to the control group despite an improvement from baseline in three studies. 47 – 49 Cognition was not significantly improved in the one study it was reported in. 51 The findings of the qualitative review demonstrated that, overall, art therapy was viewed as an acceptable treatment by patients and service providers, with relatively few reports describing art therapy as unhelpful or unacceptable.

Some of the outcomes reported in the quantitative studies appear to map on to the qualitative findings around the beneficial and, in a smaller number of cases, the harmful outcomes of taking part in art therapy. Table 30 illustrates this mapping of outcomes from each review.

Mapping of qualitative findings against quantitative outcome measures

Findings from the qualitative review that appear to map on to the quantitative coping outcome include both helpful and unhelpful qualitative findings. Self-esteem also mapped on to qualitative findings. Quantitative outcome domains that mapped to a lesser extent to the qualitative findings were QoL, distress, mood and anxiety (although in opposite directions). There was no qualitative evidence that mapped specifically to the quantitative outcome domains of depression, trauma or cognition.

More in-depth synthesis of the findings of the two reviews was particularly challenging given that, despite art therapy being defined as a complex intervention, the quantitative primary studies did not explore the mechanisms of art therapy that may modify its effectiveness, such as therapist skill. However, the qualitative review findings can help to elucidate the potential treatment effect modifiers identified in the quantitative review, despite the fact that in most cases it was not possible to assess their effect on outcomes. The potential treatment effect modifiers identified in the studies included, in the quantitative review included, experience/qualification of the art therapist, individual versus group art therapy, age, gender and pre-existing physical conditions.

Experience/qualification of the art therapist

The review of the quantitative evidence demonstrated that there was considerable variability in the reporting of the accreditation of the therapist, although most studies were conducted by a person who was seen be qualified as an art therapist. The findings of the qualitative review demonstrated that a good relationship with the art therapist was reported as an important for art therapy to be helpful. Therefore, it appears that the experience and skill of the art therapist may be an important mechanism of art therapy.

Individual versus group art therapy

The quantitative review reported that the majority of RCTs are of group art therapy, with only four of the 15 RCTs examining individual art therapy. 49 , 55 , 56 , 62 Of the studies of individual art therapy, two 49 , 62 did not demonstrate an improvement on quantitative measures compared with the control group. Given that the qualitative findings also pointed to the importance of relationships with other group members as a particularly beneficial aspect of art therapy, with this finding seen in across several studies, an important mechanism in art therapy may be the group setting.

Pre-existing physical condition

The quantitative review highlighted that in nine studies patients had pre-existing physical conditions. 50 , 51 , 54 – 58 , 61 , 62 The remaining six studies were in people who were depressed, 47 , 59 people with PTSD, 48 , 49 or older people. 52 , 53 Neither the qualitative review nor the quantitative review found evidence that the effectiveness or helpfulness of art therapy differed across patients with or without pre-existing physical conditions. However, the qualitative review showed that a small number of themes appeared to apply mainly to people with pre-existing physical conditions. These themes included the facilitation of an improved relationship with family, friends and caregivers; facilitation of an understanding of the illness in two studies, 72 , 84 one of obesity and one of palliative care impatients; distraction from pain; distraction from the illness/escapism; and providing the opportunity for legacy. These findings may have implications for how art therapy is delivered to different populations to maximise beneficial effects.

Although age and gender were identified as potential treatment modifiers in the quantitative review, neither review was able to demonstrate any evidence that these variables had an effect on quantitative outcomes or patients’ perspectives and attitudes towards art therapy.

Discussion of the qualitative review

The aim of the qualitative systematic review was to provide a detailed user perspective on the acceptability and relative benefits and potential harms of art therapy. Overall, art therapy was viewed as an acceptable treatment across the populations of participants studied.

A number of beneficial aspects of art therapy emerged, together with a relatively smaller number of harmful aspects of art therapy, with relative harms being reported in only two studies. 72 , 73 An important theme emerging from the data was the relationship with the art therapist. This was raised as a positive and beneficial aspect of art therapy but also as potentially harmful, and further as a recommendation for service provision. A good relationship between the patient and art therapist was viewed as essential for successful, effective art therapy. However, harm could be caused in situations in which a positive relationship was not achieved, the therapist was viewed as unskilled, when emotions activated through therapy could not be resolved or the therapist was suddenly unavailable through sudden termination of the service. This finding was seen in evidence reported by patients and by service providers, 74 , 81 who also stressed the importance of a good therapeutic relationship.

Some themes, such as the importance of expression, the relationship with the art therapist and with other group members and the facilitation of an increased understanding of self, were consistent across populations, while a small number of themes appeared to apply to populations in which a diagnosis of a pre-existing physical condition was present. These themes included the facilitation of an improved relationship with family, friends and caregivers, identified in one study of a cancer population, 72 facilitation of an understanding of the illness in two studies (one of obesity 84 and one of cancer 73 ), distraction from pain in one study of cancer, 72 distraction from the illness/escapism in two studies of cancer populations 72 , 73 and one of an obesity population 84 and providing the opportunity for legacy in a study of a cancer population. 72

Understanding and personal achievement were other important themes emerging from the evidence. In addition, some barriers to participation were reported. A small number of participants also reported that they did not want to take part in art therapy, which reiterates the importance of considering patient preference in choice of treatment. 14 , 15

The combination of the findings from the quantitative and qualitative reviews examined how outcomes from the quantitative review mapped on to themes emerging from the qualitative review. This demonstrated that a number of themes from the qualitative review appear to map on to the quantitative coping outcome. This included both helpful and unhelpful qualitative themes. Self-esteem also mapped on to qualitative findings. Furthermore, the combining of the two reviews identified a number of mechanisms within art therapy that may modify the effectiveness and acceptability of the treatment and should be considered in further research and in the implementation of art therapy.

Limitations

Overall the evidence base was small ( n  = 12), with only two studies examining service provider views 74 , 81 and, furthermore, only one of these 74 examined art therapists’ views. The majority of the included studies were of low or moderate quality. Limitations on word limits imposed by journals may have contributed to this, as theses and grey literature provided better-quality evidence. Lack of rich data was the main limiting factor relating to the qualitative evidence base.

Other significant limitations in the evidence base include the fact that the vast majority of studies reported only positive findings. This may have been because of researcher bias, in that most of the authors of the reports were art therapists, 85 and the method of investigation in a number of studies appears to be biased towards the reporting of positive findings.

There was a lack of evidence comparing art therapy with other treatment options; therefore, we are unable to make comparisons regarding the acceptability of art therapy compared with other potential treatments participants might be offered.

Combining the qualitative and quantitative data proved difficult because of the paucity of the evidence base as a whole and the fact that meta-analysis was not possible. However, coping emerged as an important factor across both reviews, and this is an outcome domain that is likely to be pertinent to people with long-term health conditions. The small evidence base means it is not currently possible to make any generalisations around age, gender or setting.

• Conclusions

From the small number of qualitative studies identified, art therapy was reported to be an acceptable treatment. The benefits associated with art therapy included the development of relationships with the therapist and other group members, understanding the self/own illness/the future, gaining perspective, distraction, personal achievement, expression, relaxation and empowerment. Small numbers of patients reported varying reasons for not wanting to take part and therefore art therapy may not be a preferred treatment option for everyone. A small number of cases highlighted potentially negative effects of art therapy, which included the evoking of feelings that could not be resolved. Overall, there was low to moderate certainty in the review findings.

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• Cite this Page Uttley L, Scope A, Stevenson M, et al. Systematic review and economic modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic mental health disorders. Southampton (UK): NIHR Journals Library; 2015 Mar. (Health Technology Assessment, No. 19.18.) Chapter 3, The acceptability and relative benefits and potential harms of art therapy: qualitative systematic review.
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