Art Making as a Mental Health Recovery Tool for Change and Coping

Introduction

Mental disorders institute a huge social and economic burden for wellness care systems worldwide (Zschucke et al., 2013; Kenbubpha et al., 2018). In Prc, 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 than severely in other countries, especially for developing ones. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, at that place is an urgent demand to implement scalable mental wellness interventions to address this burden. While pharmacological treatment is the first selection for mental disorders to alleviate the major symptoms, many antipsychotics contribute to poor quality of life and debilitating agin effects. Therefore, clinicians take turned toward to complementary treatments, such as art therapy in addressing the health needs of patients more than than half a century ago.

Art therapy, is defined by the British Association of Fine art Therapists as: "a form of psychotherapy that uses fine art media as its primary mode of expression and advice. Clients referred to art therapists are non required to have experience or skills in the arts. The art therapist's chief 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 homo services profession that enriches the lives of individuals, families, and communities through active art-making, creative procedure, applied psychological theory, and homo experience inside a psycho-therapeutic relationship" (American Art Therapy Clan, 2018) according to the American Art Association. It has gradually go a well-known class 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, cartoon, music, trip the light fantastic, drama, and writing) (Deshmukh et al., 2018; Chiang et al., 2019). Among them, drawings and paintings have been historically recognized as the almost useful part of therapeutic processes within psychiatric and psychological specialties (British Association of Art Therapists, 2015). Moreover, many other art forms gradually fall nether 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 but focused on studies of art therapy which mainly includes painting and drawing as media. Specifically, it focuses on capturing psychodynamic processes past ways of "inner pictures," which become visible by the creative procedure (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). Information technology has been gradually recognized and used every bit an culling treatment for therapeutic processes within psychiatric and psychological specialties, as well every bit 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). Information technology 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 Fine art Therapy Association, 2018).

Yet, 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 "fine art therapy" published from January 2006 to Dec 2020 were searched in the PubMed database. The post-obit topics were used: Title/Abstract = "art therapy," Indexes Timespan = 2006–2020.

A total of 652 records were found. So, nosotros manually screened out the literatures that contained the discussion "art" only was not relevant with the subject of this study, such every bit state of the art therapy, antiretroviral therapy (Fine art), and assisted reproductive technology (ART). Finally, 479 records about fine art therapy were identified. Since we aimed to focus on art therapy included painting and drawing as major media, nosotros screened out literatures deeper, and identified 413 (84%) literatures involved in painting and drawing (Figure i).

Effigy 1. Number of publications near art therapy.

As we tin can run across, the number of literature about art therapy is increasing slowly in the last xv years, reaching a elevation in 2020. This indicates that more try was fabricated on this topic in contempo years (Effigy 1).

Overview of Art Therapy

As defined past the British Association of Art Therapists, art therapy is a course of psychotherapy that uses art media every bit its chief mode of communication. Based on above literature, several highlights need to exist summarized. (i) The chief 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). (three) Art therapy is mainly used for cancer, depression and anxiety, 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 of import part 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 tin can not only be served as an useful therapeutic method to aid patients to open and share their feelings, views, and experiences, but also as an auxiliary handling 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 damage OR dementia OR Alzheimer's disease OR Autism OR Schizophrenia OR mental disorder. Equally a result, a total of 23 studies (v%) (Table ane) were included and classified later reading the abstract and the total text carefully. These studies include 9 articles on depression and feet, four articles on cognitive impairment and dementia, three articles on Alzheimer's illness, three articles on autism, and 4 articles on schizophrenia. In addition to the English literature, in fact, some Chinese literatures also described the awarding of art therapy in mental diseases, which were not listed but referred to in the post-obit specific literatures.

Tabular array 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 individual's role in society (Birgitta et al., 2018). Depression is a disabling and plush 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 operation (Cramer et al., 2005). Medication is the most commonly used constructive way to salve symptoms of depression and anxiety. However, nonadherence are crucial shortcomings in using antidepressant to care for depression and feet (van Geffen et al., 2007; Nielsen et al., 2019).

In recent years, many studies take shown that art therapy plays a significant part in alleviating low symptoms and anxiety. Gussak (2007) performed an observational survey almost populations in prison of northern Florida and identified that art therapy significantly reduces depressive symptoms. Similarly, a randomized, controlled, and unmarried-blind study about art therapy for depression with the elderly showed that painting as an adjuvant treatment for depression tin reduce depressive and feet 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) accept shown that art therapy also significantly reduces depressive symptoms in students. For example, Wang et al. (2011) conducted grouping painting therapy on 30 patients with low for iii months, and constitute that painting therapy could promote their social function recovery, better their social adaptability and quality of life. Another randomized clinical trial as well showed that it could subtract mean anxiety scores in the iii–12 year painting grouping (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 exist employed to express patients' anxiety and fear, vent negative emotions by applying projection, thereby significantly improve the mood and reduce symptoms of low 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 low, anxiety, and reduce stressful feelings. Chiefly, even in the follow-up catamenia, fine art therapy still has a lasting result on cancer patients (Thyme et al., 2009). Interestingly, art therapy based on famous painting appreciation could also significantly reduce feet and low associated with cancer (Lee et al., 2017). Amongst cancer patients treated in outpatient health intendance, art therapy too plays an important role in alleviating their physical symptoms and mental health (Götze et al., 2009). Therefore, art therapy as an auxiliary handling of cancer is of bang-up 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.

Cerebral Harm, and Dementia

Dementia, a progressive clinical syndrome, is characterized by widespread cognitive impairment in retentiveness, thinking, behavior, emotion and performance, leading to worse daily living (Deshmukh et al., 2018). According to the Alzheimer'southward Disease International 2015, there is 46.viii million people suffered from dementia, and numbers almost doubling every xx years, ascension to 131.five one thousand thousand by 2050. Although art therapy has been used as an culling handling for the dementia for long time, the positive effects of painting therapy on cognitive part remain largely unknown. Ane intervention assigned older adults patients with dementia to a grouping-based fine art therapy (including painting) observed significant improvements in the clock cartoon examination (Pike, 2013), whereas two other randomized controlled trials (Hattori et al., 2011; Rusted et al., 2016) on patients with dementia accept failed to obtain significant cognitive improvement in the painting group. Moreover, a cochrane systematic review (Deshmukh et al., 2018) included ii clinical studies of art therapy for dementia revealed that there is no sufficient evidence well-nigh the efficacy of art therapy for dementia. This may be because patients with severely cognitive damage, 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 balmy cognitive impairment, an intermediate stage betwixt normal aging and dementia, in club to prevent further transformation into dementia. To date, mild cerebral impairment is drawing much attending to the importance of painting intervening at this phase in guild to alter the course of subsequent cerebral decline as before long every bit possible (Petersen et al., 2014). Recently, a randomized controlled trial (Yu et al., 2021) showed meaning human relationship betwixt improvement firsthand retentivity/working memory span and increased cortical thickness in right middle frontal gyrus in the painting art group. With the long-term cognitive stimulation and appointment from multiple sessions of painting therapy, it is likely that painting therapy could atomic number 82 to enhanced cognitive functioning for these patients.

Alzheimer's Illness

Alzheimer's disease (AD) is a sub-type of dementia, which is normally associated with chronic pain. Previous studies suggested that art therapy could be used every bit a complementary treatment to relief hurting 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 every bit 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 hurting in patients with mild Ad. In addition to release chronic hurting, fine 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 aloofness calibration and quality of life after 12 weeks of painting handling 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, soapbox content and mood later on 3-weeks painting intervention (Narme et al., 2012).

Schizophrenia

Schizophrenia is a circuitous functional psychotic mental affliction that affects about 1% of the population at some indicate in their life (Kolliakou et al., 2011). Not only practise sufferers feel "positive" symptoms such equally hallucinations, delusions, only as well feel negative symptoms such as varying degrees of anhedonia and asociality, impaired working memory and attending, 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 charge per unit of ten 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 information technology is not articulate whether fine art therapy leads to clinical comeback in schizophrenia with low (Ruiz et al., 2017). Anyway, many randomized clinical trials reported positive outcomes. For instance, Richardson et al. (2007) conducted painting therapy for six months in patients with chronic schizophrenia and found that fine 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 ane-year follow-up and found that grouping painting therapy in patients with schizophrenia could not only reduce psychotic symptoms, but also heave self-esteem and improve social function.

What's more than, the characteristics of the painting can too be used to approximate 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 feature of the exam results can exist used to gauge the patient'southward feet, 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 lonely in patients with schizophrenia (Hongyan and JinJie, 2010; Min, 2010).

Autism

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental syndrome with no unified pathological or neurobiological etiology, which is characterized by difficulties in social interaction, communication bug, and a trend to appoint 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 brand broad connections in a more comfortable and effective way (Babaei et al., 2020). Emery (2004) did a example written report almost a 6-year-old boy diagnosed with autism and establish that fine art therapy is of great value to the development, growth and communication skills of the male child. Recently, one study (Jalambadani, 2020) using 40 children with ASD participating in painting therapy showed that painting therapy had a meaning comeback in the social interactions, adaptive behaviors and emotions. Therefore, encouraging children with ASD to limited their experience past using nonverbal expressions is crucial to their development. Evans and Dubowski (2001) believed that creating images on newspaper could help children limited their internal images, thereby enhance their imagination and abstract thinking. Painting tin 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 Cathay, Art therapy could too improve the language and communication skills, cognitive and behavioral performance of children with ASD.

Moreover, art therapy could exist 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 written report (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 give-and-take, art therapy plays a significant role in children with ASD, not only every bit a method of handling, but besides in understanding and investigating patients' problems.

Other Applications

In improver to the higher up mentioned diseases, art therapy has too been adopted in other applications. Dysarthia is a common sequela of cerebral palsy (CP), which direct affects children's language intelligibility and psycho-social adjustment. Oral communication therapy does not always aid CP children to speak more intelligibly. Interestingly, the fine art therapy can significantly meliorate the language intelligibility and their social skills for children with CP (Wilk et al., 2010).

In brief, these studies advise that art therapy is meaningful and accustomed past both patients and therapists. Most often, art therapy could strengthen patient's emotional expression, self-esteem, and self-awareness. Still, our findings are based on relatively pocket-size samples and few skilful-quality qualitative studies, and require cautious interpretation.

The Awarding Prospects of Art Therapy

With the development of mod medical engineering, life expectancy is besides increasing. At the same fourth dimension, it also brings some side furnishings and psychological problems during the treatment process, specially for patients with mental disease. Therefore, at that place is an increasing demand for finding appropriate complementary therapies to better life quality of patients and psychological health. Art therapy is primarily offered as individual art therapy, in this review, we establish that art therapy was about commonly used for low and anxiety.

Based on the above findings, art therapy, every bit 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 piece of cake to be accepted by patients.

Art therapy in hospitals and clinical settings could be very helpful to aid handling and therapy, and to enhance communications between patients and on-site medical staffs in a non-verbal mode. Moreover, fine art therapy could be more effective when combined with other forms of therapy such equally music, dance 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 take shown that art therapy could ameliorate the quality of life and mental health of patients, standard and rigorous clinical trials with large samples are nonetheless lacking. Moreover, the long-term upshot is withal to be assessed due to the lack of follow-up assessment of art therapy.

In some cases, art therapy using painting equally 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), bereft space for the artwork to dry out without getting in the way or getting damaged, and negative medical settings and family unit environments. All the same, these difficulties can exist overcome due to cracking benefits of the art therapy. We thus humbly believe that fine art therapy has great potential for mental disorders.

In the future, fine art therapy may exist more thoroughly investigated in the following directions. Kickoff, more high-quality clinical trials should be carried out to gain more reliable and rigorous evidence. Second, the evaluation methods for the effectiveness of fine art therapy need to exist equally diverse as possible. Information technology is necessary for the investigation to include not merely subjective scale evaluations, but also objective ways such as brain imaging and hematological examinations to be more convincing. Tertiary, 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 virtually art therapy should be gradually formed on the basis of accumulated evidence. Finally, machinery of art therapy should exist further investigated in a variety of ways, such as at the neurological, cellular, and molecular levels.

Author Contributions

JH designed the whole written report, analyzed the information, and wrote the manuscript. JZ searched for selected the studies. LH participated in the interpretation of data. HY and JX offered expert suggestions. All authors read and canonical the final manuscript.

Funding

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

Conflict of Involvement

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

Publisher's Notation

All claims expressed in this article are solely those of the authors and do not necessarily stand for 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 merits that may be made past its manufacturer, is not guaranteed or endorsed by the publisher.

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