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The Arts in Psychotherapy

Art therapy in mental health: a systematic review of approaches and practices.

EBP offers opportunities to amalgamate supporting research with pragmatic experience.

This review aims to commence a bridge between what art therapists know and what they do.

The four areas where articles on art therapy approaches focused on were: depression, borderline personality disorder, schizophrenia, and post-traumatic stress disorder.

Future studies could incorporate more details on the approaches researched to enhance transferability of findings to practice.

This systematic review aims to develop a bridge between what art therapists know and what they do in supporting those with mental health issues. Research undertaken between 1994 and 2014 was examined to ascertain the art therapy approaches applied when working with people who have mental health issues, as well as to identify how art therapy approaches were used within the clinical mental health system. Thirty articles were identified that demonstrated an art therapy approach to a particular mental health issue. The search strategy resulted in articles being grouped into four diagnostic terms: depression, borderline personality disorder, schizophrenia, and post-traumatic stress disorder. A synthesis of the identified articles resulted in the identification of research areas that need advancement. Future studies could incorporate more details on the art therapy approaches used to enhance transferability of practice. Moreover, adding art therapists’ critique about the art therapy approach from their applied perspective, would assist in the development of evidence-based practice that is not just current, but feasible, too. Finally, the client voice needs to be incorporated in future studies to address questions of the relationship between client expectations and the perceived success of art therapy.

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American Art Therapy Association

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:.




"Being at the Beginning" by Jaimie Peterson

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.

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research papers about art therapy

Background: Art therapy (AT) is frequently offered to children and adolescents with psychosocial problems. AT is an experiential form of treatment in which the use of art materials, the process of creation in the presence and guidance of an art therapist, and the resulting artwork are assumed to contribute to the reduction of psychosocial problems. Although previous research reports positive effects, there is a lack of knowledge on which (combination of) art therapeutic components contribute to the reduction of psychosocial problems in children and adolescents.

Method: A systematic narrative review was conducted to give an overview of AT interventions for children and adolescents with psychosocial problems. Fourteen databases and four electronic journals up to January 2020 were systematically searched. The applied means and forms of expression, therapist behavior, supposed mechanisms of change, and effects were extracted and coded.

Results: Thirty-seven studies out of 1,299 studies met the inclusion criteria. This concerned 16 randomized controlled trials, eight controlled trials, and 13 single-group pre–post design studies. AT interventions for children and adolescents are characterized by a variety of materials/techniques, forms of structure such as giving topics or assignments, and the use of language. Three forms of therapist behavior were seen: non-directive, directive, and eclectic. All three forms of therapist behavior, in combination with a variety of means and forms of expression, showed significant effects on psychosocial problems.

Conclusions: The results showed that the use of means and forms of expression and therapist behavior is applied flexibly. This suggests the responsiveness of AT, in which means and forms of expression and therapist behavior are applied to respond to the client's needs and circumstances, thereby giving positive results for psychosocial outcomes. For future studies, presenting detailed information on the potential beneficial effects of used therapeutic perspectives, means, art techniques, and therapist behavior is recommended to get a better insight into (un)successful art therapeutic elements.


Psychosocial problems are highly prevalent among children and adolescents with an estimated prevalence of 10%−20% worldwide ( Kieling et al., 2011 ; World Health Organization, 2018 ). These problems can severely interfere with everyday functioning ( Bhosale et al., 2015 ; Veldman et al., 2015 ) and increase the risk of poorer performance at school ( Veldman et al., 2015 ). The term psychosocial problems is used to emphasize the close connection between psychological aspects of the human experience and the wider social experience ( Soliman et al., 2020 ) and cover a wide range of problems, namely, emotional, behavioral, and social. Emotional problems are often referred to as internalizing problems, such as anxiety, depressive feelings, withdrawn behavior, and psychosomatic complaints. Behavioral problems are often considered as externalizing problems, such as hyperactivity, aggressive behavior, and conduct problems. Social problems are problems related to the ability of the child to initiate and maintain social contacts and interactions with others. Often, emotional, behavioral, and social problems occur jointly ( Vogels, 2008 ; Jaspers et al., 2012 ; Ogundele, 2018 ). The etiology of psychosocial problems is complex and varies with regard to the problem(s) and/or the specific individual. A number of theories seek to explain the etiology of psychosocial problems. The most common theory in Western psychology and psychiatry is the biopsychosocial theory, which assumes that a combination of genetic predisposition and environmental stressors triggers the onset of psychosocial problems ( Lehman et al., 2017 ). But also, attachment theories get renewed attention ( Duschinsky et al., 2015 ). These theories focus on the role of the early caregiver–child relationships and assume that (a lack of) security of attachment affects the child's self-(emotion)regulatory capacity and therefore his or her emotional, behavioral, and social competence ( Veríssimo et al., 2014 ; Brumariu, 2015 ; Groh et al., 2016 ). Research has identified a number of biological, psychological, and environmental factors that contribute to the development or progression of psychosocial problems ( Arango et al., 2018 ), namely, trauma, adverse childhood experiences, genetic predisposition, and temperament ( Boursnell, 2011 ; Sellers et al., 2013 ; Wright and Simms, 2015 ; Patrick et al., 2019 ).

Psychosocial problems in children and adolescents are a considerable expense to society and an important reason for using health care. But, most of all, psychosocial problems can have a major impact on the future of the child's life ( Smith and Smith, 2010 ). Effective interventions for children and adolescents, aiming at psychosocial problems, could prevent or reduce the likelihood of long-term impairment and, therefore, the burden of mental health disorders on individuals and their families and the costs to health systems and communities ( Cho and Shin, 2013 ).

The most common treatments of psychosocial problems in children and adolescents include combinations of child- and family-focused psychological strategies, including cognitive behavioral therapy (CBT) and social communication enhancement techniques and parenting skills training ( Ogundele, 2018 ). These interventions are designed with the idea that cognitions affect the way that children and adolescents feel and behave ( Fenn and Byrne, 2013 ). However, this starting point is considered not suitable for all youngsters, in particular, for children and adolescents who may find it difficult to formulate or express their experiences and feelings ( Scheeringa et al., 2007 ; Teel, 2007 ). For such situations in clinical practice, additional therapies are often offered. Art therapy (AT) is such a form of therapy.

AT is an experiential form of treatment and has a special position in the treatment of children and adolescents because it is an easily accessible and non-threatening form of treatment. Traditionally, AT is (among others) used to improve self-esteem and self-awareness, cultivate emotional resilience, enhance social skills, and reduce distress ( American Art Therapy Association, 2017 ), and research has increasingly identified factors, such as emotion regulation ( Gratz et al., 2012 ) and self-esteem ( Baumeister et al., 2003 ) as mechanisms underlying multiple forms of psychosocial problems.

Art therapists work from different orientations and theories, such as psychodynamic; humanistic (phenomenological, gestalt, person-centered); psychoeducational (behavioral, cognitive–behavioral, developmental); systemic (family and group therapy); as well as integrative and eclectic approaches. But also, there are various variations in individual preference and orientation by art therapists ( Van Lith, 2016 ). In AT, the art therapist may facilitate positive change in psychosocial problems through both engagement with the therapist and art materials in a playful and safe environment. Fundamental principles in AT for children and adolescents are that visual image-making is an important aspect of the natural learning process and that the children and adolescents, in the presence of the art therapist, can get in touch with feelings that otherwise cannot easily be expressed in words ( Waller, 2006 ). The ability to express themselves and practice skills can give a sense of control and self-efficacy and promotes self-discovery. It, therefore, may provide a way for children and clinicians to address psychosocial problems in another way than other types of therapy ( Dye, 2018 ).

Substantial clinical research concerning the mechanisms of change in AT is lacking ( Gerge et al., 2019 ), although it is an emerging field ( Carolan and Backos, 2017 ). AT supposed mechanisms of change can be divided into working mechanisms specific for AT and overall psychotherapeutic mechanisms of change, such as the therapeutic relationship between client and therapist or the expectations or hope ( Cuijpers et al., 2019 ). Specific mechanisms of change for AT include, for instance, the assumption that art can be an effective system for the communication of implicit information ( Gerge, and Pedersen, 2017 ) or that art-making consists of creation, observation, reflecting, and meaning-making, which leads to change and insight ( Malchiodi, 2007 ).

Recently, it has been shown that AT results in beneficial outcomes for children and adolescents. Cohen-Yatziv and Regev (2019) published a review on AT for children and adolescents and found positive effects in children with trauma or medical conditions, in juvenile offenders, and in children in special education and with disabilities. While increasing insight into the effects of AT for different problem areas among children is collected, it remains unclear whether specific elements of AT interventions and mechanisms of change may be responsible for these effects. In clinical practice, art therapists base their therapy on rich experiential and intuitive knowledge. This knowledge is often implicit and difficult to verbalize, also known as tacit knowledge ( Petri et al., 2020 ). Often, it is based on beliefs or common sense approaches, without a sound basis in empirical results ( Haeyen et al., 2017 ). This intuitive knowledge and beliefs consist of (theoretical) principles, art therapeutic means and forms of expression, and therapist behavior [including interactions with the client(s) and handling of materials] that art therapists judge necessary to produce desired outcomes ( Schweizer et al., 2014 ). Identifying the elements that support positive outcomes improves the interpretation and understanding of outcomes, provides clues which elements to use in clinical practice, and will give a sound base for initiating more empirical research on AT ( Fixsen et al., 2005 ). The aim of this review is to provide an overview of the specific elements of art therapeutic interventions that were shown to be effective in reducing psychosocial problems in children and adolescents. In this review, we will focus on applied means and forms, therapist behavior, supposed mechanisms of change of art therapeutic interventions. As the research question was stated, i.e., which art therapeutic elements support positive outcomes in psychosocial problems of children and adolescents (4–20)?

Study Design

A systematic narrative review is performed according to the guidelines of the Cochrane Collaboration for study identification, selection, data extraction, and quality appraisal. Data analysis was performed, conforming narrative syntheses.

Eligibility Criteria

In this review, we included peer-reviewed published randomized controlled trials (RCTs), non-randomized clinical controlled trials (CCTs), and studies with group pre–posttest designs for AT of psychosocial problems in children and adolescents (4–20 years). Studies were included regardless of whether AT was present within the experimental or control condition. Qualitative data were included when data analysis methods specific for this kind of data were used. Only publications in English, Dutch, or German were included. Furthermore, only studies in which AT was provided by a certified art therapist to individuals or groups, without limitations on duration and number of sessions, were inserted. Excluded were studies in which AT was structurally combined with another non-verbal therapy, for instance, music therapy. Studies on (sand)play therapy were also excluded. Concerning the outcome, studies needed to evaluate AT interventions on psychosocial problems. Psychosocial problems were broadly defined as emotional, behavioral, and social problems. Considered emotional (internalizing) problems were, for instance, anxiety, withdrawal, depressive feelings, psychosomatic complaints, and posttraumatic stress problems/disorder. Externalizing problems were, for instance, aggressiveness, restlessness, delinquency, and attention/hyperactivity problems. Social problems were problems that the child has in making and maintaining contact with others. Also included were studies that evaluated AT interventions targeted at children/adolescents with psychosocial problems and showed results on supposed underlying mechanisms such as, for instance, self-esteem and emotion regulation.

Fourteen databases and four electronic journals were searched: PUBMED, Embase (Ovid), PsycINFO (EBSCO), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Web of Science, Cinahl, Embase, Eric, Academic Search Premier, Google Scholar, Merkurstab, ArtheData, Relief, and Tijdschrift Voor Vaktherapie (Journal of Arts Therapies in the Netherlands). A search strategy was developed using keywords (art therapy in combination with a variety of terms regarding psychosocial problems) for the electronic databases according to their specific subject headings or structure. For each database, search terms were adapted according to the search capabilities of that database ( Appendix 1 ). The search period had no limitation until the actual first search date: October 5, 2018. The search was repeated on January 30, 2020. If online versions of articles could not be traced, the authors were contacted with a request to send the article to the first author. The reference lists of systematic reviews, found in the search, were hand searched for supplementing titles to ensure that all possible eligible studies would be detected.

Study Selection

A single RefWorks file of all identified references was produced. Duplicates were removed. The following selection procedure was independent of each other carried out by four researchers (LB, SvH, MS, and KP). Titles and abstracts were screened for eligibility by three researchers (LB, SvH, and KP). The full texts were subsequently assessed by three researchers (LB, MS, and KP) according to the eligibility criteria. Any disagreement in study selection between a pair of reviewers was resolved through discussion or by consultation of the fourth reviewer (SvH).

Quality of the Studies

The quality of the studies was assessed by two researchers (LB and KP) applying the EPHPP “Quality Assessment Tool for Quantitative Studies” ( Thomas et al., 2004 ). Independent of each other, they came to an opinion, after which consultation took place to reach an agreement. To assess the quality, the Quality Assessment Tool was used, which has eight categories: selection bias, study design, confounders, blinding, data collection methods, withdrawal and dropouts, intervention integrity, and analysis. Once the assessment was completed, each examined study received a mark ranging between “strong,” “moderate,” and “weak.” The EPHPP tool has a solid methodological rating ( Thomas et al., 2004 ).

Data Collection and Analysis

The following data were collected from the included studies: continent/country, type of publication of study, year of publication, language, impact factor of the journal published, study design, the primary outcome, measures, setting, type of clients, comorbidity, physical problems, total N, experimental N, control N, proportion male, mean age, age range, the content of the intervention, content control, co-intervention, theoretical framework AT, other theoretical frameworks, number of sessions, frequency sessions, length sessions, outcome domains and outcome measures, time points, outcomes, and statistics. An inductive content analysis ( Erlingsson and Brysiewicz, 2017 ) was conducted on the characteristics of the employed ATs concerning the means and forms of expression, the associated therapist behavior, the described mechanisms of change, and whether there were significant effects of the AT interventions. A narrative analysis was performed.

The first search (October 2018) yielded 1,285 unique studies. In January 2020, the search was repeated, resulting in 14 additional unique studies, making a total of 1,299. Four additional studies identified from manually searching the reference lists from 30 reviews were added, making a total of 1,303 studies screened on title and abstract. In the first search, 1,085 studies, and in the second search, nine studies were excluded, making a total of 1,094 studies being excluded on title and abstract. This resulted in 209 full-text articles to assess eligibility. In the full-text selection phase, from the first search, another 167 studies were excluded; in the second search, five studies were excluded. This makes a total of 172 studies being excluded in the full-text phase. Twenty-three studies were excluded because a full text was unavailable; five studies because the language was not English, Dutch, or German; 99 studies did not meet the AT definition; 16 studies had a wrong design; 10 studies did not treat psychosocial problems; and 19 studies concerned a wrong population. In total, 37 studies were included (see Figure 1 for an overview of the complete selection process).

Figure 1 . PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart.

The final review included 16 RCTs, eight CCTs, and 13 single-group pre–post designs (total n = 37). Of the RCTs, a mixed-method design, involving both quantitative and qualitative data, was used in two studies. In one RCT, the control group received AT meeting our criteria, while the experimental group did not receive such a therapy (11). In another RCT, the experimental and the control group both received AT meeting our criteria (13). Also, two CCT studies used a mixed-method design, but these qualitative results were not included due to inappropriate analysis. Of the single-group pre–posttest designs, two studies had a mixed-method (quantitative and qualitative) design ( Table 1 ).

Table 1 . Study characteristics/outcome.

Of the 16 RCTs, two studies were evaluated as weak, 11 studies received a moderate score, and three studies were labeled as strong. Concerning the CCTs, five studies were evaluated as weak, one study as moderate, and two studies as strong. Of the 13 pre–posttest designs, five studies were assessed as weak and eight studies as moderate ( Table 1 ).

Study Population

The studies in this review included children and adolescents (ages 2–20) with a wide range of psychosocial problems and diagnoses. Most of the studies included children from the age of 6 years onward, with children's groups ranging from 6 to 15, adolescent groups ranging from 11 to 20, and mixed groups with an age range of 6–20 years. In 13 studies, both boys and girls were included, three studies only included boys, three studies only included girls, and 18 studies did not report the gender of the participants. Psychiatric diagnoses were reported, such as depression, autism spectrum disorder (ASD), conduct disorder (CD), post-traumatic stress disorder (PTSD), and mild intellectual disability (MID). However, also more specific problems were reported, such as children with suicidal thoughts and behavior, children having a brother/sister with a life-threatening disease, boys and girls in an educational welfare program needing emotional and psychological help, and orphans with a low self-esteem. Another group of children that were reported had medical concerns, such as persistent asthma, traumatic injuries, or serious medical diagnoses such as cancer, often combined with anxiety problems and/or trauma-related problems ( Table 1 ).

Number of Participants

The sample sizes of the RCTs ranged from 16 to 109. The total number of children of all RCTs was 707, of which 317 were allocated to an experimental condition and 390 to a control condition ( Table 1 ). The sample sizes of the CCTs ranged from 15 to 780, and the total number of participants was 1,115. The total number of participants who received an AT treatment was 186; the total number of the control groups was 929. Notice that the sample size for the CCTs was influenced by one study in which a control sample database of 780 was used. The sample size of the included pre–posttest designs ranged from 8 to 94 participants, with a total number of 411 participants ( Table 1 ).

Type of Intervention, Frequency, and Treatment Duration

In the 37 studies, a total of 39 AT interventions were studied. In two studies, two AT interventions were studied. Of the 39 interventions, 30 studies evaluated group interventions, seven studies evaluated an individually offered intervention, one study evaluated an individual approach within a group setting, and in one study, the intervention was alternately offered as a group intervention or as an individual intervention. The number of sessions of the AT interventions varied from once to 25 times. The frequency of the AT interventions varied from once a week ( n = 14) or twice a week ( n = 5) and variations such as four times a week in 2 weeks ( n = 1); six sessions were varying from one to three times a week ( n = 1), 10 sessions during 12 weeks ( n = 1), and eight sessions in 2 weeks ( n = 1). The frequency of sessions has not been reported in nine studies. In five studies, the intervention was offered once ( Table 1 ).

Control Interventions

In six RCTs, care, as usual, was given to the control groups. In study four, this also concerned AT, but it was offered in a program that consisted of different forms of treatment as child life services, social work, and psychiatric consults and therefore did not meet our criteria for inclusion. The control groups receiving “care as usual” received routine education and activities of their programs in school (6); counseling/medications and group activities as art, music, sports, computer games, and dance (8); standard arts- and craft-making activities in a group (9); and standard hospital services (14). One study did not specify what happened as care as usual (2). In five RCTs, a specific intervention of activity was offered in the control condition. These control interventions involved 3 h of teaching (5), a discussion group (7), offering play material (magneatos) (12), and a range of games (11), and one study offered weekly socialization sessions, these sessions were offered by the same professionals as the experimental group, and activities were playing board games, talking about weekend activities, and taking walks on the school grounds (16). Two RCT studies did not mention the condition in the control group (1, 10). Two studies mentioned that the control group did not receive any intervention program (3, 11). One study mentioned that the control group had the same assessments as the treatment group but did not receive therapy until all of the assessments were collected (15).

Regarding the eight CCTs, two studies described the control condition in more detail, consisting of academic work (21) or 3 h of informal recreational activities (24). No intervention was offered to the control group in four studies (19, 20, 22, 23). The control intervention was not described within two studies (17, 18) ( Table 1 ).

Applied Means and Forms of Expression

The applied means and forms of expression in the AT interventions could be classified into three categories: art materials/techniques, topics/assignments given, and language as a form of verbal expression accompanying the use of art materials. Results will be shown for 39 AT interventions in total, coming from 37 studies ( Table 2 ). Two studies applied two different types of AT interventions. These two types of AT will be referred to as 13 a/b and 29 a/b.

Table 2 . Characteristics AT interventions.


Regarding the category art materials/techniques, three subcategories were found. In the first subcategory, only two-dimensional art media/techniques were used, such as drawing, painting, or printing (the art product possessed length and width, but not depth). Used as materials were for instance, (acrylic) paint, markers, color pencil, crayons, gouache and water, white pieces of paper, cardboard, construction paper with pencils and colored markers, a “sketch” coloring, pencils, markers, and oil pastels (1, 3, 6, 7, 10, 14, 18, 21, 23). No specific art techniques concerning the way the materials were applied were mentioned in this subcategory. In the second subcategory, both two-dimensional and three-dimensional art media and techniques (art that can be defined in three dimensions: height, width, and depth) were offered: clay, papier-mâché masks, paint, paper decoration forms and markers, pictures and journals, paper, cardboard, construction materials, hospital socks, buttons and threads, sewing materials, magic beans, sand, fiberfill, photos, wood, stone, plaster, felt and other textiles, and yarn. In this subcategory, specific art techniques were mentioned, such as paper cutting and paper folding, collage technique, bookmaking, building a face, basket-making, clay techniques, guided fantasy, group painting, story-making through a doll, placing feelings in boxes, drawing/sculpting feelings, making clay shapes, creating self-portraits, and molding clay (2, 5, 8, 11, 13a, 19, 20, 22, 26, 27, 28, 29a, 29b, 30, 31, 32, 33, 36, 37). In the third category, both two-dimensional and three-dimensional art materials/techniques were applied, which matched the specific assignment or topic given (4, 9, 12, 13b, 14, 15, 17, 24, 25). For instance, drawings were made, and the collage technique was used to make a book (9). Four sets of facial features (eyes, noses, mouths, and brows), as well as a mannequin head, were offered for representing facial emotions (12), and in one study, patients used buttons, threads, and sewing materials with which they constructed their Healing Sock Creature, which the children filled with magic beans, sand, or fiberfill (15).


Three subcategories were found concerning the category topics/assignments. The first subcategory, free working with the materials without topics/assignments given , was applied in five AT interventions (3, 5, 11, 13a, 16). In the second subcategory, 26 AT interventions used assignment(s) or gave topics (1, 2, 4, 7, 8, 9, 10, 12, 13b, 14, 15, 17, 19, 20, 21, 22, 23, 24, 25, 27, 29 a/b, 32, 33, 36, 37). The third subcategory concerned combinations of these two. Two studies mixed free working and giving topics/assignments (28, 30), and seven studies did not describe the intervention explicit enough to classify them (6, 18, 26, 31, 34, 35, 36). A wide range of activities based on topics and/or assignments were reported. Eleven categories could be detected; (1) getting familiar with the art material (1, 17) like “learning about art media” (1) and “warm-up clay activities and introduction to theme-related clay techniques” (17); (2) focusing on family perspective , like for instance, “draw first childhood memory/family relations”(1, 23), drawing family as animal (19); (3) working with visualization, fantasy, and meditation (1, 10, 20, 21), such as guided fantasy with clay, and story-making through a doll (20); (4) expressing emotions (1, 14, 19, 20, 23, 32) like “the participant was asked to create four different faces, representing happiness, sadness, anger, and fear” (14) or “make an anger collage” (19); (5) focusing on specific problems such as chronic disease or stress-related events (2, 4, 8, 9, 14, 15, 19, 37) such as “the experience associated with stress is drawn on small white paper and the future solution contents will be drawn on colorful, larger paper” (8) and “drawing feelings, drawing perpetrators, placing of these in boxes” (19); (6) applying group activities (10, 19, 20, 32), for instance, “make a group painting”(20) and “all the children were asked to work on a group project to bring closure by drawing a ceremony on a large paper together with comments” (10); (7) working on an exhibition of artwork (10, 32), for instance, “at the end, a small exhibition of artwork was made” (10); (8) focusing on the material/technique (17, 21, 27, 37) such as “making shapes using clay” (17) and “mold clay into a pleasing form, which could be an animal, a person, an object, or an abstract form” (21); (9) focusing on specific art techniques (19, 21, 29) such as “arrange a variety of objects in a pleasing orientation and draft the still life with a pencil” (21) or “make a photo collage”(19); (10) working with a product/object as a result (24, 25, 27, 32) such as, for instance, “making a bracelet” (32), “making paper bags” (27), or creating therapeutic art books (25); (11) applying general activities (1, 7, 19, 22, 27, 32) like drawing of a picture (7) and “the given theme was heroes”(22). Two studies (13b, 33) gave assignments/topics but did not specify these.

The Role of Language

Three subcategories were found concerning the role of language as a form of verbal expression accompanying the use of art materials and techniques: the produced artwork was mainly discussed afterward in a group meeting or on an individual basis (1, 2, 3, 4, 9, 10, 11, 13b, 14, 17, 29, 36) or feelings and concerns were mainly discussed and reflected on while working (5, 12, 13a, 15, 18, 22, 25, 26, 28) and other varieties such as: the work was (verbally) presented (4) and/or patients also retold the narrative created (5). In one study (7), the originator gave a title, offered associations to it, and said how he/she felt before and after drawing other members gave their associations. In one study (8), all artworks were gathered as a collection and reviewed at the end of the intervention (last session) together with the parents.

Therapist Behavior

Regarding therapist behavior, the information is structured in two categories: the therapist behavior, including social interactions with the client(s) , and the handling of materials by the therapist, including material interactions with the client(s) .

Therapist Behavior, Including Social Interactions With Their Client(s)

The information revealed three broad behaviors: non-directive behavior, directive behavior, and behavior that can be considered eclectic . Non-directive behavior refers to AT interventions in which the therapists showed mainly a following and facilitating attitude toward the children/adolescents. Thirteen AT interventions applied this kind of therapist behavior (13a, 15, 16, 17, 18, 20, 21, 22, 23, 25, 29a, 30, 36). Interactions with clients were for example, “the therapist was non-interpretive, with the participants creating their direct statements and finding their meanings in the individual artwork they created” (21) and “the therapist facilitates the creation of the artistic product and is supportive” (13a). Directive behavior refers to AT interventions in which the therapist showed an active and leading role toward the children/adolescents. Ten AT interventions (4, 8, 10, 11, 12, 13b, 24, 26, 28, 29b) used this kind of therapist behavior. Interactions with the clients were, for example, “the therapist asks exception/difference questions” (8) or “the participant was directed to choose a mouth, nose, eyes, and brows that represented the correct emotion” (12). A mix of these two types of therapist behaviors (eclectic) was applied in nine AT interventions (2, 5, 7, 9, 14, 32, 33, 34, 35), for instance: “each adolescent was asked at the beginning of the session to do a ‘feelings check-in’ describing how he or she was feeling in the moment and a ‘feelings check-out’ at the end of the session. In the art-making period, a minimal discussion took place” (9) or “art therapists worked with their clients to form therapeutic goals during initial sessions, followed by both structured and unstructured weekly AT sessions” (34). In seven AT interventions (1, 3, 6, 19, 27, 31, 37), insufficient information was given to classify the therapist's behavior.

The Handling of Materials by the Therapist, Including Material Interactions With the Client(s)

Information was provided by seven studies: “the therapist assists and supports the youngster in carrying out the activity” (5), “the therapist embeds solution-focused questions and skills in the art-making process” (8), “during working with materials, there was minimal discussion” (9), “the child was directed to choose features/materials that represented the correct emotion” (12), “the therapist gave delineated verbal instructions and directions for art media” (13a), “the therapist-assisted the child having difficulty with a specific medium” (13b), “the therapist became the co-creator” (15), and “the therapist avoided giving art instructions” (25).

Supposed Mechanisms of Change

In the introduction and discussion sections of the articles, a range of supposed mechanisms of change as substantiation of the intervention and outcomes were described ( Table 2 ). The supposed mechanisms of change could be categorized into two categories: art therapy specific and general psychotherapeutic mechanisms of change .

Specific Mechanisms of Change

Eight subcategories of a specific mechanism of change were detected. The first category was Art therapy as a form of expression to reveal what is inside . This large subcategory, could be divided into three forms: art as a form of visualizing and communication in general (1, 13, 15, 19, 20, 26, 28, 33, 35, 36), such as, “it enables the child to visualize” (15); art as a manageable expression and/or regulation of emotions (1, 2, 3, 7, 8, 10, 19, 20, 23, 27, 28, 31, 33, 35, 37), e.g., “through art emotions can be processed” (2); and art as a way of expression through specific processes (1, 4, 5, 9, 10, 11, 14, 15, 17, 19, 22, 25, 28, 29, 31, 32), for instance, “reduces threat inherent in sharing experiences of trauma by permitting a constructive use of displacement via the production of imagistic representations” (9). The second category was Art therapy as a way of becoming aware of oneself , mentioned by 10 studies (1, 2, 11, 13, 16, 23, 24, 25, 35, 36), for instance, “to regain a sense of personal agency” (1). The third category was defined as art therapy as a way to form a narrative of life , like “facilitation of the integration of the experience into one's larger, autobiographical life narrative” (4), while the fourth category dealt with art therapy as integrative activation of the brain through experience , which was mentioned in six studies (4, 12, 14, 16, 34, 26), for instance, “utilizing the integrative capacity of the brain by accessing the traumatic sensations and memories in a manner that is consistent with the current understanding of the transmission of experience to language”(4). The fifth category art therapy as a form of exploration and/or reflection was mentioned in seven studies (1, 9, 15, 18, 30, 5, 8), for instance, “to explore existential concerns” (1), and the sixth category the specifics of the art materials/techniques offered in art therapy was mentioned in three studies (13, 17, 30), for instance, “because they could change the shape as they wished, which contributed to a positive evaluation of their own performance”(17). The seventh category art therapy as a form to practice and/or learn skills was mentioned in four studies (10, 19, 28, 33), for example, “in art therapy interventions, children can learn coping responses, new skills, or problem-solving techniques” (10). Finally, the eighth category art therapy, as an easily accessible, positive and safe intervention by the use of art materials was mentioned by 15 studies (1, 2, 6, 8, 10, 16, 19, 23, 24, 25, 28, 29, 30, 32, 37), for instance, “non-verbal expression that is possible in art therapy is a safe way”(10).

General Mechanisms of Change

Two subcategories of general mechanisms of change could be defined. The first subcategory was defined as art therapy as a form of group process , mentioned by eight studies (7, 9, 13, 18, 20, 29, 30, 36), for instance, “present thoughts and feelings in a non-verbal way within the structure of the group”(7). The second, the therapeutic alliance in art therapy , was mentioned by six studies (5, 8, 16, 18, 26, 29), for instance, “the primary role of the therapist as listening, accepting, and validating” (16).

Synthesized Findings

Means and forms of expression and therapist behavior.

Concerning the search for similarities and differences, the three found forms of therapist behavior were used to distribute the means and forms, which gave the following results.

The Therapist Behavior Was Non-directive

The therapist showed mainly a following and facilitating attitude toward the children/adolescents; in this category ( n = 13), the use of means and forms of expression was variable, but most often, children and adolescents worked on base of topics and assignments with both two- and three-dimensional materials and techniques, while during working, process and product were discussed. Specifically, four AT interventions used only two-dimensional materials/techniques (15, 18, 21, 23), six AT interventions offered both two- and three-dimensional materials/techniques (13a, 20, 22, 29a, 30, 36), and three AT interventions offered materials/techniques fitting the topic/assignment (15, 17, 25), which included a combination of two- and three-dimensional materials/techniques. Three AT interventions let the clients work freely without topics and assignments given (13a, 18, 30), eight AT interventions were based on topics/assignments (15, 20, 21, 22, 23, 25, 29a, 36), and two AT interventions combined both ways (17, 30). Concerning the use of language, in three AT interventions, there was a discussion on process/product afterward (17, 29a, 36), in five AT interventions, there was a verbal exchange while working (13a, 15, 18, 22, 25), and five studies (16, 20, 21, 23, 30) in this category did not make their use of language explicit as an additional form of expression. The most mentioned subcategories of supposed mechanisms of change for this category were “art therapy as a form of expression to reveal what is inside,” “art therapy as a form of exploration,” and “art therapy as a way of experiencing the self.”

The Therapist Behavior Was Directive

The therapist showed mainly an active and leading role toward the children/adolescents; the use of means and forms of expression was again variable in this category ( n = 10), but most often, children and adolescents worked on base of topics and assignments with both two- and three-dimensional materials/techniques, whereby the process and work were reflected upon afterward in different forms. Specifically, one intervention used only two-dimensional materials/techniques (10), five AT interventions offered both two- and three-dimensional materials/techniques (8, 11, 26, 28, 29b), and four AT interventions offered materials/techniques fitting the topic/assignment (4, 12, 13b, 24), which included two- and three-dimensional materials/techniques. Two AT interventions let the clients work without topics and assignments given (11, 28), and seven AT interventions were based on topics/assignments (4, 8, 10, 12, 13b, 24, 29b), one AT intervention combined both ways (28), and one study did not provide information on this topic (26). Concerning the use of language, in five AT interventions, there was a discussion on process/product afterward (4, 10, 11, 13b, 29b), in three AT interventions, there was a verbal exchange while working (12, 26, 28), and one study used language in a specific form (reviewing the collection with children and parents) (8). One AT intervention discussed the work afterward in a different form (a narrative retold) (4). One intervention did not make the use of language explicit as an additional form of expression (24). The most-reported subcategories of supposed mechanisms of change were the same as for the non-directive therapist behavior.

The Therapist Both Performed Directive and Non-directive Behavior (Eclectic) Toward Clients

Also, the use of means and forms of expression was variable in this category ( n = 9). All kinds of materials/techniques were used but most often were worked on base of topics/assignments. The use of language was not often mentioned, but if it was used, it was used as a discussion afterward. Specifically: two AT interventions used only two-dimensional materials/techniques (7, 14), four AT interventions offered both two- and three-dimensional materials/techniques (2, 5, 32, 33), and two AT interventions offered materials/techniques fitting the topic/assignment (9, 14), which included both two- and three-dimensional materials/techniques. One study did not provide information on this topic (34). In one AT intervention, the clients worked freely without topics and assignments given (14), and six AT interventions were based on topics/assignments (2, 5, 7, 9, 32, 33). Concerning the use of language, in three AT interventions, there was a discussion on process/product afterward (2, 9, 14), no AT interventions mentioned a verbal exchange while working, and four studies (32, 33, 34, 35) in this category did not make their use of language explicit as an additional form of expression. The most-reported subcategories of supposed mechanisms of change for this category were “art therapy as a form of expression to reveal what is inside”; “art therapy as a form of exploration,” and “art therapy as an easily/safe accessible intervention.”

In seven studies (1, 3, 6, 19, 27, 31, 37), the AT interventions were not enough explicated to make combinations.

Therapist Behaviors in Relation to Psychosocial Outcomes

The division into three categories of non-directive, directive, and eclectic therapist behavior gave the opportunity to show outcomes in accordance with these. To structure the outcome, these are reported by categorizing psychosocial problems into internalizing problems, externalizing problems, and social problems and in outcomes that can be considered underlying mechanisms of psychosocial problems. These underlying mechanism outcomes were divided into the domains self-concept/self-esteem and emotion regulation.

Non-directive Therapist Behavior

Eight studies (15, 16, 18, 20, 21, 23, 25, 36), which applied the non-directive therapist behavior, focused on Internalizing Problems as an outcome. These results showed significant improvement in post-traumatic stress symptoms (23); emotional functioning (36, 16), depression, rejection, and anxiety (16), reduction of symptoms of Separation Anxiety Disorder (18), and symptoms of anxiety and depression (20). The quality of two studies (16, 23) was strong, and the other three studies were assessed as being of weak quality. Also, four times no significant improvement was reported for negative mood states (15), negative mood and distress (25), feelings of anxiety (23), and anxiety, depression, internalizing problems, and emotional symptoms (21). The quality of these studies was strong (23) or weak (15, 21, 25).

Five studies (13a, 16, 21, 29, 36) showed results for Externalizing Problems . The results showed significant improvement in inattention/hyperactivity problems for the Honors track group (21) (weak), behavioral conduct (29) (moderate), attention span (16) (strong), and problem behavior (13a) (moderate). However, also, no significant improvement was reported on behavioral problems (36, 16) and inattention/hyperactivity for the Average track group (21).

Four studies (16, 21, 29a, 36) reported results for Social Problems . A significant effect was found on social functioning and resilience (36) (weak), social acceptance (29a) (moderate), personal adjustment (21), and degree of perceived support available from others and reliance upon others (16) (strong). No significant improvement was found for personal adjustment (21). The qualitative data revealed improvement in behavioral and peer interaction (36, 21).

Some studies evaluating interventions with non-directive therapist behavior showed results on outcomes that can be considered underlying mechanisms of psychosocial problems. For the domain Self-concept/Self-esteem , nine studies (13a, 16, 20, 21, 23, 25, 29a, 30, 36) showed results on this domain. They reported significant improvement in self-esteem (21, 30); feelings around body image (30) (weak); self-approval (29a); sense of identity, overall personality, positive feelings about themselves (16); and resilience (36). Also, no significant improvement was shown on this domain, e.g., self-esteem (10, 21, 25, 29a), self-concept (23) (strong), and Locus of Control (13a) (refers to how strongly people believe they have control over the situations and experiences), which was a study of moderate quality. Qualitative results showed improvement in this domain on resilience (13, 36). Two studies reported results on Emotion Regulation . In one study, a significant improvement was seen in emotion regulation and maladaptive strategies (22) (moderate), while in another study, no improvement was found. This study was assessed as being a weak study (17). Qualitative results showed that participants reported that “ventilation of uncomfortable feelings occurred, and an outlet for alleviating stress was provided” (21), and there were improvements in emotional expression and cognition (36).

Directive Therapist Behavior

Four studies that applied the directive therapist behavior (4, 8, 24, 28) showed results for Internalizing Problems . In these studies, there was a significant improvement in internalizing behaviors (28), PTSD, and sleep-related problems (8). The quality of these studies was moderate (28) and strong (8). No significant improvement was reported for mood, depression (24), PTSD, and acute stress (4). The quality of these two studies was strong and moderate.

Four studies (10, 13b, 26, 28) reported results for Externalizing Problems , and significant improvement was found on anger (10), problem behavior (13b), hyperactivity/inattention (26), hyperactivity scores, and problem behavior (28). Also, no significant improvement was reported, specifically on problem behaviors (26). The qualitative results of these AT interventions described improved classroom behavior (13). The quality of these studies was moderate (10, 13, 28) and weak (26).

Four studies (11, 26, 28, 29) reported results for Social Problems . These studies reported significant improvement for close friendship (29) and assertion (28). But in other studies, no significant improvement was reported for social skills (26), socially lonely (11), and responsibility (28). The quality of the studies was assessed as being moderate (11, 29) and weak (26, 28). Qualitative results revealed that “the clients appeared to initiate social exchanges more independently and were improved on sharing feelings, thoughts, and ideas” (26).

Some studies applying directive therapist behavior showed results on (supposed) underlying mechanisms. Five studies (10, 11, 13, 24, 29) showed results on Self-esteem/Self-concept . Significant improvement was found on self-esteem (10) and self-approval (29). Also, no significant improvement was found on self-esteem (29, 24, 11), a sense of empowerment (11), responsibility for success/failure at school (11), Locus of Control (13), and educational self-esteem (10). The quality of the studies was strong (24) and moderate (10, 11, 13, 29). Also, positive qualitative results were reported in this domain, i.e., “a shift in self-image, were more confident and assured of their skills, and were more capable of expressing their ideas, thoughts, and feelings and in sharing these. They also showed an increased capacity to reflect on their behaviors and display self-awareness” (26) and improved Locus of Control (13). One study reported no significant improvement in Emotion Regulation (12). This study was of moderate quality.

Eclectic Therapist Behavior

Seven studies (2, 5, 9, 14, 32, 33, 34) in which interventions with eclectic therapist behavior was applied showed results on Internalizing Problems . Significant improvement was reported on internalizing problems (5), anxiety (2, 32, 33), and parent & child worry (2), depression, dissociation, sexual concerns, sexual preoccupation, and sexual distress (33), dissociative symptomatology (32), and post-traumatic stress (9, 32, 33). However, no significant results were reported on anxiety (34), depression (2, 32), dissociation (fantasy) (33), sexual concerns (32), and PTSD symptoms (14). The quality was assessed as being weak (2, 9) and moderate (14, 32, 33, 34).

Five studies (2, 5, 32, 33, 35) reported on Externalizing Problems , and they reported significant improvement on externalizing problems (5), problematic behaviors (35), and anger (33). No significant improvement was reported for disruptive behavior (2), hyper-response (33), and anger (2, 32). The study quality was weak (2, 35) and moderate (5, 32, 33).

Two studies (2, 7) reported on Social Problems , and significant improvement was found for parent and child communication (2) (weak). No significant improvement was reported on sociability, responsibility, and assertiveness (7).

Within the category eclectic therapist behavior, one study showed results on underlying mechanisms, specifically no significant improvement on Self-concept (34). This study was being assessed with moderate quality.

Overall Results

As is shown in Table 3 , more than 50% of the studies on the effects of AT interventions using non-directive therapist behavior showed significant effects on the outcome domains, with high impact on externalizing (80%), social problems (75%), and internalizing problems (62,5%). Self-esteem/self-concept and emotion regulation showed lower figures, with 55.6 and 50%, respectively. AT interventions in which directive therapist behavior was used showed a different picture. The number for treating externalizing problems stood out, with 100% of the studied AT interventions being significantly effective in this domain. However, percentages of significant interventions for internalizing problems, social problems, self-esteem/self-concept were equal to or <50%. AT interventions using eclectic therapist behavior showed best results on internalizing and externalizing problems with, respectively 71.4 and 60% of the AT interventions that were evaluated on these outcome domains.

Table 3 . Number and percentage of interventions per type of therapist behavior showing significant effects on outcomes.

The purpose of this systematic narrative review was to provide an overview of AT interventions that were effective in reducing psychosocial problems in children and adolescents. The emphasis was on the applied means and forms of expression during AT, the therapeutic behavior applied, and the supposed mechanisms of change to substantiate the use of the intervention. The main results showed that a broad spectrum of art materials and techniques are used in AT treatments for psychosocial problems in children and adolescents. No specific art materials or techniques stood out. Also, forms of structure such as working on the basis of topics or assignments and the way language is applied during or after the sessions vary widely and do not seem to relate to a specific category of therapist behavior. From this point of view, it seems less important which (combination of) materials/techniques and forms of structure art therapists use in treatments of psychosocial problems. The wide variety of materials, techniques, and assignments that are used in AT shows that AT is very responsive to individual cases in their treatments. This is in line with the concept that art therapists can attune to the client's possibilities and needs with art materials/techniques ( Franklin, 2010 ).

Therapist behavior appeared to be the only distinctive component in the interventions. Three broad forms were found: non-directive, directive, and eclectic. In practice, art therapists often define their practice with orientations such as psychodynamic, gestalt, person-centered, etc. or choose an approach according to their individual preferences ( Van Lith, 2016 ). For instance, a stance in which the therapist sees its role as being a witness to the experience of the inherent process of knowing the self ( Allen, 2008 ) is often related to a non-directive therapist behavior or a stance in which they elicit meaning-making by engendering a new perspective ( Karkou and Sanderson, 2006 ) is often related to a form of directive therapist behavior. Also, many art therapists work from the point of view that the art therapist should adapt to the client needs, which can be considered an eclectic approach ( Van Lith, 2016 ) and which incorporates both forms of therapist behavior. Next to individual preferences, many psychotherapeutic approaches are being used in art therapeutic treatments of children and adolescents ( Graves-Alcorn and Green, 2014 ; Frey, 2015 ; Gardner, 2015 ; Van Lith, 2016 ). However, in the end, they all range on a continuum from non-directive to directive therapist behavior ( Yasenik and Gardner, 2012 ).

The results of this review show that AT for children and adolescents with psychosocial problems can lead to improvement in all domains for all three forms of therapist behavior in combination with a variety of means and forms. And, although the focus of this review was less on therapy outcomes, the results confirm the conclusion of Cohen-Yatziv and Regev (2019) that AT for children and adolescents with psychosocial problems can be effective. Non-directive therapist behavior, whereby the therapist is following and facilitating, shows the most significant effects in this study for psychosocial problems, next to eclectic therapist behavior for internalizing and externalizing problems. Also, it was striking that directive therapist behavior was effective for externalizing problems in all studies evaluating interventions with this type of therapist behavior, while this was not the case for the other outcome domains. Children and adolescents with externalizing problems may thus profit from directive, non-directive, and eclectic art therapist behavior. In addition, the findings suggest that we need to carefully consider using directive behavior in children with internalizing or social problems.

To substantiate the use of the AT interventions and the results, a variety of supposed mechanisms of change were described. Both specific and more general mechanisms of change were reported to substantiate AT interventions. The majority concerned specific AT mechanisms of change. Often, AT is considered a form of expression to reveal what is inside or its effects are explained by an exploration of feelings, emotions, and thoughts. These mechanisms of change were seen in AT interventions with non-directive, directive, and eclectic therapist behavior. The simultaneous occurrence of supposed mechanisms of change in all these categories of therapist behavior that differ substantially from one another can be explained by the central use of art materials, which distinguishes AT from the other ATs and from other psychotherapeutic approaches ( Malchiodi, 2012 ). It can be considered as an additional and specific value of AT and, therefore, frequently used as substantiation for the used AT interventions and their effects.

Corresponding between the studies that showed positive results was the adaptation of the materials/techniques, forms of structure, and therapist behavior to the problems and needs of the children and adolescents involved. This process is called responsiveness. Responsiveness consists of interacting in a way such that the other is understood, valued, and supported in fulfilling important personal needs and goals. It can be seen as a moment-by-moment process of the therapeutic alliance between therapist and client ( Sousa et al., 2011 ). Responsiveness supports and strengthens both the relationship and its members ( Reis and Clark, 2013 ). In AT, therapist behavior and the use of materials and techniques can both be adapted to these needs and may be considered an important element in explaining the positive effects of AT. Processes such as responsiveness and therapeutic alliance relate partially to attachment theories. In AT, a therapeutic alliance includes, next to the client and art therapist, a third “object,” the art medium, comprised of art materials, art-making, and artworks ( Bat Or, and Zilcha-Mano, 2018 ). From the perspective of attachment theory, the encounter between client and art material in AT may reflect attachment-related dynamics ( Snir et al., 2017 ). Therefore, art therapists recapitulate positive relational aspects through purposeful creative experiences that offer sensory opportunities to reinforce a secure attachment ( Malchiodi and Crenshaw, 2015 ). In this way, materials and techniques can offer the child and adolescent a “safe bridge” to bond with the therapist and explore and grow in developmental areas that are treated.

Given the results, relational, experiential (combined with art) knowledge to connect to the children's and adolescent's problems and needs seems indispensable for art therapists. This study included AT interventions performed by certified art therapists. Art therapists get a thorough education in relational and experiential (art) skills and obtain tacit knowledge through practice. By having more insight into the importance of the role of therapist behavior and the use of materials/techniques in AT interventions for children and adolescents, art therapists can improve results. Choices for therapist behavior and the use of materials/techniques should not depend that much on context or individual preference but on the client's problems and needs and which therapist behavior fits the client best. The results of this study provide clues on which and how to use AT elements in clinical practice, but above all, it gives a sound base for initiating more empirical research on AT. For practice and research purposes, a thorough elaboration and description of the therapist behavior in manuals are then of importance.

Strengths and Limitations of This Review

In this study, a narrative synthesis was performed because of the focus on substantive aspects and the heterogeneity of the studies. A common criticism of narrative synthesis is that it is difficult to maintain transparency in the interpretation of the data and the development of conclusions. It threatens the value of the synthesis and the extent to which the conclusions are reliable. For instance, in this study, we searched for similarities and differences in two core elements of AT ( Schweizer et al., 2014 ). Sometimes, forced choices had to be made in the division of the defined components into group categories and, eventually, to divide them into categories of therapist behavior. Separating and distinguishing components of an intervention are not straightforward.

From the literature, it is known that studies with positive results are overrepresented in the literature ( Mlinarić et al., 2017 ). Probably also in this study, therefore, publication bias must be taken into account when interpreting the results.

Also, regarding showing significant results, some studies showed significant and no significant results in the same domain. This can cause bias, for example, considering a study to be significantly effective in internalizing problems, but in reality, the study shows significant results in anxiety, but for instance, not in depression. It should be taken into account that, in this study, only a broad overarching view is given.

In this study, we included RCTs, CCTs, and group pre–posttest designs because these three designs (in this order) can be considered to provide the most reliable evidence ( Bondemark and Ruf, 2015 ). Questionable is whether these types of designs are the most appropriate designs for (a part of) the research question posed in this study. For detailed, more qualitative information on interventions, case studies seem very suitable. Potential advantages of a single case study are seen in the detailed description and analysis to gain a better understanding of “how” and “why” things happen ( Ridder, 2017 ).


Remarkably, seven studies did not describe their AT interventions sufficiently explicitly concerning the use of means and forms of expression and therapist behavior. This, while art materials/techniques and therapist behavior constitute the basis for AT interventions ( Moon, 2012 ). Insight into the core elements of interventions helps us better understand why and how certain interventions work. By understanding these components of an intervention, we can compare interventions and improve the effectiveness of interventions ( Blase and Fixsen, 2013 ). Therefore, for future AT studies, it is recommended to present more information on used therapeutic perspectives, means, art materials and techniques, and therapist behavior.

The results of this study show that AT interventions for children and adolescents are characterized by a variety of materials/techniques, forms of structure such as giving topics or assignments, the use of language, and therapist behavior. These results point out to more specific aspects of the dual relationship of material–therapist, which contributes to the effects, such as, for instance, responsiveness. More (qualitative) research into these specific aspects of the therapeutic relationship and the role of the relational aspects of the material could provide more insight and be of great value regarding AT for children and adolescents.

The results of the AT interventions show that AT leads to positive results for psychosocial problems, although, in some studies, both significant and not significant results were seen within a domain. A more personalized research approach, which is linked to individual treatment goals, can possibly give more clarity on the effects. Goal Attainment Scales (GAS) can be considered useful for this purpose.


This study shows that the use of means and forms of expression and therapist behavior is applied flexibly. This suggests a responsiveness of AT, in which means and forms of expression and therapist behavior are applied to respond to the client's needs and circumstances, thereby giving positive (significant) results for psychosocial problems. Searching for specific elements in the use of materials and the three defined forms of therapist behavior that influence the result is therefore recommended.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Author Contributions

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

This research was funded by NHL/Stenden, University of Applied Science in Leeuwarden and Care-group Alliade in Heerenveen, Netherlands.

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.


We would like to thank Mrs. T. van Ittersum of the Research Institute SHARE/Research office UMCG in Groningen for her help with search strategy and data collection.

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Keywords: art therapy, psychosocial problems, children, adolescents, systematic narrative review

Citation: Bosgraaf L, Spreen M, Pattiselanno K and Hooren Sv (2020) Art Therapy for Psychosocial Problems in Children and Adolescents: A Systematic Narrative Review on Art Therapeutic Means and Forms of Expression, Therapist Behavior, and Supposed Mechanisms of Change. Front. Psychol. 11:584685. doi: 10.3389/fpsyg.2020.584685

Received: 20 July 2020; Accepted: 24 August 2020; Published: 08 October 2020.

Reviewed by:

Copyright © 2020 Bosgraaf, Spreen, Pattiselanno and Hooren. 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: Liesbeth Bosgraaf,

This article is part of the Research Topic

The Psychological and Physiological Benefits of the Arts

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Research Article

The effectiveness of art therapy for anxiety in adults: A systematic review of randomised and non-randomised controlled trials

Roles Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Faculty of Health, University of Applied Sciences Leiden, Leiden, The Netherlands, Clinical Neurodevelopmental Sciences, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands

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Roles Conceptualization, Formal analysis, Investigation, Writing – review & editing

Affiliations Faculty of Health, University of Applied Sciences Leiden, Leiden, The Netherlands, KenVak, Research Centre for the Arts Therapies, Heerlen, The Netherlands

Roles Conceptualization, Writing – review & editing

Affiliations KenVak, Research Centre for the Arts Therapies, Heerlen, The Netherlands, Centre for the Arts Therapies, Zuyd University of Applied Sciences, Heerlen, The Netherlands, Faculty of Psychology and Educational Sciences, Open University, Heerlen, The Netherlands

Roles Writing – review & editing

Affiliation Clinical Neurodevelopmental Sciences, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands

Roles Conceptualization, Supervision, Writing – review & editing

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliation Faculty of Health, University of Applied Sciences Leiden, Leiden, The Netherlands

  • Annemarie Abbing, 
  • Anne Ponstein, 
  • Susan van Hooren, 
  • Leo de Sonneville, 
  • Hanna Swaab, 


  • Published: December 17, 2018
  • Reader Comments

Fig 1

Anxiety disorders are one of the most diagnosed mental health disorders. Common treatment consists of cognitive behavioral therapy and pharmacotherapy. In clinical practice, also art therapy is additionally provided to patients with anxiety (disorders), among others because treatment as usual is not sufficiently effective for a large group of patients. There is no clarity on the effectiveness of art therapy (AT) on the reduction of anxiety symptoms in adults and there is no overview of the intervention characteristics and working mechanisms.

A systematic review of (non-)randomised controlled trials on AT for anxiety in adults to evaluate the effects on anxiety symptom severity and to explore intervention characteristics, benefitting populations and working mechanisms. Thirteen databases and two journals were searched for the period 1997 –October 2017. The study was registered at PROSPERO (CRD42017080733) and performed according to the Cochrane recommendations. PRISMA Guidelines were used for reporting.

Only three publications out of 776 hits from the search fulfilled the inclusion criteria: three RCTs with 162 patients in total. All studies have a high risk of bias. Study populations were: students with PTSD symptoms, students with exam anxiety and prisoners with prelease anxiety. Visual art techniques varied: trauma-related mandala design, collage making, free painting, clay work, still life drawing and house-tree-person drawing. There is some evidence of effectiveness of AT for pre-exam anxiety in undergraduate students. AT is possibly effective in reducing pre-release anxiety in prisoners. The AT characteristics varied and narrative synthesis led to hypothesized working mechanisms of AT: induce relaxation; gain access to unconscious traumatic memories, thereby creating possibilities to investigate cognitions; and improve emotion regulation.


Effectiveness of AT on anxiety has hardly been studied, so no strong conclusions can be drawn. This emphasizes the need for high quality trials studying the effectiveness of AT on anxiety.

Citation: Abbing A, Ponstein A, van Hooren S, de Sonneville L, Swaab H, Baars E (2018) The effectiveness of art therapy for anxiety in adults: A systematic review of randomised and non-randomised controlled trials. PLoS ONE 13(12): e0208716.


Received: July 15, 2018; Accepted: November 22, 2018; Published: December 17, 2018

Copyright: © 2018 Abbing et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All files are available from .

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.


Anxiety disorders are disorders with an ‘abnormal’ experience of fear, which gives rise to sustained distress and/ or obstacles in social functioning [ 1 ]. Among these disorders are panic disorder, social phobia, agoraphobia, specific phobia, obsessive-compulsive disorder (OCD) and generalized anxiety disorder (GAD). The prevalence of anxiety disorders is high: 12.0% in European adults [ 2 ] and 10.1% in the Dutch population [ 3 ]. Lifetime prevalence for women ranges from 16.3% [ 2 , 4 ] to 23.4% [ 3 ] and for men from 7.8% to 15.9% [ 2 , 3 ] in Europe. It is the most diagnosed mental health disorder in the US [ 5 ] and incidence levels have increased over the last half of the 20 th century [ 6 ].

Anxiety disorders rank high in the list of burden of diseases. According to the Global Burden of Disease study [ 7 ], anxiety disorders are the sixth leading cause of disability, in terms of years lived with disability (YLDs), in low-, middle- and high-income countries in 2010. They lead to reduced quality of life [ 8 ] and functional impairment, not only in personal life but also at work [ 4 , 9 , 10 ] and are associated with substantial personal and societal costs [ 11 ].

The most common treatments of anxiety disorders are cognitive behavioral therapy (CBT) and/ or pharmacotherapy with benzodiazepines, tricyclic antidepressants, monoamine oxidase inhibitors and selective serotonin reuptake inhibitors [ 1 ]. These treatments appear to be only moderately effective. Pharmacological treatment causes side effects and a significant percentage of patients (between 20–50% [ 12 – 15 ] is unresponsive or has a contra-indication. Combination with CBT is recommended [ 16 ] but around 50% of patients with anxiety disorders do not benefit from CBT [ 17 ].

To increase the effectiveness of treatment of anxiety disorders, additional therapies are used in clinical practice. An example is art therapy (AT), which is integrated in several mental health care programs for people with anxiety (e.g. [ 18 , 19 ]) and is also provided as a stand-alone therapy. AT is considered an important supportive intervention in mental illnesses [ 20 – 22 ], but clarity on the effectiveness of AT is currently lacking.

AT uses fine arts as a medium, like painting, drawing, sculpting and clay modelling. The focus is on the process of creating and (associated) experiencing, aiming for facilitating the expression of memories, feelings and emotions, improvement of self-reflection and the development and practice of new coping skills [ 21 , 23 , 24 ].

AT is believed to support patients with anxiety in coping with their symptoms and to improve their quality of life [ 20 ]. Based on long-term experience with treatment of anxiety in practice, AT experts describe that AT can improve emotion regulation and self-structuring skills [ 25 – 27 ] and can increase self-awareness and reflective abilities [ 28 , 29 ]. According to Haeyen, van Hooren & Hutschemakers [ 30 ], patients experience a more direct and easier access to their emotions through the art therapies, compared to verbal approaches. As a result of these experiences, AT is believed to reduce symptoms in patients with anxiety.

Although AT is often indicated in anxiety, its effectiveness has hardly been studied yet. In the last decade some systematic reviews on AT were published. These reviews covered several areas. Some of the reviews focussed on PTSD [ 31 – 34 ], or have a broader focus and include several (mental) health conditions [ 35 – 39 ]. Other reviews included AT in a broader definition of psychodynamic therapies [ 40 ] or deal with several therapies (CBTs, expressive art therapies (e.g., guided imagery and music therapy), exposure therapies (e.g., systematic desensitization) and pharmacological treatments within one treatment program) [ 41 ].

No review specifically aimed at the effectiveness of AT on anxiety or on specific anxiety disorders. For anxiety as the primary condition, thus not related to another primary disease or condition (e.g. cancer or autism), there is no clarity on the evidence nor of the employed therapeutic methods of AT for anxiety in adults. Furthermore, clearly scientifically substantiated working mechanism(s), explaining the anticipated effectiveness of the therapy, are lacking.

The primary objective is to examine the effectiveness of AT in reducing anxiety symptoms.

The secondary objective is to get an overview of (1) the characteristics of patient populations for which art therapy is or may be beneficial, (2) the specific form of ATs employed and (3) reported and hypothesized working mechanisms.

Protocol and registration

The systematic review was performed according to the recommendations of the Cochrane Collaboration for study identification, selection, data extraction, quality appraisal and analysis of the data [ 42 ]. The PRISMA Guidelines [ 43 ] were followed for reporting ( S1 Checklist ). The review protocol was registered at PROSPERO, number CRD42017080733 [ 44 ]. The AMSTAR 2 checklist was used to assess and improve the quality of the review [ 45 ].

Eligibility criteria

Types of study designs..

The review included peer reviewed published randomised controlled trials (RCTs) and non-randomised controlled trials (nRCTs) on the treatment of anxiety symptoms. nRCTs were also included because it was hypothesized that nRCTs are more executed than RCTs, for the research field of AT is still in its infancy.

Only publications in English, Dutch or German were included. These language restrictions were set because the reviewers were only fluent in these three languages.

Types of participants.

Studies of adults (18–65 years), from any ethnicity or gender were included.

Types of interventions.

AT provided to individuals or groups, without limitations on duration and number of sessions were included.

Types of comparisons.

The following control groups were included: 1) inactive treatment (no treatment, waiting list, sham treatment) and 2) active treatment (standard care or any other treatment). Co-interventions were allowed, but only if the additional effect of AT on anxiety symptom severity was measured.

Types of outcome measures.

Included were studies that had reduction of anxiety symptoms as the primary outcome measure. Excluded were studies where reduction of anxiety symptoms was assessed in non-anxiety disorders or diseases and studies where anxiety symptoms were artificially induced in healthy populations. Populations with PTSD were not excluded, since this used to be an anxiety disorder until 2013 [ 46 ].

The following 13 databases and two journals were searched: PUBMED, Embase (Ovid), EMCare (Ovid), PsychINFO (EBSCO), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Review of Effects, Web of Science, Art Index, Central, Academic Search Premier, Merkurstab, ArtheData, Reliëf, Tijdschrift voor Vaktherapie.

A search strategy was developed using keywords (art therapy, anxiety) for the electronic databases according to their specific subject headings or structure. For each database, search terms were adapted according to the search capabilities of that database ( S1 File Full list of search terms).

The search covered a period of twenty years: 1997 until October 9, 2017. The reference lists of systematic reviews—found in the search—were hand searched for supplementing titles, to ensure that all possible eligible studies would be detected.

Study selection

A single endnote file of all references identified through the search processes was produced. Duplicates were removed.

The following selection process was independently carried out by two researchers (AA and AP). In the first phase, titles were screened for eligibility. The abstracts of the remaining entries were screened and only those that met the inclusion criteria were selected for full text appraisal. These full texts were subsequently assessed according to the eligibility criteria. Any disagreement in study selection between the two independent reviewers was resolved through discussion or by consultation of a third reviewer (EB).

Data collection process

The data were extracted by using a data extraction spreadsheet, based on the Cochrane Collaboration Data Collection Form for intervention reviews ( S1 Table Data collection form).

The form concerned the following data: aim of the study, study type, population, number of treated subjects, number of controlled subjects, AT description, duration, frequency, co-intervention(s), control description, outcome domains and outcome measures, time points, outcomes and statistics.

After separate extraction of the data, the results of the two independent assessors were compared and discussed to reach consensus.

Risk of bias in individual studies

The risk of bias (RoB) was independently assessed by the two reviewers with the Cochrane Collaboration’s tool for assessing RoB [ 47 ]. Bias was assessed over the domains: selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of researchers conducting outcome assessments), attrition bias (incomplete outcome data), reporting bias (selective reporting). A judgement of ‘low’, ‘high’ or ‘unclear’ risk of bias was provided for each domain. Since the RoB tool was developed for use in pharmacological studies, we followed the recommendations of Munder & Barth [ 48 ] that placed the RoB tool in the context of psychotherapy outcome research. Performance bias is defined here as "studies that did not use active control groups or did not assess patient expectancies or treatment credibility", instead of only 'blinding of participants and personnel'.

A summary assessment of RoB for each study was based on the approach of Higgins & Green [ 47 ]: overall low RoB (low risk of bias in all domains), unclear RoB (unclear RoB in at least one domain) and high RoB (unclear RoB in more than one domain or high RoB in at least one domain).

The primary outcome measure was anxiety symptoms reduction (pre-post treatment). The outcomes are presented in terms of differences between intervention and control groups (e.g., risk ratios or odds ratios). Within-group outcomes are also presented, to identify promising outcomes and hypotheses for future research.

Data from studies were combined in a meta-analyses to estimate overall effect sizes, if at least two studies with comparable study populations and treatment were available that assessed the same specific outcomes. Heterogeneity was examined by calculating the I 2 statistic and performing the Chi 2 test. If heterogeneity was considered relevant, e.g. I 2 statistic greater than 0.50 and p<0.10, sources of heterogeneity were investigated, subanalyses were performed as deemed clinically relevant, and subtotals only, or single trial results were reported. In case of a meta-analysis, publication bias was assessed by drawing a funnel plot based on the primary outcome from all trials and statistical analysis of risk ratios or odds ratios as the measure of treatment effect.

A content analysis was conducted on the characteristics of the employed ATs, the target populations and the reported or hypothesized working mechanisms.

Quality of evicence

Quality (or certainty) of evidence of the studies with significant outcomes only was was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) [ 49 ]. Evidence can be scored as high, moderate, low or very low, according to a set of criteria.

The search yielded 776 unique citations. Based on title and abstract, 760 citations were excluded because the language was not English, Dutch or German (n = 23), were not about anxiety (n = 164), or it concerned anxiety related to another primary disease or condition (n = 175), didn’t concern adults (18–65 years) (n = 152), were not about AT (n = 94), were not a controlled trial (n = 131), or were lacking a control group (n = 22) or anxiety symptoms were not used as outcome measure (n = 1).

Of the remaining 16 full text articles, 13 articles were excluded. Reasons were: lack of a control group [ 50 – 54 ], anxiety was related to another primary disease or condition [ 55 , 56 ], or the study population consisted of healthy subjects [ 57 , 58 ], did not concern subjects in the age between 18–65 years [ 59 ], or was not peer-reviewed [ 60 ] or did not have pre-post measures of anxiety symptom severity [ 61 , 62 ]. A list of all potentially relevant studies that were excluded from the review after reading full-texts, is presented in S2 Table Excluded studies with reasons for exclusion . Finally, three studies were included for the systematic review ( Fig 1 ).


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Screening of references from systematic reviews.

The systematic literature search yielded 15 systematic reviews. All titles from the reference lists of these reviews were screened (n = 999), of which 27 publications were eligible for abstract screening and were other than the 938 citations found in the search described above (see Study selection). From these abstracts, 18 were excluded because they were not peer reviewed (n = 3), not in English, Dutch or German (n = 1), not about anxiety (n = 2), or were about anxiety related to cancer (n = 2), were not about AT (n = 2) or were not a controlled trial (n = 8). Nine full texts were screened for eligibility and were all excluded. Six full texts were excluded because these concerned psychodynamic therapies and did not include AT [ 63 – 68 ]. Two full texts were excluded because they concerned multidisciplinary treatment and no separate effects of AT were measured [ 18 , 19 ]. The final full text was excluded because it concerned induced worry in a healthy population [ 69 ]. No studies remained for quality appraisal and full review. The justified reasons for exclusion of all potentially relevant studies that were read in full-text form, is presented in S2 Table Excluded studies with reasons for exclusion .

Study characteristics

The review includes three RCTs. The study populations of the included studies are: students with PTSD symptoms and two groups of adults with fear for a specific situation: students prior to exams and prisoners prior to release. The trials have small to moderate sample sizes, ranging from 36 to 69. The total number of patients in the included studies is 162 ( Table 1 ).


In one study, AT is combined with another treatment: a group interview [ 72 ]. The other two studies solely concern AT ( Table 2 ) [ 70 , 71 ].


The provided AT varies considerably: mandala creation in which the trauma is represented [ 70 ] or colouring a pre-designed mandala, free clay work, free form painting, collage making, still life drawing [ 71 ], and house-tree-person drawings (HTP) [ 72 ]. Session duration differs from 20 minutes to 75 minutes. The therapy period ranges from only once to eight weeks, with one to ten sessions in total ( Table 2 ). In one study, the control group receives the co-intervention only: group interview in Yu et al. [ 72 ]. Henderson et al. [ 70 ] use three specific drawing assignments as control condition, which are not focussed on trauma, opposed to the provided art therapy in the experimental group. Sandmire et al. [ 71 ] used inactive treatment. Here, AT is compared to comfortably sitting. Study settings were outpatient: universities (US) and prison (China). None of the RCTs reported on sources of funding for the studies.

See S3 Table for an extensive overview of characteristics and outcomes of the included studies.

Risk of bias within studies

Based on the Cochrane Collaboration’s tool for assessing risk of bias, estimations of bias were made. Table 3 shows that the risk of bias (RoB) is high in all studies.


Selection bias : overall, methods of randomization were not always described and selection bias can therefore not be ruled out, which leads to unclear RoB. Henderson et al. [ 70 ] described the randomisation of participants over experimental and control groups. However, it is unclear how gender and type of trauma are distributed. Sandmire et al. [ 71 ] did not describe the randomization method but there was no baseline imbalance. Also Yu et al. [ 72 ] did not decribe the randomisation method, but two comparable groups were formed as concluded on baseline measures. Nevertheless it is unclear whether psychopathology of control and experimental groups are comparable.

Performance bias : Sandmire’s RCT had inactive control, which gives a high risk on performance bias [ 48 ]. Like in psychotherapy outcome research, blinding of patients and therapists is not feasible in AT [ 48 , 73 ]. It is not possible to judge whether the lack of blinding influenced the outcomes and also none of the studies assessed treatment expectancies or credibility prior to or early in treatment, so all studies were scored as ‘high risk’ on performance bias.

Detection bias : in all studies only self-report questionnaires were used. The questionnaires used are all validated, which allows a low risk score of response bias. However, the exact circumstances under which measures are used are not described [ 70 , 71 ] and may have given rise to bias. Presence of the therapist and or fear for lack of anonymity may have influenced scores and may have led to confirmation bias (e.g.[ 74 ]), which results in a ‘unclear’ risk of detection bias.

Attrition bias : in the study of Henderson it is not clear whether the outcome dataset is complete.

Reporting bias : there are no reasons to expect that there has been selective reporting in the studies.

Other issues : in Sandmire et al. [ 71 ] it was noted that the study population constists of liberal arts students, who are likely to have positive feelings towards art making and might expericence more positive effects (reduction of anxiety) than students from other disciplines.

Overall risk of bias : since all studies had one or more domains with high RoB, the overall RoB was high.

Outcomes of individual studies

The measures used in the studies are shown in Table 4 . The outcome measures for anxiety differ and include the State-Trait Anxiety Inventory (STAI) (used in two studies), the Hamilton Anxiety Rating Scale (HAM-A) and the Zung Self-rating Anxiety Scale (SAS) (used in one study). Quality of life was not measured in any of the included studies.


Anxiety–in study with inactive control.

Sandmire et al. [ 71 ] showed significant between-group effects of art making on state anxiety (tested with ANOVA: experimental group (mean (SD)): 39.3 (9.4) - 29.5 (8.6); control group (mean (SD)): 36.2 (8.8) - 36.0 (10.9)\; p = 0.001) and on trait anxiety (experimental group (mean (SD)): 39.1 (5.8) - 33.3 (6.1); control group (mean (SD)): 38.2 (10.2) - 37.3 (11.2); p = 0.004) There were no significant differences in effectiveness between the five types of art making activities.

Anxiety–in studies with active control.

Henderson et al. [ 70 ] reported no significant effect of creating mandalas (trauma-related art making) versus random art making on anxiety symptoms (tested with ANCOVA: experimental group (mean (SD)): 45.05 (10.75) - 41.16 (11.30); control group (mean (SD): 49.05 (12.29) - 44.05 (10.12), p -value: not reported) immediately after treatment. At follow-up after one month there was also no significant effect of creating mandalas on anxiety symptoms: experimental group (mean (SD): 40.95 (11.54); control group (mean (SD): 42.0 (13.26)), but there was significant improvement of PTSD symptom severity at one-month follow-up ( p = 0.015).

Yu et al. (2016) did not report analyses of between-group effects. Only the experimental group, who made HTP drawings followed by group interview, showed a significant pre- versus post-treatment reduction of anxiety symptoms (two-tailed paired sample t-tests: HAM-A (mean (SD): 24.36 (9.11) - 17.42 (10.42), p = 0.001; SAS (mean (SD): 62.63 (9.46) - 56.78 (11.64,) p = 0.004). The anxiety level in the control group on the other hand, who received only group interview, increased between pre- and post-treatment (HAM-A (mean (SD): 24.75 (6.14) - 25.22 (7.37), not significant; SAS (mean (SD): 62.57 (7.36) - 66.11 (10.41), p = 0.33).

Summary of outcomes and quality.

Of three included RCTs studying the effects of AT on reducing anxiety symptoms, one RCT [ 71 ] showed a significant anxiety reduction, one RCT [ 72 ] was inconclusive because no between-group outcomes were provided, and one RCT [ 70 ] found no significant anxiety reduction, but did find signifcant reduction of PTSD symptoms at follow-up.

Regarding within-group differences, two studies [ 71 , 72 ] showed significant pre-posttreatment reduction of anxiety levels in the AT groups and one did not [ 70 ].

The quality of the evidence in Sandmire [ 71 ] as assessed with the GRADE classification is low to very low (due to limited information the exact classification could not be determined). The crucial risk of bias, which is likely to serious alter the results [ 49 ], combined the with small sample size (imprecision [ 75 ]) led to downgrading of at least two levels.


Because data were insufficiently comparable between the included studies due to variation in study populations, control treatments, the type of AT employed and the use of different measures, a meta-analysis was not performed.

Narrative synthesis

Benefiting populations..

AT seems to be effective in the treatment of pre-exam anxiety (for final exams) in adult liberal art students [ 71 ], although the quality of evidence is low due to high RoB. Based on pre-posttreatment anxiety reduction (within-group analysis) AT may be effective for adult prisoners with pre-release anxiety [ 72 ].

Characteristics of AT for anxiety.

Sandmire et al. [ 71 ] gave students with pre-exam stress one choice out of five art-making activities: mandala design, free painting, collage making, free clay work or still life drawing. The activity was limited to one session of 30 minutes. This was done in a setting simulating an art center where students could use art materials to relieve stress. The mandala design activity consisted of a pre-designed mandala which could be completed by using pencils, tempera paints, watercolors, crayons or markers. The free form painting activity was carried out on a sheet of white paper using tempera or water color paints which were used to create an image from imagination. Participants could also use fine-tip permanent makers, crayons, colored pencils and pastels to add detailed design work upon completion of the initial painting. Collage making was also one of the five options. This was done with precut images and text, by further cutting out the images and additonal images from provided magazins and gluing them on a white piece of paper. Participants could also choose for a clay activity to make a ‘pleasing form’. Examples were a pinch pot, coil pot and small animal figures. The final option for art-making was a still life drawing, by arranging objects into a pleasing assembly and drafting with pencil. Additionally, diluted sepia ink could be used to paint in tonal values.

Yu et al. [ 72 ] used the HTP drawings in combination with group interviews about the drawings, to treat pre-release anxiety in male prisoners. The procedure consists of drawing a house, a tree and a person as well as some other objects on a sheet of paper. Yu follows the following interpretation: the house is regarded as the projection of family, the tree represents the environment and the person represents self-identification [ 76 ]. The HTP drawing is usually used as a diagnostic tool, but is used in this study as an intervention to enable prisoners to become more aware of their emotional issues and cognitions in relation to their upcoming release. A counselor gives helpful guidance based on the drawing and reflects on informal or missing content, so that the drawings can be enriched and completed. After completion of the drawings, prisoners participated in a group interview in which the unique attributes of the drawings are related to their personal situation and upcoming release.

Henderson et al. [ 70 ] treated traumatised students with mandala creation, aiming for the expression and representation of feelings. The participants were asked to draw a large circle and to fill the circle with feelings or emotions related to their personal trauma. They could use symbols, patterns, designs and colors, but no words. One session lasted 20 minutes and the total intervention consisted of three sessions, on three consecutive days. One month after the intervention, the participants were asked about the symbolic meaning of the mandala drawings.

Working mechanisms of AT.

Sandmire used a single administration of art making to treat the handling of stressful situations (final exams) of undergraduate liberal art students. The art intervention did not explicitly expose students to the source of stress, hence a general working mechanism of AT is expected. The authors claim that art making offers a bottom-up approach to reduce anxiety. Art making, in a non-verbal, tactile and visual manner, helps entering a flow-like-state of mind that can reduce anxiety [ 77 ], comparable to mindfulness.

Yu reports that nonverbal symbolic methods, like HTP-drawing, are thought to reflect subconscious self-relevant information. The process of art making and reflection upon the art may lead to insights in emotions and (wrong) cognitions that can be addressed during counseling. The authors state that “HTP-drawing is a natural, easy mental intervention technique through which counselors can guide prisoners to form helpful cognitions and behaviors within a relative relaxing and well-protected psychological environment”. In this case the artwork is seen as a form of unconscious self-expression that opens up possibilities for verbal reflections and counseling. In the process of drawing, the counselor gives guidance so the drawing becomes more complete and enriched, what possibly entails a positive change in the prisoners’ cognitive patters and behavior.

Henderson treated PTSD symptoms in students and expected the therapy to work on anxiety symptoms as well. The AT intervention focussed on the creative expression of traumatic memories, which can been seen as an indirect approach to exposure, with active engagement. The authors indicate that mandala creation (related to trauma) leads to changes in cognition, facilitating increasing gains. Exposure, recall and emotional distancing may be important attributes to recovery.

Summarizing, three different types of AT can be distinguised: 1) using art-making as a pleasant and relaxing activity; 2) using art-making for expression of (unconsious) cognitive patterns, as an insightful tool; and 3) using the art-making process as a consious expression of difficult emotions and (traumatic) memories.

Based on these findings, we can hypothesize that AT may contribute to reducing anxiety symptom severity, because AT may:

  • induce relaxation, by stimulating a flow-like state of mind, presumably leading to a reduction of cortisol levels and hence stress and anxiety reduction (stress regulation) [ 71 ];
  • make the unconscious visible and thereby creating possibilities to investigate emotions and cognitions, contributing to cognitive regulation [ 70 , 72 ].
  • create a safe environment for the conscious expression of (difficult) emotions and memories, what is similar to exposure, recall and emotional distancing, possibly leading to better emotion regulation [ 70 ].

Currently there is no overview of evidence of effectiveness of AT on the reduction of anxiety symptoms and no overview of the intervention characteristics, the populations that might benefit from this treatment and the described and/ or hypothesized working mechanisms. Therefore, a systematic review was performed on RCTs and nRCTs, focusing on the effectiveness of AT in the treatment of anxiety in adults.

Summary of evidence and limitations at study level

Three publications out of 776 hits of the search met all inclusion and exclusion criteria. No supplemented publications from the reference lists (999 titles) of 15 systematic reviews on AT could be included. Considering the small amount of studies, we can conclude that effectiveness research on AT for anxiety in adults is in a beginning state and is developing.

The included studies have a high risk of bias, small to moderate sample sizes and in total a very small number of patients (n = 162). As a result, there is no moderate or high quality evidence of the effectiveness of AT on reducing anxiety symptom severity. Low to very low-quality of evidence is shown for AT for pre-exam anxiety in undergraduate students [ 71 ]. One RCT on prelease anxiety in prisoners [ 72 ] was inconclusive because no between-group outcome analyses were provided, and one RCT on PTSD and anxiety symptoms in students [ 70 ] found significant reduction of PTSD symtoms at follow-up, but no significant anxiety reduction. Regarding within-group differences, two studies [ 71 , 72 ] showed significant pre-posttreatment reduction of anxiety levels in the AT groups and one did not [ 70 ]. Intervention characteristics, populations that might benefit from this treatment and working mechanisms were described. In conclusion, these findings lead us to expect that art therapy may be effective in the treatment of anxiety in adults as it may improve stress regulation, cognitive regulation and emotion regulation.

Strengths and limitations of this review

The strength of this review is firstly that it is the first systematic review on AT for primary anxiety symptoms. Secondly, its quality, because the Cochrane systematic review methodology was followed, the study protocol was registered before start of the review at PROSPERO, the AMSTAR 2 checklist was used to assess and improve the quality of the review and the results were reported according to the PRISMA guidelines. A third strength is that the search strategy covers a long period of 20 years and a large number of databases (13) and two journals.

A first limitation, according to assessment with the AMSTAR 2 checklist, is that only peer reviewed publications were included, which entails that many but not all data sources were included in the searches. Not included were searches in trial/study registries and in grey literature, since peer reviewed publication was an inclusion criterion. Content experts in the field were also not consulted. Secondly, only three RCTs met the inclusion criteria, each with a different target population: students with moderate PTSD, students with pre-exam anxiety and prisoners with pre-release anxiety. This means that only a small part of the populations of adults with anxiety (disorders) could be studied in this review. A third (possible) limitation concerns the restrictions regarding the included languages and search period applied (1997- October 2017). With respect to the latter it can be said that all included studies are published after 2006, making it likely that the restriction in search period has not influenced the outcome of this review. No studies from 1997 to 2007 met the inclusion and exclusion criteria. This might indicate that (n)RCTs in the field of AT, aimed at anxiety, are relatively new. A fourth limitation is the definition of AT that was used. There are many definitions for AT and discussions about the nature of AT (e.g. [ 78 ]). We considered an intervention to be art therapy in case the visual arts were used to promote health/wellbeing and/or the author called it art therapy. Thus, only art making as an artistic activity was excluded. This may have led to unwanted exclusion of interesting papers.

A fifth limitation is the use of the GRADE approach to assess the quality of evidence of art therapy studies. This tool is developed for judging quality of evidence of studies on pharmacological treatments, in which blinding is feasible and larger sample sizes are accustomed. However the assessed study was a RCT on art therapy [ 71 ], in which blinding of patients and therapists was not possible. Because the GRADE approach is not fully tailored for these type of studies, it was difficult to decide whether the the exact classification of the available evidence was low or very low.

Comparison to the AT literature

The results of the review are in agreement with other findings in the scientific literature on AT demonstrating on the one hand promising results of AT and on the other hand showing many methodological weaknesses of AT trials. For example, other systematic reviews on AT also report on promising results for art therapy for PTSD [ 31 – 34 , 37 ] and for a broader range of (mental) health conditions [ 35 – 39 ], but since these reviews also included lower quality study designs next to RCTs and nRCTs, the quality of this evidence is likely to be low to very low as well. These reviews also conclude on methodological shortcomings of art therapy effectiveness studies.

Three approaches in AT were identified in this review: 1) using art-making as a relaxing activity, leading to stress reduction; 2) using the art-making process as a consious pathway to difficult emotions and (traumatic) memories; leading to better emotion regulation; and 3) using art-making for expression, to gain insight in (unconscious) cognitive patterns; leading to better cognitive regulation.

These three approaches can be linked to two major directions in art therapy, identified by Holmqvist & Persson [ 74 ]: “art-as-therapy” and “art-in-psychotherapy”. Art-as-therapy focuses on the healing ability and relaxing qualities of the art process itself and was first described by Kramer in 1971 [ 79 ]. This can be linked to the findings in the study of Sandmire [ 71 ], where it is suggested that art making led to lower stress levels. Art making is already associated with lower cortisol levels [ 80 ]. A possible explanation for this finding can be that a trance-like state (in flow) occurs during art-making [ 81 ] due to the tactile and visual experience as well as the repetitive muscular activity inherent to art making.

Art-in-psychotherapy , first described by Naumberg [ 82 ] encompasses both the unconscious and the conscious (or semi-conscious) expression of inner feelings and experiences in apparently free and explicit exercises respectively. The art work helps a patient to open up towards their therapist [ 74 ], so what the patient experienced during the process of creating the art work, can be deepened in conversation. In practice, these approaches often overlap and interweave with one another [ 83 ], which is probably why it is combined in one direction ‘art-in-psychotherapy’. It might be beneficial to consider these ways of conscious and unconscious expression separately, because it is a fundamental different view on the importance of art making.

The overall picture of the described and hypothesized working mechanisms that emerged in this review lead to the hypotheses that anxiety symptoms may decrease because AT may support stress regulation (by inducing relaxation, presumably comparable to mindfulness [ 64 , 84 ], emotion regulation (by creating the safe condition for expression and examination of emotions) and cognitive regulation (as art work opens up possibilities to investigate (unconscious) cognitions). These types of regulation all contribute to better self-regulation [ 85 ]. The hypothesis with respect to stress regulation is further supported by results from other studies. The process of creating art can promote a state of mindfulness [ 57 ]. Mindfulness can increase self-regulation [ 84 ] which is a moderator between coping strength and mental symptomatology [ 86 ]. Improving patient’s self-regulation leads, amongst others, to improvement of coping with disease conditions like anxiety [ 85 , 86 ]. Our findings are in accordance with the findings of Haeyen [ 30 ], stating that patients learn to express emotions more effectively, because AT enables them to “examine feelings without words, pre-verbally and sometimes less consciously”, (p.2). The connection between art therapy and emotion regulation is also supported by the recently published narrative review of Gruber & Oepen [ 87 ], who found significant effective short-term mood repair through art making, based on two emotion regulation strategies: venting of negative feelings and distraction strategy: attentional deployment that focuses on positive or neutral emotions to distract from negative emotions.

Future perspectives

Even though this review cannot conclude effectiveness of AT for anxiety in adults, that does not mean that AT does not work. Art therapists and other care professionals do experience the high potential of AT in clinical practice. It is challenging to find ways to objectify these practical experiences.

The results of the systematic review demonstrate that high quality trials studying effectiveness and working mechanisms of AT for anxiety disorders in general and specifically, and for people with anxiety in specific situations are still lacking. To get high quality evidence of effectiveness of AT on anxiety (disorders), more robust studies are needed.

Besides anxiety symptoms, the effectiveness of AT on aspects of self-regulation like emotion regulation, cognitive regulation and stress regulation should be further studied as well. By evaluating the changes that may occur in the different areas of self-regulation, better hypotheses can be generated with respect to the working mechanisms of AT in the treatment of anxiety.

A key point for AT researchers in developing, executing and reporting on RCTs, is the issue of risk of bias. It is recommended to address more specifically how RoB was minimalized in the design and execution of the study. This can lower the RoB and therefor enhance the quality of the evidence, as judged by reviewers. One of the scientific challenges here is how to assess performance bias in AT reviews. Since blinding of therapists and patients in AT is impossible, and if performance bias is only considered by ‘lack of blinding of patients and personnel’, every trial on art therapy will have a high risk on performance bias, making the overall RoB high. This implies that high or even medium quality of evidence can never be reached for this intervention, even when all other aspects of the study are of high quality. Behavioral interventions, like psychotherapy and other complex interventions, face the same challenge. In 2017, Munder & Barth [ 48 ] published considerations on how to use the Cochrane's risk of bias tool in psychotherapy outcome research. We fully support the recommendations of Grant and colleagues [ 73 ] and would like to emphasize that tools for assessing risk of bias and quality of evidence need to be tailored to art therapy and (other) complex interventions where blinding is not possible.

The effectiveness of AT on reducing anxiety symptoms severity has hardly been studied in RCTs and nRCTs. There is low-quality to very low-quality evidence of effectiveness of AT for pre-exam anxiety in undergraduate students. AT may also be effective in reducing pre-release anxiety in prisoners.

The included RCTs demonstrate a wide variety in AT characteristics (AT types, numbers and duration of sessions). The described or hypothesized working mechanisms of art making are: induction of relaxation; working on emotion regulation by creating the safe condition for conscious expression and exploration of difficult emotions, memories and trauma; and working on cognitive regulation by using the art process to open up possibilities to investigate and (positively) change (unconscious) cognitions, beliefs and thoughts.

High quality trials studying effectiveness on anxiety and mediating working mechanisms of AT are currently lacking for all anxiety disorders and for people with anxiety in specific situations.

Supporting information

S1 checklist. prisma checklist..

S1 File. Full list of search terms and databases.

S1 Table. Data extraction form.

S2 Table. Excluded studies with reasons for exclusion.

S3 Table. Background characteristics of the included studies.


We would like to thank Drs. J.W. Schoones, information specialist and collection advisor of the Warlaeus Library of Leiden University Medical Center (LUMC), for assisting in the searches.

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Art Therapy Research Paper

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research papers about art therapy

Art Therapy Research Paper

Psychological effects of grief analysis.

Psychological Effects of Grief, development plays an important role in the processing of loss. This text explains many of the psychological aspects of grief and loss at each development on the understanding of sudden death. The motivation for this text is to integrate understandings of sudden loss with knowledge of human development over the life course. This aspect of grief has not received the attention it deserves. Sudden loss stimulates an acute sense of vulnerability and subsequent hypervigilance just as trauma does (Lopez Levers, 2012).

How Does Art Therapy Affect Children

_A box of crayons, pots of finger paints, or tubs of playdough can take us right back to childhood. Pottering with art supplies is super fun, but are these simple tools capable of doing much more for children, especially those with behavioral and psychological disorders? Art therapy stimulates children's natural imagination that is found to be beneficial in treating learning and behavioral disorders, healing traumatic memories, and coping with grief._

Grief In Nicholas Wolterstorff's Lament For A Son

It is first and foremost the grief of one person over the death of his son. Here the author accepts that he has grief because he has loved his son and that son is no more. As much he loved his son, so much is his grief. When we go through this book keeping in mind Elisabeth Kübler-Ross’ five stages of grief, we find that the development of the thoughts of the author is also almost the same.

What Is The Loss Of Innocence In Laurie Halse Anderson's Speak

Children in the age range thirteen to fifteen are often transitioning through a critical time of their lives. They frequently look to others as a cicerone on how they themselves should act. In the novel, Speak by Laurie Halse Anderson, Melinda Sordino calls the cops on an end-of-summer party at which she was raped. The novel depicts Melinda’s excursion as to how she copes with the heart-wrenching events that have affected her momentously as well as creating “[a] frightening and sobering look at the cruelty and viciousness that pervade much of contemporary high school life.” (Kirkus Reviews, Pointer Review). The tragic event along with the rejection of her friends took a rather large toll on Melinda Sordino, in which, at one point, she stops

Personal Narrative: Dealing With Grief

Dealing with the death of a loved one can be an emotionally difficult experience, but by effectively dealing with the grief, I was able to successfully recover and move on. Two years ago, my family and I got the horrendous news that my aunt, who raised my mom, had passed away after a long journey of lung failure. It was truly a tough burden for all of us to endure. To begin with, I mourned over the loss for such a long stretch of time. I would frequently be recollecting all of the memories and unforgettable times that we had together. Crying was another phase of the mourning process for me, and because of this I went through a very sad period in my life. Secondly, I harbored a great deal of anger towards the situation as a whole, even though

Art Therapy: A Phenomenological Analysis

art therapy 's most important contribution to general therapy and even to phenomenology itself, because art therapy pays attention to the authentic experience in two ways. First of all there is the direct experience of creating art and second of all there is the direct experience of looking at the art. The second direct experience requires some help to learn how to look in order to see all that can be seen in their art expression (Betensky,

The Sanctuary Of School Summary

Stuckey, Heather L., and Jeremy Nobel. “The Connection Between Art, Healing, and Public Health: A Review of Current Literature.” American Journal of Public Health 100.2 (2010): 254–263. PMC. Web. 28 Sep.

Adult Grief Group Paper

Adult Grief Group- 9 week closed group for adults ages 18+ages. The group goes through each step of grief along with a focus on specific struggles such as holidays, change of roles after death of l loved one and spiritual reflection. The groups are set up for 8 clients per clinician all groups(if more than one) for 20 min Psycho education then splints into the groups to provide time for each client to share and seek peer support. This is an extensive program designed to guide a individual through grief work to a place of hope beyond grief. I usually dedicate one week to a project that includes art Therapy for adults. Journal topic is given as homework. Draw, think, write etc. (active 15 mins of grief work) outside of group.

Robert Latchman's Impact On The Mentally Ill

For example, when most people are diagnosed with any type of mental disease, the first and foremost thing to do is get them on some type of medication. Nevertheless thanks to new and upcoming research there has been proven evidence that “ engagement with artistic activities, either as an observer of the creative efforts of others or as an initiator of one’s own creative efforts, can enhance one’s moods, emotions, and other psychological states as well as have a salient impact on important physiological parameters” (The Connection Between Art, Healing, And Public Health: A Review of Current Literature) by Heather L. Stuckey and Jeremy Nobel). Any type of art between, music, drawing, painting, writing, or etc. has been used to help ease the emotion of the mentally ill. Not only can it create a sense of safety, but the please some get from making art has been proven to ease anxiety, decrease depression, calm nerves, and help cope with things that may be harder for one to take in with a mental

Father To Death Row Essay

After reading two articles focusing on the families of death row inmates, the next article Children of the Condemned: Grieving the Loss of a Father to Death Row focuses on the children affected by having a father on death row. Beck and Jones (2008) examined the effects of a death sentence on children of the condemned. Additionally, the article discusses the concept of disenfranchised grief and nonfinite loss that form the children 's grief process. Beck and Jones (2008) conducted their study by interviewing nineteen children of death row inmates, through lawyers and having parental consent. The data from Beck and Jones (2008) study showed “The most prevalent theme was the children’s discussion of the importance of having their parent in their

Pediatric Bereavement Camp Research Paper

The loss of a loved one can in many cases cause feelings of grief and a wide range of emotions

Sandra Lopez

"Does Grief Vary by Age, as Well as by Culture?" Journal of Psychosocial Nursing & Mental Health Services 41.11 (2003): 8-9. ProQuest. Print. Stephen Bailey questions the article, “Does Grief Vary by Age, as well as by Culture?” by asking the authors if it is helpful to distinguish between mourning as a sociological concept and grieving as a psychological concept. Paul T. Clements, one of the authors, replied and explained mourning as a social procedure, yet it is so naturally interlaced with grieving that to try and separate the two is not a simple undertaking, nor is it useful for researchers or clinicians. Paul Clements thinks this is brilliantly reflected in the term psychosocial nursing, on the grounds that paying little mind to whether youngsters and their families are grieving or mourning. What makes a difference most to them is the way they feel and the ways the procedure influences their everyday lives. Not discussing the demise does not make it go away. Discussing death using age-suitable and culturally applicable terms can give a foundation to versatile adapting. Shaila Bhave had to talk about it with her friend and Judith Templeton, just so all the drama going on in her head can be reduced. Paul Clements expresses that grief is not an endpoint but rather an adventure. It is regular for grief to be a deep rooted

Observation Of Child Drawing

For children, drawing involves both a process (making of art) and a product (the completed art expression). These drawings need to be considered within the context of the child’s developmental, social, cultural and emotional experiences. (Malchiodi, 1998). I have chosen to examine three drawings by C, an 8-year-old girl I have been having therapeutic play sessions with. She was referred to me by her father, due to her inability to concentrate at school, hyperactivity, and impulsivity, which cause her to get into trouble at school, and in social situations. C is an only child, living at home with her parents. She is Taiwanese, and her mother tongue is Mandarin.

Burke Art Influence

Through the centuries, art can differ and appear in several ways, but art will always have a positive effect on people. Art can be defined as a way to express what you feel or to create an emotional response from the person exposed to art. Art can make the person exposed to it remember great memories that warm the heart. Artists create art because it’s their talent and passion; however, they unconsciously shape lives and history with their artwork. Several artists, such as William Edmondson and Selma Burke create art because it is their calling and influence others to strive for something better with their artwork. In addition, every artist is different and unique; they all have a different story that makes them who they are. Burke and Edmonson

Essay On Loss And Grief

To be able to know how to deal with the losses that are discussed in the following chapters, it is important to have a clearer understanding of loss and grief and how to cope with grief following

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Art Therapy Essay Examples

The authors in this article reviewed numerous records of studies that were done to test the effectiveness of creative art therapies treating PTSD (Post Traumatic Stress Disorder). They narrowed their review down to seven studies that used a controlled study structure and had conveyed evidence...

The Social work intern is currently interning at Sheltering Arms and Family Service. Sheltering Arms is a non-profit organization established in 1831. The population that is assisted is very diverse in all categories whether it’s ethnicity, race or all ages. The services it offers fall...

I’ve always wanted to combine my love of art and my compassion for people. I plan to do this by studying Social Work for my second master’s degree and eventually becoming an art therapist. My first master’s degree was in Fine Art; while making my...

The Movement theatre is an ideal place to understand better modern Georgian culture and look at the theatre from the other side. Since the actors tell the story only through movements, there is no language barriers, and the theater tries its best to please everyone,...

In the developmental psychology, human relationship is the fundamental key of physical and psychological well-being, as human survives by depending on each other. According to the first and second principle of sociocultural level of analysis, human relationship is built because human being has the basic...

A recent scientific journal provided proof that the use of art therapy can improve psychological stability and help alleviate depression, anger, stress and anxiety levels. High levels of anxiety and depression can affect a patient not only psychologically but also physically. Through new studies, health...

The article “Does Art Therapy Work? Identifying the Activate Ingredients of Art Therapy Efficacy” states that art, itself, can help clients cope with emotional pain. Art can effectively improve one’s mental state. Author Lynn Kapitan, editor of Art Therapy: Journal of the American Art Therapy...

A diagnosis of depression involves a loss of interest in usual activities or feelings of sadness accompanied by an array of possible symptoms that must be present for at least two weeks (American Psychiatric Association, 2017). The Centers for Disease Control and Prevention (CDC) (2017)...

“Women have greater odds of adverse mental health among deployed veterans,” (Hoglund and Schwartz, 2014, Lehavot et al. , 2012, Maiocco & Smith, 2016). In today’s society, a lot more women are joining the military. According to the Department of Veterans Affairs, there were 1....

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