research papers about art therapy

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The Research Committee is dedicated to encouraging, supporting, and promoting a broad base of research that is grounded in diverse methodologies. By providing information to the public and the membership, the committee promotes standards of art therapy research, produces a registry of outcomes based research, and honors professional and student research activity.

Art therapy priority research areas, focusing research efforts in the following areas:.

• Outcome/efficacy research
• Art therapy and neuroscience
• Research on the processes and mechanisms in art therapy
• Art therapy assessment validity and reliability
• Cross-cultural/multicultural approaches to art therapy assessment and practice
• Establishment of a database of normative artwork across the lifespan

SEEKING TO ADDRESS THE FOLLOWING RESEARCH QUESTIONS:

• What interventions produce specific outcomes with particular populations or specific disorders?
• How does art therapy compare to other therapeutic disciplines that do not include art practice in terms of various outcomes?
• How reliable and valid is any art therapy assessment?
• What neurobiological processes are involved in art making during art therapy?
• To what extent do a person’s verbal associations to artwork created in art therapy enhance, support, or contradict?
• What are ways of making art therapy more effective for clients of different ethnic and racial backgrounds?

SUGGESTED POPULATIONS TO RESEARCH:

• Psychiatric major mental illness
• Medical/Cancer
• At-risk youth in schools

BIBLIOGRAPHIC SEARCH TOOL

AATA’s Art Therapy Bibliographic Search Tool allows you to find listings of art therapy publications and theses from FOUR research sources: the Art Therapy Outcomes Bibliography, the Art Therapy Assessment Bibliography, the Multicultural Committee Selected Bibliography and Resource List, and the National Art Therapy Thesis and Dissertation Abstract Compilation.

The Art Therapy Bibliographic Search Tool enables you to search bibliographic entries based on one or all of the following characteristics: author name, category/treatment group, keywords, title, reference type, and year of publication.

AATA Member Exclusive:   All AATA members have the benefit of viewing more details about each database entry, including abstracts, topics, and comments!

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

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

Introduction

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

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

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

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

Publications of Art Therapy

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

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

Figure 1. Number of publications about art therapy.

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

Overview of Art Therapy

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

Art Therapy for Mental Disorders

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

Table 1. Studies of art therapy in mental diseases.

Depression Disorders and Anxiety

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

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

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

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

Cognitive Impairment, and Dementia

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

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

Alzheimer’s Disease

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

Schizophrenia

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

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

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

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

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

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

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

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

Other Applications

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

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

The Application Prospects of Art Therapy

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

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

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

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

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

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

Author Contributions

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

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

Conflict of Interest

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

Publisher’s Note

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

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Keywords : 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.

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

Academic, Master of Art Therapy Program, Western Sydney University

Senior Lecturer, Child and Adolescent Psychiatry, UNSW Sydney

Disclosure statement

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

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

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

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

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

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

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

An option for those who can’t find the words

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

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

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

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

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

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

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

Our research

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

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

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

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

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

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

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

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

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

What do young people think?

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

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

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

A promising area

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

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

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

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Art Therapy

2022, Longer-Term Psychiatric Inpatient Care for Adolescents

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What Creative Arts Therapies Teach Us About DBT Skills Training

Bridging dbt with the arts for deeper understanding..

Posted April 15, 2024 | Reviewed by Jessica Schrader

• What Is Therapy?
• Find a therapist near me
• Research supports the effectiveness of combining DBT with creative arts to improve outcomes.
• Facilitators can teach wise-mind skills through drama therapy techniques.
• Action-based DBT utilizes storytelling and role-play to make skill learning more accessible and impactful.

In the ever-evolving realm of mental health, therapists are always exploring new and innovative methods to enhance traditional treatments. Creative arts therapists have led the way in utilizing art-based interventions to teach DBT skills.

Creative arts therapy combines visual arts, movement, drama, music, writing, and other creative processes to support clients in their healing process. Many mental health clinicians have embraced creative arts therapy interventions to improve their clients' health and wellness.

There is a growing body of research that indicates that therapists can utilize creative interventions to help clients learn and generalize DBT skills. In this post, I will provide a brief literature review of therapists who have been doing this integrative work and provide an example of how drama therapy can be utilized to teach the DBT skill of wise mind.

DBT and Art Therapy

Research indicates that integrating art therapy into established psychotherapy forms, such as cognitive-behavioral therapies, can have significant positive effects on client well-being. For example, a study by Monti et al. (2012) demonstrated the potential of mindfulness -based art therapy (MBAT) in alleviating emotional distress, highlighting the power of combining art therapy with the core feature of mindfulness in DBT. Though this study did not specifically discuss DBT, it demonstrated that implementing mindfulness, a core component of DBT, can assist individuals who are facing significant physical and emotional stressors.

Building on research that examined mindfulness and art therapy, several practitioners have contributed articles that specifically address the integration of DBT and art therapy within clinical populations. For example, researchers Huckvale and Learmonth (2009) led the charge by developing a new and innovative art therapy approach grounded in DBT for patients facing mental health challenges. Furthermore, Heckwolf, Bergland, and Mouratidis (2014) demonstrated how visual art and integrative treatments could help clients access DBT, resulting in stronger generalization and implementation of these skills outside of the session. The clinicians concluded that this integrative approach to treatment could reinforce skills, contribute to interdisciplinary team synergy, and enact bilateral integration.

Other notable examples from art therapists include Susan Clark’s (2017) DBT-informed art therapy, a strategic approach to treatment that incorporates creative visual exercises to explore, practice, and generalize DBT concepts and skills.

Expanding Beyond Visual Art Therapy

DBT has now been integrated with other expressive art therapies, including drama and music. Art therapists Karin von Daler and Lori Schwanbeck (2014) were instrumental in this expansion when they developed Creative Mindfulness, an approach to therapy integrating various expressive arts therapies with DBT. Creative Mindfulness “suggests a way of working therapeutically that is as containing and structured as DBT and as creative, embodied, and multi-sensory as expressive arts” (p. 235). These clinicians incorporated improvisation into their work, a tool that can be simultaneously playful, experiential, and grounding, ultimately producing substantial new insights for clients.

Moreover, music and drama therapists have recognized the benefits of multisensory skill teaching, expanding the creative techniques used to teach DBT skills ( Deborah Spiegel, 2020 ; Nicky Morris, 2018 , and Roohan and Trottier, 2021 ).

My Own Experience Integrating Drama Therapy and DBT

Personally, I am a big advocate of both dialectical behavior therapy (DBT) and drama therapy. In fact, I love these modalities so much that I dedicated not only my master's thesis but also my dissertation to better understanding how to reinforce DBT skills through dramatic techniques. In the process, I developed a new approach called Action-Based DBT that uses dramatic interventions like storytelling, embodiment, and role-playing to create a supportive environment for participants to learn skills in a more personalized and embodied way. An expert panel review demonstrated that this format can effectively support skill learning, especially for clients who struggle with the standard format of DBT skills training. Additionally, mental health clinicians found the program easily adaptable across populations in both individual and group settings.

Embodying the Mind States

To illustrate this approach and its effectiveness, the following is an example of how drama therapy methods can teach the DBT skill of wise mind within the context of an action-based DBT group.

The facilitator begins the group session by reviewing general guidelines and introducing the targeted DBT skill for the day: wise mind. The group then participates in improvisational warm-up activities to promote creativity , positive social interaction, and group connectivity. Following the warm-up, the facilitator distributes the DBT mind states handout (Linehan, 2015) and provides brief psychoeducation on this skill. Three chairs are placed in the front of the group room, facing the semi-circle of clients. Each chair had a piece of colored construction paper taped to the front, reading as Reasonable, Wise and Emotion . The facilitator explains that each chair represents one of the three mind states: reasonable mind, emotion mind and wise mind. To encourage exploration of the mind states, the facilitator can assign a more specific role to each state of mind. For example, the reasonable mind is The Computer, the emotion mind is The Tornado, and the wise mind is The Sage. Group members are invited to think of a scenario in which they felt they had difficulty accessing their wise mind. Clients then take turns embodying each mind state by sitting in the chair and speaking from the respective role. When a client first sits in a chair, the facilitator aids in enrolling the individual by asking questions about the role (i.e. The Computer, The Tornado, The Sage). For example, the facilitator may ask about the posture, tone of voice, or a “catchphrase” for this role. The client then embodies the role and responds to questions from the group as the specific mind state. After the embodiment, clients engage in verbal processing. The wise mind directive supports clients in developing kinaesthetic awareness of the three mind states. Embodying these mind states within the context of a supportive group and engaging in verbal processing around the experience can increase awareness of the mind states, which is helpful for clients who are trying to understand their emotional response to lived events outside of the group setting.

The creative arts therapies offer a dynamic pathway to teaching and reinforcing DBT skills. Incorporating visual art, drama, or music in the process of learning DBT skills allows clients to engage with these concepts in a multisensory and embodied way.

In my personal experience, weaving drama therapy techniques into DBT skills training has proven to be profoundly impactful. The Action-Based DBT approach, with its emphasis on storytelling and embodiment, offers an immersive and experiential learning environment that can be especially beneficial for those who find traditional methods challenging.

Looking ahead, my next post will delve into how storytelling can be harnessed to teach DBT skills in a way that is both engaging and memorable.

To find a therapist, please visit the Psychology Today Therapy Directory .

Clark, S. M. (2017). DBT-informed art therapy: Mindfulness, cognitive behavior therapy, and the creative process. Jessica Kingsley Publishers.

Heckwolf, J. I., Bergland, M. C., & Mouratidis, M. (2014). Coordinating principles of art therapy and DBT. The Arts in Psychotherapy, 41(4), 329-335.

Huckvale, K., & Learmonth, M. (2009). A case example of art therapy in relation to dialectical behaviour therapy. International Journal of Art Therapy, 14(2), 52-63.

Monti, D. A., Kash, K. M., Kunkel, E. J., Brainard, G., Wintering, N., Moss, A. S., Rao, H., Zhu, S., & Newberg, A. B. (2012). Changes in cerebral blood flow and anxiety associated with an 8-week mindfulness programme in women with breast cancer. Stress and Health, 28(5), 397-407.

Morris, N. (2018). Dramatherapy for borderline personality disorder: Empowering and nurturing people through creativity. Routledge.

Roohan Mary Kate, Trottier Dana George. (2021) Action-based DBT: Integrating drama therapy to access wise mind. Drama Therapy Review, 7 (2), 193 https://doi.org/10.1386/dtr_00073_1

Spiegel, D., Makary, S., & Bonavitacola, L. (2020). Creative DBT activities using music: Interventions for enhancing engagement and effectiveness in therapy. Jessica Kingsley Publishers.

Von Daler, K., and Schwanbeck, L. (2014). Creative mindfulness: Dialectical behavior therapy and expressive arts therapy. In L. Rappaport (Ed.), Mindfulness and the arts therapies: Theory and practice (pp. 107-116). Jessica Kingsley Publishers.

Mary Kate Roohan, Psy.D., is a licensed psychologist and drama therapist and the founder of Thrive and Feel, a therapy practice that supports clients in managing emotional sensitivity.

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Interventions In Group Therapy For Pstd Research Paper Examples

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Group interventions in PSTD are preferred to individual treatments due to the benefits of group therapy. The group environment provides safety, cohesion and empathy. The individuals get an opportunity to form trusting relationships. There is no single treatment strategy of the condition due to the nature of its complexity. There are four main group interventions known as cognitive behavioural therapy, psychodynamic therapy, art therapy and psychological debriefing. Cognitive behaviour therapy which involves exposure and stress inoculation therapy has been proven to be quite effective. It is used to treat fear and cognitive distortions. It is a lengthy and intensive treatment.

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Art Interventions for Children With Autism Spectrum Disorder: A Scoping Review

Allison bernier.

Allison Bernier is Entry-Level Occupational Therapy Doctoral Student, Department of Occupational Therapy, University of Texas Medical Branch, Galveston.

Karen Ratcliff

Karen Ratcliff, PhD, OTR/L, is Associate Professor, Department of Occupational Therapy, University of Texas Medical Branch, Galveston.

Claudia Hilton

Claudia Hilton, PhD, OTR/L, is Associate Professor, Department of Occupational Therapy, University of Texas Medical Branch, Galveston.

Patricia Fingerhut

Patricia Fingerhut, PhD, OTR/L, is Professor and Chair, Department of Occupational Therapy, University of Texas Medical Branch, Galveston.

Chi-Ying Li

Chi-Ying Li, PhD, OTR/L, is Associate Professor, Department of Occupational Therapy, University of Texas Medical Branch, Galveston; ude.bmtu@ilihc

Associated Data

Importance: Autism spectrum disorder (ASD) is a neurological condition characterized by impairments in social interaction, communication, and behavior. Occupational therapy practitioners use creative arts interventions for children with ASD, but relevant evidence for these interventions is lacking.

Objective: To provide occupational therapists evidence of the benefit of creative arts interventions for children with ASD by evaluating treatment efficacy and connecting the evidence with the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4 ).

Data Sources: We searched peer-reviewed articles in six databases: CINAHL, Cochrane, PubMed, Ovid, PsycInfo, and Scopus. Eighteen articles published between 2000 and 2020 met Level 1b or 2b evidence criteria and were retrieved for full review; 15 were included in this scoping review.

Study Selection and Data Collection: We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to extract data. Inclusion criteria were as follows: (1) Level 1b or 2b study; (2) quantitative data; (3) published in English; (4) population of children (ages <18 yr); (5) primary diagnosis of ASD; and (6) creative arts intervention in the forms of drawing, painting, or coloring; music; or theater.

Findings: Creative arts interventions benefited children with ASD in two OTPF–4 areas (process and social interaction) pertaining to the Performance Skills domain and one OTPF–4 area (body functions) pertaining to the Client Factors domain. We found similar effects for group and individual intervention sessions, and significant improvements required multiple sessions.

Conclusions and Relevance: Our findings provide evidence for the efficacy of creative arts interventions to enhance occupation-based outcomes for children with ASD.

What This Article Adds: Our findings support occupational therapy practitioners’ use of creative arts interventions to improve OTPF–4 -based client factors and process and social interaction skills for children with ASD.

The findings of this scoping review support occupational therapy practitioners’ use of creative arts interventions to enhance occupation-based outcomes for children with autism spectrum disorder (ASD).

Autism spectrum disorder (ASD) is a neurological condition characterized by impairments in social interaction, communication, and behavior and restricted and repetitive patterns and interests ( American Psychiatric Association, 2013 ). People with ASD often have fixed behaviors and sensory processing challenges, such as tactile defensiveness ( Kern et al., 2006 ). Occupational therapy interventions help clients improve their sensory processing, behavior, and interaction skills ( Case-Smith & Arbesman, 2008 ). Some common ASD interventions used by occupational therapists include sensory-based or behavioral interventions, social cognitive training, developmental skills interventions, interactive training, and parent-mediated approaches ( Case-Smith & Arbesman, 2008 ).

The definition of art can be broad and encompass numerous different activities. Perruzza and Kinsella (2010 ) considered creative arts occupations as any arts-based activities that elicit creativity in a person. These can include painting, drawing, creative writing, music, and textile arts and crafts. We applied Perruzza and Kinsella’s (2010) notion of creative arts occupations to define art in this study. We then considered whether the selected creative arts are commonly used by occupational therapists in practice and whether they have a potential positive impact on children with ASD. Creative arts activities have been shown to have positive effects on the performance skills of children with ASD ( Bharathi, Venugopal, & Vellingiri, 2019 ; Brancatisano et al., 2020 ; Corbett et al., 2011 ; Schweizer et al., 2019 ). For example, children with ASD often have trouble communicating and interacting with others. Drawing or painting allows them to express themselves and communicate in an indirect way with others ( Schweizer et al., 2019 ). Although there is abundant research on the topic of art activities in interventions for ASD, so far no research has systematically examined how occupational therapists use different art interventions in treating children with ASD. Even though relevant evidence is lacking, occupational therapists are equipped to integrate sensory processing and behavioral skills by using art in therapy.

Creative arts interventions have been shown to be effective in targeting behavioral, social, and developmental deficits in children with ASD ( Schweizer et al., 2019 ). Creative arts allow children with ASD to express themselves through different media and provide a safe space for them to communicate and develop their skills ( Bharathi, Venugopal, & Vellingiri, 2019 ; Schweizer et al., 2019 ). Occupational therapists are well suited to use creative arts interventions in therapy with children with ASD ( Case-Smith & Arbesman, 2008 ). Using different art materials can provide a wide range of sensory experiences (e.g., auditory, tactile; Bharathi, Jayaramayya, et al., 2019 ; Schweizer et al., 2019 ) and capture the status of depression and anxiety ( Li et al., 2011 ). This unique feature of art activities can benefit people with sensory processing and emotional regulation challenges, which are common among children with ASD ( Schweizer et al., 2019 ). For example, using picture creation and visual tangible aids can help children with ASD better integrate sensory and cognitive experiences and facilitate behavioral changes ( Schweizer et al., 2019 ). However, whether art activities can improve occupation-based outcomes remains unclear, prompting the need to connect evidence with the use of creative arts interventions and occupational therapy for children with ASD.

The Occupational Therapy Practice Framework: Domain and Process ( OTPF–4; American Occupational Therapy Association [AOTA], 2020 ) outlines the scope and domain of occupational therapy practice. This framework outlines specific aspects of the practice domain that interconnect to empower a person’s identity, well-being, and participation. Occupational therapists use the OTPF–4 as a foundation for selecting interventions that address specific aspects of the occupation-based domains to maximize clients’ overall health. The OTPF–4 domains are Occupations, Client Factors, Performance Skills, Performance Patterns, and Contexts ( AOTA, 2020 ). It is important for occupational therapists to identify effective OTPF–4 -based interventions that are tailored to clients’ needs.

The two aims of this scoping review were to (1) explore specific OTPF–4 domains that can be targeted through creative arts and (2) establish efficacy evidence of art interventions in the occupational therapy literature for children with ASD. One survey conducted in Sweden found that only 44% of occupational therapists used creative arts as interventions, and most of these interventions were designed for psychiatric health care ( Müllersdorf & Ivarsson, 2012 ). This implies that although research has indicated that creative arts are an effective intervention for children with ASD ( Bharathi, Venugopal, & Vellingiri, 2019 ; Brancatisano et al., 2020 ; Corbett et al., 2011 ; Schweizer et al., 2019 ), they are still not widely used for this population in occupational therapy practice. This review fills this gap in knowledge and sheds light on how to provide evidence-based creative arts interventions for children with ASD in occupational therapy. Our findings will allow occupational therapists to incorporate evidence-based art activities into their practice when working with children who have ASD to enhance effective occupation-based art interventions.

We followed Arksey and O’Malley (2005 ) and Levac et al.’s (2010) four steps to conduct this scoping review. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Moher et al., 2009 ) procedure to document the literature selection process ( Figure 1 ). We searched six databases—CINAHL, Cochrane, PubMed, Ovid, PsycInfo, and Scopus—using the following search terms: art, painting, art therapy, drawing, creative arts therapy, color, music, theater, therapy, intervention, autism spectrum disorders, ASD, and autism . These terms reflect Perruzza and Kinsella’s (2010 ) definition of creative arts occupations. To ensure the process was thorough, a librarian who specializes in systematic reviews assisted us with the search, which identified 1,997 articles. After duplicates were removed, 1,787 articles were screened. Titles and abstracts of these 1,787 articles were reviewed for eligibility. A total of 18 full-text articles were screened for eligibility. Fifteen articles met the inclusion criteria and were included in this study.

Flow diagram of the study selection process.

Note. Figure format from “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff, and D. G. Altman; PRISMA Group, 2009, PLoS Medicine, 6 (6), e1000097. https://doi.org/10.1371/journal.pmed.1000097

Inclusion and Exclusion Criteria

We included only peer-reviewed research published from January 2000 to April 2020. The inclusion criteria were as follows: (1) Level 1b or 2b study; (2) quantitative data; (3) published in English; (4) population of children (ages <18 yr), based on the definition used by the United Nations Children’s Fund (1995) ; (5) primary diagnosis of ASD; and (6) intervention in the form of general creative arts (including drawing, coloring, painting, or making things with clay), music, and theater. We selected creative arts, music, and theater because they are commonly used by occupational therapists in practice and met our definition of creative arts ( Perruzza & Kinsella, 2010 ). We also expected them to provide positive potential benefits that would address the predominant limitations commonly seen among children with ASD.

The five exclusion criteria were (1) population of nonchildren (ages ≥18 yr); (2) a primary diagnosis other than ASD; (3) combined interventions using art and other activities (i.e., interventions that included a modified diet along with art intervention were excluded); (4) interventions with multiple modalities that were expected to confound the effect of art interventions, including virtual reality, robots, auditory integration therapy, music-evoked rewards, or sound beam imitation; and (5) use of only qualitative outcome measures.

Occupational Therapy Practice Framework

We used the latest edition of the OTPF , the OTPF–4 ( AOTA, 2020 ). This edition is similar to the previous one; however, the OTPF–4 modified domains to outline additional areas in which occupational therapists have knowledge and skills and the process that describes client-centered and occupation-based interventions. The OTPF–4 is composed of five domains: (1) Occupations, (2) Contexts, (3) Performance Patterns, (4) Performance Skills, and (5) Client Factors. Each OTPF–4 domain contains detailed subcategories.

We used the OCEBM Levels of Evidence Working Group (2009 ) guidelines to determine the level of evidence for each screened article. We included only articles with a 1b or 2b level of evidence. Level 1b evidence is defined as “well-designed individual randomized controlled trial (RCT),” in other words, not a pilot or feasibility study with a small sample, and Level 2b evidence is defined as “individual prospective cohort study, low-quality RCT (e.g., <80% follow-up or low number of participants; pilot and feasibility RCT studies), ecological studies and two-group, nonrandomized studies” ( AOTA, 2022 ). To determine the risk of bias for each article, we used two assessment guidelines: (1) Higgins et al.’s (2019) chapter “Assessing Risk of Bias in a Randomized Trial” for low-quality RCT studies and (2) Study Quality Assessment Tools from the National Heart, Lung, and Blood Institute (2014 ) for pre–post studies that did not include a control group. In addition, we summarized the treatment intensity of each included study to provide transparency for the used art interventions. We also analyzed outcome measures of the included studies and linked the outcome measures with detailed and specific aspects of the OTPF–4 domain descriptions. We then analyzed and synthesized the OTPF–4 domains targeted through creative arts interventions.

Overview of Study Characteristics

A summary of the characteristics of each study is provided in Table A.1 in the Supplemental Appendix, available online with this article at https://research.aota.org/ajot . A total of 1,171 participants were represented by the included studies, with individual sample sizes varying from 9 to 364. Participants’ ages ranged from 3.5 yr to 16 yr. Four of 15 studies were conducted outside of the United States ( Chincholkar et al., 2019 ; Crawford et al., 2017 ; Koo & Thomas, 2019 ; Poquérusse et al., 2018 ). Three used general creative arts (painting, drawing, and clay use) activity interventions ( Chincholkar et al., 2019 ; Koo & Thomas, 2019 ; Richard et al., 2015 ), 8 used music interventions ( Bharathi, Jayaramayya, et al., 2019 ; Bieleninik et al., 2017 ; Crawford et al., 2017 ; Gattino et al., 2011 ; LaGasse, 2014 ; Poquérusse et al., 2018 ; Sharda et al., 2018 ; Simpson et al., 2013 ), and 4 used theater interventions ( Corbett et al., 2016 , 2017 , 2019 ; Ioannou et al., 2020 ). Individual treatment sessions ranged from 30 min to 4 hr. Intensity ranged from a single intervention session to three sessions a week over the course of 5 mo. The art interventions used, and the duration of each intervention, are outlined in Table A.2. We suggest that occupational therapists use Table A.2 as a guideline when designing and incorporating art interventions into their work with children with ASD to promote evidence-based practice.

Levels of Evidence

In accordance with established guidelines ( U.S. Preventive Services Task Force, 2018 ), we examined the level of evidence for each study and identified 7 articles as Level 1b ( Bieleninik et al., 2017 ; Corbett et al., 2017 , 2019 ; Crawford et al., 2017 ; Ioannou et al., 2020 ; Sharda et al., 2018 ; Simpson et al., 2013 ) and 8 as Level 2b ( Bharathi, Jayaramayya, et al., 2019 ; Chincholkar et al., 2019 ; Corbett et al., 2016 ; Gattino et al., 2011 ; Koo & Thomas, 2019 ; LaGasse, 2014 ; Poquérusse et al., 2018 ; Richard et al., 2015 ). Details of each study’s design are provided in Table A.1.

Risk of Bias

Nine RCT studies had a moderate risk of bias ( Bharathi, Jayaramayya, et al., 2019 ; Corbett et al., 2016 , 2017 , 2019 ; Ioannou et al., 2020 ; Koo & Thomas, 2019 ; LaGasse, 2014 ; Richard et al., 2015 ; Simpson et al., 2013 ). Five articles were determined to have a low risk of bias ( Bieleninik et al., 2017 ; Crawford et al., 2017 ; Gattino et al., 2011 ; Poquérusse et al., 2018 ; Sharda et al., 2018 ). One article was a one-group pre–post study ( Chincholkar et al., 2019 ), and we determined it to have a low risk of bias. Tables A.3 and A.4 provide detailed risk-of-bias information for each study.

Outcome Measures

Several outcome measures were used among the studies. Four studies used the Childhood Autism Rating Scale (CARS) or second version (CARS-2) ( Bharathi, Jayaramayya, et al., 2019 ; Chincholkar et al., 2019 ; Gattino et al., 2011 ; Koo & Thomas, 2019 ), and 4 studies used the Peer Interaction Paradigm ( Corbett et al., 2016 , 2017 , 2019 ; Ioannou et al., 2020 ). Two studies each used the Autism Diagnostic Observation Schedule ( Bieleninik et al., 2017 ; Crawford et al., 2017 ), the Social Responsiveness Scale (SRS; Corbett et al., 2016 ; LaGasse, 2014 ), the Developmental NEuroPSYchological Assessment (NEPSY; Corbett et al., 2016 , 2019 ), or the State–Trait Anxiety Inventory for Children ( Corbett et al., 2017 ; Ioannou et al., 2020 ). Chincholkar et al. (2019 ) also used the Vineland Social Maturity Scale to measure social maturity and social behavior. Other measures used were the Diagnostic Analysis of Nonverbal Accuracy 2, the Child Facial Expressions subscale (DANVA 2–CF; Richard et al., 2015 ), the Children’s Communication Checklist–2 (CCC–2; Sharda et al., 2018 ), the Beach Family Quality of Life Scale (FQoL; Sharda et al., 2018 ), the Vineland Adaptive Behavior Scales, Maladaptive Behavior subscale ( Sharda et al., 2018 ), the Autism Treatment Evaluation Checklist (ATEC; LaGasse, 2014 ), the TRIAD Special Skills Assessment ( Bharathi, Jayaramayya, et al., 2019 ), salivary α-amylase ( Poquérusse et al., 2018 ), observation of engagement and problem behaviors ( Simpson et al., 2013 ), the Adaptive Behavior Assessment System ( Corbett et al., 2016 ), the PSI-SF and short version of the Warwick–Edinburgh Mental Well-Being Scale ( Crawford et al., 2017 ), and the PPVT–2 ( Sharda et al., 2018 ; see Table A.1).

Fourteen of 16 outcome measures had good reliability ( r > .80) and construct validity ( Ahmad & Warriner, 2001 ; Corbett et al., 2016 , 2017 ; de Bildt et al., 2005 ; Doll, 1936 ; Hoffman et al., 2006 ; Lord et al., 2000 ; Magiati et al., 2011 ; Norbury et al., 2004 ; Nowicki & Duke, 2008 ; Poquérusse et al., 2018 ; Ruble et al., 2008 ; Schopler et al., 1980 ; Simpson et al., 2013 ). The two outcome measures with lower reliability ( r < .80) were the SRS and the DANVA 2–CF ( Corbett et al., 2016 ). The SRS specifically had lower reliability for females ( r < .80) but higher reliability for males ( r > .80; Corbett et al., 2016 ; Nowicki & Duke, 2008 ). The CARS, CCC–2, FQol, and ATEC had shorter administration times, only 5 to 15 min ( Hoffman et al., 2006 ; Magiati et al., 2011 ; Norbury et al., 2004 ; Schopler et al., 1980 ). The NEPSY took the longest to administer, 2 to 5 hr ( Ahmad & Warriner, 2001 ).

Summary of Creative Arts Interventions for Children With Autism Spectrum Disorder

We categorized the creative arts interventions into three categories: (1) general activities ( n = 3), (2) music ( n = 8), and (3) theater ( n = 4). In the sections that follow, we summarize the findings for each category.

General Activities

Three studies used general creative activities of drawing, painting, or coloring ( Chincholkar et al., 2019 ; Koo & Thomas, 2019 ; Richard et al., 2015 ). Two studies used 30-min sessions, with 1 study consisting of eight 30-min sessions ( Koo & Thomas, 2019 ) and the other consisting of 16 30-min sessions over 2 mo ( Chincholkar et al., 2019 ). In both studies, each session allowed the child to choose their art material (draw, paint, clay, or craft) to work through basic art concepts and motor skills ( Koo & Thomas, 2019 ; Chincholkar et al., 2019 ), which focuses on drama, risk taking, and problem-solving skills in children. The third study used an intervention that consisted of asking the child to use the facial features of a mouth, nose, eyes, and eyebrows to construct four different faces—happy, sad, angry, and fearful—in one 60-min session ( Richard et al., 2015 ).

Two of the 3 studies observed a positive effect in children with ASD. Koo and Thomas (2019 ) found a notable increase in social reply consistency and level of intellectual response relating to others as measured with the CARS. Chincholkar et al. (2019 ) found considerable improvements in visual response, verbal communications, and social communication. However, Richard et al. (2015 ) found no statistically significant difference in the ability to recognize emotions from before to after the intervention for the control and intervention groups. None of the articles examined whether positive improvements lasted after intervention.

Eight studies examined the effect of music interventions ( Bharathi, Jayaramayya, et al., 2019 ; Bieleninik et al., 2017 ; Crawford et al., 2017 ; Gattino et al., 2011 ; LaGasse, 2014 ; Poquérusse et al., 2018 ; Sharda et al., 2018 ; Simpson et al., 2013 ).

Three studies used structured individual music interventions to address specific learning skills ( Bieleninik et al., 2017 ; Crawford et al., 2017 ; Sharda et al., 2018 ). This type of intervention required one to three 30- to 45-min sessions per week for 2 to 5 mo. The sessions focused on singing or musical play to target attention, synchronizing (doing what the therapist is doing), mirroring (matching the therapist, in both music and body language), and grounding (organizing and steadying the music; Bieleninik et al., 2017 ); playing tuned or untuned percussion or wind instruments to target therapy session engagement and tolerance level to choose new or different musical instruments ( Crawford et al., 2017 ); or using musical instruments, singing, or rhythmic cues to target communication, taking turns, integrating senses, and musical interaction ( Sharda et al., 2018 ).

Three studies used less structured 1:1 interventions that required higher levels of improvisation ( Bharathi, Jayaramayya, et al., 2019 ; Gattino et al., 2011 ; Poquérusse et al., 2018 ). These types of interventions involved singing, dancing, and playing with the musical instruments while listening to songs ( Bharathi, Jayaramayya, et al., 2019 ); playing with the musical instruments and listening to music when a song was played on a CD player ( Gattino et al., 2011 ); or peer interaction and discussion about the emotions felt when listening to different musical pieces ( Poquérusse et al., 2018 ). One study allowed for the group to improvise a performance using the musical instruments ( Poquérusse et al., 2018 ).

One study was conducted in small groups ( LaGasse, 2014 ). These 50-min small-group sessions occurred twice a week for 5 wk. Sessions consisted of creating structured group musical experiences and encouraged participants to listen to and communicate with each other. The children were provided sensory experiences, such as sitting on therapy balls, jumping, running, stomping, or deep pressure, before and after the group music, and the sessions ended with cooperative play ( LaGasse, 2014 ). Simpson et al. (2013 ) used music as a way to deliver instructions in the intervention and found that children with ASD engaged more in a labeling task if the instructions were sung rather than spoken.

All 8 of these studies found at least one positive effect of using music in interventions with children with ASD. These improvements were seen specifically in verbal communication (e.g., speech and semantics), engagement, social awareness, social relations (e.g., increasing family interactions), less parental stress, less child stress, more joint attention, improved eye gaze, better understanding and perspective taking, more responding to others, and improved ability to maintain social interactions and interests. Among these 8 studies, 1 found that only nonverbal communication improved ( Gattino et al., 2011 ) and that maladaptive behaviors, such as inappropriate initiations and ASD– like mannerisms, were reduced. Two studies found no significant difference in the initiation of postintervention communication compared with the control group ( Bharathi, Jayaramayya, et al., 2019 ; LaGasse, 2014 ). One study found no difference in children’s responses to communication, social withdrawal, ATEC speech and communication scores, sociability, and health and physical behavior before and after the intervention ( LaGasse, 2014 ). Bharathi, Jayaramayya, et al. (2019 ) also found that the positive effect did not last in the posttest and follow-up periods. Simpson et al. (2013 ) found that singing had a notable effect on engagement but not on reducing challenging behaviors.

Four studies used theater interventions, specifically, the Social Emotional NeuroScience Endocrinology (SENSE) theater approach ( Corbett et al., 2016 , 2017 , 2019 ; Ioannou et al., 2020 ). This intervention is delivered through 10 4-hr group sessions and incorporates peer support using learning theory behavioral strategies. It involves theater games, role playing, improvisation, character development, rehearsals, and the production of a play ( Corbett et al., 2016 , 2017 , 2019 ; Ioannou et al., 2020 ). Three of the 4 studies also used video modeling, in which children were asked to watch 20 videos and practice target behaviors, including acting out songs and role plays for about 15 min a day ( Corbett et al., 2016 , 2017 ; Ioannou et al., 2020 ).

All 4 studies found positive effects of theater interventions in children with ASD. Specific improvements were seen in solicited group play, unsolicited group play, trait anxiety, social cognition, cortisol levels, social ability, communication symptoms, playing with toys with peers around, immediate memory of faces, delayed memory of faces, and Theory of Mind. A significant decrease in isolated play was also reported ( Ioannou et al., 2020 ). One study found that improvements in communication lasted for 2 mo after the intervention ( Corbett et al., 2016 ). Although 1 study found improvements in unsolicited group play ( Ioannou et al., 2020 ), another observed no difference ( Corbett et al., 2019 ). One study found no difference in unsolicited self-play ( Ioannou et al., 2020 ). Two studies found no change in state anxiety levels ( Corbett et al., 2017 ; Ioannou et al., 2020 ). State anxiety is defined as a temporary reaction to an event, whereas trait anxiety is defined as a more stable personality feature ( Saviola et al., 2020 ).

Connecting Effectiveness of Art Interventions With the OTPF–4

All studies targeted at least one aspect of the OTPF–4 domains (Table A.5). Fourteen of the 15 used interventions that targeted aspects of the Performance Skills domain. Twelve of those 14 studies targeted OTPF–4 social interaction skills ( Bharathi, Jayaramayya, et al., 2019 ; Bieleninik et al., 2017 ; Chincholkar et al., 2019 ; Corbett et al., 2016 , 2019 ; Crawford et al., 2017 ; Gattino et al., 2011 ; Ioannou et al., 2020 ; Koo & Thomas, 2019 ; LaGasse, 2014 ; Richard et al., 2015 ; Sharda et al., 2018 ). Two of the 14 focused on process skills, which are part of the Performance Skills domain ( LaGasse, 2014 ; Simpson et al., 2013 ). Seven studies targeted Client Factors, specifically, body functions. Among these 7, 3 targeted the body function of specific mental functions, such as higher level cognitive processes; attention; and emotional and global mental functions, such as temperament and personality ( Bieleninik et al., 2017 ; Corbett et al., 2019 ; Sharda et al., 2018 ). The remaining 4 studies targeted specific emotional functions, as part of mental functions of the body functions category ( Corbett et al., 2017 ; Crawford et al., 2017 ; Ioannou et al., 2020 ; Poquérusse et al., 2018 ).

The purpose of this scoping review was to identify specific OTPF–4 domains in which creative arts interventions can be effectively used by occupational therapists to help children with ASD. On the basis of evidence from 15 selected articles, we found that the evidence from 13 supports the efficacy of drawing and painting, music, and theater for children with ASD. Evidence supports the idea that creative arts activities specifically target the OTPF–4 Performance Skills and Client Factors domains. These creative arts interventions appear to have a similar impact on outcomes regardless of whether they are delivered to a group or an individual.

We found strong evidence to support the efficacy of creative arts interventions for children with ASD. Fourteen of the 15 studies used a control group for comparison. Although all creative arts interventions targeted different aspects of the child, no specific art form showed a greater effect than the others. The evidence suggests that art interventions allow children with ASD to express themselves through different media and gain a different perspective about themselves, others, and the world around them. The elements provided by art interventions appear to facilitate social learning in children with ASD. Our review supports the idea that creative art forms of the three included interventions (drawing and painting, music, and theater) influence the OTPF–4 Performance Skills and Client Factors domains for children with ASD. Our review also provides evidence of the benefit of using different creative art delivery formats and durations to enhance occupation-based skills for children with ASD.

One of the 15 articles found a nonsignificant result ( Richard et al., 2015 ). This intervention involved only one session and targeted performance skills. Richard et al.’s (2015 ) approach was to ask children to construct four different faces (happy, sad, angry, and fearful), using facial features of a mouth, nose, eyes, and eyebrows. The outcome measure was the DANVA 2–CF, which is used to assess facial expressions. The results indicated that both the control and intervention groups had a slight increase in scores, but neither within- nor between-groups differences were found in posttest scores. Richard et al.’s (2015) study also had a moderate risk of bias, implying that constructing facial expressions may not be an effective approach to use with children with ASD. This may be due to the fact that emotions do not have concrete features, so children with ASD cannot easily capture proper facial expressions.

We expect that children with ASD may require multiple sessions before the impact of an art intervention is observed. However, 1 article found that a single session of music intervention resulted in reduced stress levels ( Poquérusse et al., 2018 ). Perhaps the client factor of stress level is more responsive to a single creative art activity session than the performance skills addressed in Richard et al. (2015 )’s study.

General creative arts activities (e.g., painting or drawing) examined in this review were found to affect only targeted performance skills (social interaction skills). Our findings are consistent with those of previous research reporting that art activities, such as painting and drawing, can improve communication and social skills in children with ASD through effective self-expression ( Schweizer et al., 2019 ). Through general art activities, children with ASD are given unique sensory experiences to safely communicate and develop social skills with the therapist or other children ( Schweizer et al., 2019 ). Painting and drawing allow children with ASD to communicate through alternative channels and enhance self-expression ( Chincholkar et al., 2019 ).

Music interventions targeted OTPF–4 Client Factors and Performance Skills of social interaction and process skills. Music has been shown to improve arousal and attention ( Bharathi, Venugopal, & Vellingiri, 2019 ) and communication skills ( Brancatisano et al., 2020 ) in children with ASD. Our findings are consistent with those of previous studies and support the incorporation of music into occupational therapy interventions. Music activates specific parts of the brain, which can stimulate learning processes in children with ASD, resulting in positive behavioral changes ( Bharathi, Jayaramayya, et al., 2019 ). Music also allows children with ASD to express themselves nonverbally ( Bharathi, Venugopal, & Vellingiri, 2019 ), facilitating the active development of social skills.

Theater interventions were found to target social interaction skills (Performance Skills domain) as well as attention, emotion regulation, temperament, and personality (Client Factors domain). Our occupation-based review also supports previous research suggesting that theater interventions can enhance social skills and communication skills in children with ASD ( Corbett et al., 2011 ). Previous research also suggests that the repetition and rehearsal aspects of theater interventions enhance learning and lead to improvements in social skills and communication. Through theatrical features, such as modeled behavior, children with ASD can learn how to identify social cues and develop positively reinforced appropriate behaviors ( Corbett et al., 2011 ).

Implications for Future Research

Research with a higher level of evidence, such as multisite RCTs, is still needed to support the effectiveness of creative arts interventions for children with ASD. At present, no guideline exists to help occupational therapists design treatment plans that include creative arts components for children with ASD. We suggest that future research examine whether one form, or a combination of multiple creative art forms, is more effective. In addition, future research could determine whether certain creative arts activities are more useful in developing performance and participation in certain OTPF–4 domains and whether specific durations and intensity are most effective.

Limitations

We included only Level 1b or 2b evidence in this review; we excluded studies at other evidence levels. Although it is important to review higher level evidence, studies at other evidence levels may provide crucial information. For example, we noticed numerous case studies and feasibility studies that examined the efficacy of painting and drawing interventions, but we excluded them because of our inclusion and exclusion criteria. Also, all 4 of the theater interventions used the same theater intervention structure, SENSE theater. Although the intervention was supported by the evidence, our review did not include studies with other types of theater interventions. Therefore, our findings may have limited generalizability regarding the art modalities that can be recommended for this target population.

Implications for Occupational Therapy Practice

This review has several implications for occupational therapy practice. First, the findings support occupational therapists’ use of creative arts interventions to enhance performance skills and client factors among children with ASD. Painting and drawing, theater, and music interventions were found to be beneficial in several OTPF–4 domains. Occupational therapists can incorporate creative arts components into their interventions when working with children with ASD. Second, occupational therapists can design creative arts interventions for children with ASD that are based on the duration and intensity provided in Table A.2. We also suggest that more than one treatment session may be more effective when targeting performance skills. Finally, our review supports the concept that different OTPF–4 domains can be enhanced through the use of different forms of creative arts interventions for children with ASD. Occupational therapists can provide evidence-based creative arts interventions to meet the needs of this population.

This review provides evidence of the efficacy of creative arts interventions to enhance occupation-based outcomes for children with ASD. This scoping review indicates that painting, drawing, music, and theater can improve OTPF–4 client factors and performance skills in children (ages 3.5–16 yr) with ASD, specifically in process/social interaction skills and body functions. Our findings suggest that multiple sessions may produce more substantial improvements and should be used when targeting performance skills. We also found that group and individual intervention sessions had similar treatment effects for children with ASD. To support evidence-based practice, we recommend that occupational therapists design creative arts interventions for children with ASD based on the duration and intensity provided in this review. Our findings support occupational therapists’ incorporation of creative arts components in the treatment of children with ASD to enhance client factors, process, and social interaction skills.

Supplementary Material

Supplemental information, acknowledgments.

This study was funded in part by the National Institutes of Health, National Institute of Child Health and Human Development (K01HD101589; Chih-Ying Li, principal investigator). The authors declare no conflicts of interest in any regard with respect to publishing this article. We do not believe author biases in regard to social, ethnic, or cultural variables existed as this article was being prepared. This scoping review is registered in the Open Science Framework ( https://osf.io/akqjy ; because this is an open-ended registration, our review does not have a registration number but can be searched online).

* Indicates studies included in the scoping review.

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