2017 Interventions That Utilize Expressive Arts Therapy as a Strategy to Resolve Personal Issues
Introduction
Mental disorders institute a huge social and economic burden for health care systems worldwide (Zschucke et al., 2013; Kenbubpha et al., 2018). In Mainland china, the lifetime prevalence of mental disorders was 24.20%, and 1-month prevalence of mental disorders was fourteen.27% (Xu et al., 2017). The situation is more than severely in other countries, particularly for developing ones. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, in that location is an urgent need to implement scalable mental health interventions to address this burden. While pharmacological treatment is the commencement choice for mental disorders to convalesce the major symptoms, many antipsychotics contribute to poor quality of life and debilitating agin effects. Therefore, clinicians have turned toward to complementary treatments, such equally art therapy in addressing the health needs of patients more than half a century ago.
Art therapy, is defined past the British Association of Art Therapists equally: "a form of psychotherapy that uses art media equally its primary way of expression and communication. Clients referred to fine art therapists are not required to take experience or skills in the arts. The fine art therapist's primary concern is non to make an esthetic or diagnostic assessment of the client'southward image. The overall goal of its practitioners is to enable clients to modify and abound on a personal level through the utilise of artistic materials in a prophylactic and user-friendly environment" (British Association of Art Therapists, 2015), whereas every bit: "an integrative mental wellness and human services profession that enriches the lives of individuals, families, and communities through agile art-making, creative procedure, applied psychological theory, and human being experience within a psycho-therapeutic human relationship" (American Art Therapy Clan, 2018) according to the American Art Association. Information technology 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 utilise many dissimilar art materials as media (i.e., visual art, painting, drawing, music, dance, drama, and writing) (Deshmukh et al., 2018; Chiang et al., 2019). Amongst them, drawings and paintings accept been historically recognized equally the nigh useful role of therapeutic processes inside psychiatric and psychological specialties (British Association of Fine art Therapists, 2015). Moreover, many other art forms gradually fall nether the prevue of their own professions (e.one thousand., music therapy, dance/motion therapy, and drama therapy) (Deshmukh et al., 2018). Thus, we excluded these studies and simply focused on studies of art therapy which mainly includes painting and cartoon as media. Specifically, information technology focuses on capturing psychodynamic processes past means of "inner pictures," which go visible past the artistic procedure (Steinbauer et al., 1999). These pictures reflect the psychopathology of unlike psychiatric disorders and even their respective therapeutic procedure based on specific rules and benchmark (Steinbauer and Taucher, 2001). Information technology has been gradually recognized and used every bit an alternative treatment for therapeutic processes inside psychiatric and psychological specialties, equally well as medical and neurology-based scientific audiences (Burton, 2009).
The development of fine art therapy comes partly from the creative expression of the conventionalities 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 chief functions equally 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).
Notwithstanding, 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, then as to provide more clinical treatment options and research directions for therapists and researchers.
Publications of Fine art Therapy
The literatures almost "fine art therapy" published from Jan 2006 to December 2020 were searched in the PubMed database. The post-obit topics were used: Championship/Abstruse = "fine art therapy," Indexes Timespan = 2006–2020.
A total of 652 records were found. And then, we manually screened out the literatures that contained the word "art" but was not relevant with the field of study of this study, such as state of the art therapy, antiretroviral therapy (Fine art), and assisted reproductive technology (ART). Finally, 479 records nearly fine art therapy were identified. Since nosotros 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 nigh art therapy.
Equally we tin run into, the number of literature about art therapy is increasing slowly in the last 15 years, reaching a peak in 2020. This indicates that more attempt was made on this topic in recent years (Figure 1).
Overview of Art Therapy
As defined by the British Association of Art Therapists, fine art therapy is a form of psychotherapy that uses art media as its primary mode of communication. Based on to a higher place literature, several highlights need to be summarized. (1) The main media of art therapy include painting, drawing, music, drama, trip the light fantastic, drama, and writing (Chiang et al., 2019). (2) Main contents of painting and cartoon include blind drawing, screw 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 feet, autism, dementia and cognitive harm, 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 directly verbal interaction becomes difficult, and provides a safe and indirect style 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 propose that art therapy can non simply be served as an useful therapeutic method to assist patients to open up up and share their feelings, views, and experiences, merely too equally an auxiliary treatment for diagnosing diseases to aid medical specialists obtain complementary data different from conventional tests.
Art Therapy for Mental Disorders
Based on the 413 searched literatures, we further express them to mental disorders using the post-obit central words, respectively: Depression OR anxiety OR Cerebral impairment OR dementia OR Alzheimer'southward affliction OR Autism OR Schizophrenia OR mental disorder. As a result, a total of 23 studies (5%) (Table i) were included and classified subsequently reading the abstract and the full text carefully. These studies include 9 articles on depression and anxiety, four manufactures on cognitive harm and dementia, 3 articles on Alzheimer's affliction, three articles on autism, and 4 articles on schizophrenia. In add-on 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 fine art therapy in mental diseases.
Depression Disorders and Feet
Depression and feet disorders are highly prevalent, affecting individuals, their families and the private'due south role in society (Birgitta et al., 2018). Depression is a disabling and costly condition associated with a pregnant reduction in quality of life, medical comorbidities and bloodshed (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 nigh commonly used constructive way to relieve symptoms of low and anxiety. Nevertheless, nonadherence are crucial shortcomings in using antidepressant to treat depression and anxiety (van Geffen et al., 2007; Nielsen et al., 2019).
In contempo years, many studies have shown that fine art therapy plays a significant part 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 written report nearly fine 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, fine 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 grouping painting therapy on thirty patients with depression for three months, and found that painting therapy could promote their social function recovery, meliorate their social adaptability and quality of life. Another randomized clinical trial as well showed that it could decrease hateful anxiety scores in the 3–12 twelvemonth painting group (Forouzandeh et al., 2020).
Studies have shown that distress, including anxiety and low, 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 better 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 fine art therapy for cancer patients could enhance the vitality of patients and participation in social activities, significantly reduce depression, anxiety, and reduce stressful feelings. Chiefly, fifty-fifty in the follow-upwards period, art therapy still has a lasting consequence on cancer patients (Thyme et al., 2009). Interestingly, fine 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 intendance, 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 exterior civilisation, thereby diminishing depressed and anxiety symptoms.
Cognitive Impairment, and Dementia
Dementia, a progressive clinical syndrome, is characterized by widespread cognitive damage in memory, thinking, beliefs, emotion and functioning, leading to worse daily living (Deshmukh et al., 2018). Co-ordinate to the Alzheimer's Disease International 2015, there is 46.viii 1000000 people suffered from dementia, and numbers well-nigh doubling every 20 years, ascent to 131.v million by 2050. Although fine 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 (Superhighway, 2013), whereas two other randomized controlled trials (Hattori et al., 2011; Rusted et al., 2016) on patients with dementia have failed to obtain meaning cognitive improvement in the painting grouping. Moreover, a cochrane systematic review (Deshmukh et al., 2018) included 2 clinical studies of art therapy for dementia revealed that at that place is no sufficient evidence about the efficacy of art therapy for dementia. This may exist because patients with severely cognitive impairment, who was unable to accurately recollect or assess their own behavior or mental state, might lose the ability to enjoy the benefits of fine art therapy.
In summary, we should intervene earlier in patients with mild cerebral impairment, an intermediate stage between normal aging and dementia, in order to foreclose further transformation into dementia. To date, mild cerebral harm is drawing much attending to the importance of painting intervening at this phase in order to modify the course of subsequent cognitive reject every bit 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 date from multiple sessions of painting therapy, it is probable that painting therapy could atomic number 82 to enhanced cognitive functioning for these patients.
Alzheimer'southward Illness
Alzheimer'due south disease (AD) is a sub-blazon of dementia, which is normally associated with chronic pain. Previous studies suggested that art therapy could be used equally a complementary handling to relief pain for these patients since medication might induce severely side effects. In a multicenter randomized controlled trial, 28 mild Advertizing patients showed significant pain reduction, reduced anxiety, improved quality of life, improved digit bridge, and inhibitory processes, every bit well equally reduced depression symptoms after 12-week painting (Pongan et al., 2017; Alvarenga et al., 2018). Further report also suggested that private therapy rather than group therapy could exist more optimal since neuroticism can decrease efficacy of painting intervention on hurting in patients with mild AD. In addition to release chronic pain, art therapy has been reported to testify positive effects on cognitive and psychological symptoms in patients with mild AD. For example, a controlled study revealed meaning improvement in the apathy scale and quality of life after 12 weeks of painting handling mainly including colour abstruse patterns with pastel crayons or water-based paint (Hattori et al., 2011). Some other study also revealed that Advertising patients showed comeback 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 just practise sufferers feel "positive" symptoms such every bit hallucinations, delusions, simply too experience negative symptoms such as varying degrees of anhedonia and asociality, impaired working memory and attention, poverty of oral communication, and lack of motivation (Andreasen and Olsen, 1982). Many patients with schizophrenia remain symptomatic despite pharmacotherapy, and even attempts to suicide with a charge per unit 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 non articulate whether art therapy leads to clinical improvement in schizophrenia with low (Ruiz et al., 2017). Anyway, many randomized clinical trials reported positive outcomes. For case, Richardson et al. (2007) conducted painting therapy for six months in patients with chronic schizophrenia and constitute that art therapy had a positive upshot on negative symptoms. Teglbjaerg (2011) examined experience of each patient using interviews and written evaluations before and later painting therapy and at a 1-year follow-upward and found that group painting therapy in patients with schizophrenia could non only reduce psychotic symptoms, simply also boost self-esteem and improve social role.
What'south more than, the characteristics of the painting tin also be used to judge the health condition in patients with schizophrenia. For case, Hongxia et al. (2013) explored the correlation betwixt psychological wellness status and characteristics of House-Tree-Person tests for patients with schizophrenia, and showed that the particular characteristic of the test results tin exist used to approximate the patient'southward anxiety, depression, and obsessive-compulsive symptoms.
Most importantly, several other studies showed that drug plus painting therapy significantly enhanced patient compliance and self-cognition than drug therapy alone in patients with schizophrenia (Hongyan and JinJie, 2010; Min, 2010).
Autism
Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental syndrome with no unified pathological or neurobiological etiology, which is characterized past difficulties in social interaction, communication issues, and a tendency to engage in repetitive behaviors (Geschwind and Levitt, 2007).
Fine art therapy is a form of expression that opens the door to communication without verbal interaction. Information technology provides therapists with the opportunity to interact ane-on-one with individuals with autism, and brand broad connections in a more comfy and effective way (Babaei et al., 2020). Emery (2004) did a case study about a 6-yr-former boy diagnosed with autism and found that art therapy is of great value to the evolution, growth and advice skills of the male child. Recently, one written report (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 feel by using nonverbal expressions is crucial to their evolution. Evans and Dubowski (2001) believed that creating images on paper could help children express their internal images, thereby heighten their imagination and abstruse thinking. Painting can also aid autistic children express and vent negative emotions and thereby bring positive emotional feel and promote their self-consciousness (Martin, 2009). According to two studies (Wen and Zhaoming, 2009; Jianhua and Xiaolu, 2013) in Cathay, Art therapy could also improve the language and advice skills, cognitive and behavioral performance of children with ASD.
Moreover, art therapy could be used to investigate the relationship between cerebral processes and imagination in children with ASD. One report (Wen and Zhaoming, 2009; Jianhua and Xiaolu, 2013) suggested that children with ASD apply a unique cognitive strategy in imaginative cartoon. Another study (Depression et al., 2009) examined the cognitive underpinnings of spontaneous imagination in children with ASD and showed that ASD group lacks imagination, generative power, 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 inventiveness via drawing tasks.
In a give-and-take, fine art therapy plays a significant role in children with ASD, not only as a method of handling, but too in understanding and investigating patients' problems.
Other Applications
In addition to the to a higher place mentioned diseases, fine art therapy has also been adopted in other applications. Dysarthia is a common sequela of cognitive palsy (CP), which directly affects children's language intelligibility and psycho-social adjustment. Speech therapy does not ever assist 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 past both patients and therapists. Most often, art therapy could strengthen patient'southward 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 estimation.
The Awarding Prospects of Fine art Therapy
With the development of modern medical technology, life expectancy is also increasing. At the aforementioned fourth dimension, it besides brings some side effects and psychological problems during the treatment procedure, especially for patients with mental disease. 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, nosotros constitute that art therapy was virtually 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 data that is difficult to proceeds from conventional tests, guess the severity and progression of diseases, and understand patients' psychological state from painting characteristics, but besides is an useful therapeutic method, which helps patients open up and share their feelings, views, and experiences. Additionally, the implementation of fine art therapy is not limited past historic period, language, diseases or surround, and is piece of cake to exist accepted by patients.
Art therapy in hospitals and clinical settings could be very helpful to aid treatment and therapy, and to raise communications between patients and on-site medical staffs in a non-exact way. Moreover, art therapy could be more constructive when combined with other forms of therapy such equally music, trip the light fantastic and other sensory stimuli.
The medical mechanism underlying art therapy using painting equally 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 amend the quality of life and mental health of patients, standard and rigorous clinical trials with large samples are all the same defective. Moreover, the long-term result is even so to be assessed due to the lack of follow-up cess of fine art therapy.
In some cases, art therapy using painting equally the medium may be hard to exist 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 unit environments. Nevertheless, these difficulties can be overcome due to slap-up benefits of the art therapy. Nosotros thus humbly believe that art therapy has neat potential for mental disorders.
In the hereafter, art therapy may exist more thoroughly investigated in the following directions. First, more high-quality clinical trials should exist carried out to gain more than reliable and rigorous evidence. Second, the evaluation methods for the effectiveness of art therapy demand to be as diverse as possible. Information technology is necessary for the investigation to include not simply subjective scale evaluations, simply also objective ways such equally encephalon imaging and hematological examinations to be more convincing. Third, it volition exist 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 machinery of the therapy. This practice should be continuously promoted in both hospitals and communities. Quaternary, guidelines nigh art therapy should exist gradually formed on the footing of accumulated prove. Finally, mechanism of art therapy should be further investigated in a multifariousness of means, such equally 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.
Funding
This study was financially supported by the National Key R&D Program of China (2019YFC1712200), International standards enquiry on clinical enquiry and service of Acupuncture-Moxibustion (2019YFC1712205), the National Natural Science Foundation of China (62006220), and Shenzhen Science and Technology Research Plan (No. JCYJ20200109114816594).
Conflict of Involvement
The authors declare that the enquiry was conducted in the absence of whatsoever commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher'south Annotation
All claims expressed in this article are solely those of the authors and practise not necessarily correspond those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Whatsoever product that may be evaluated in this commodity, or merits that may be made by its manufacturer, is non guaranteed or endorsed by the publisher.
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